Impact of Caregiver Support on Patient Self-Care Outcomes with Heart Failure: A Systematic Review

Aim: The purpose of this systematic review was to assess the impact on patient outcomes of caregivers’ contribution to heart failure (HF) self-care. The reason for choosing this condition is because of the importance of involving the caregiver support in self-care patients with HF. Methods: The review was guided by The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; the search was conducted for years 2014 to 2019 utilizing three databases: CINHAL, PubMed, and Psych INFO. Results: The systematic review revealed that caregivers contribute to self-care and patient confidence. Five studies reported a level of confidence for health behavior (exercise, medication adherence, and diet) as a significant predictor for caregiver contributions to patient self-care. One study found that patients who were cared for by their spouses experienced a risk for a low level of confidence compared to adults-children caregivers. Four studies reported the relationship between caregiver contribution to patient self-care and health related quality of life. Two studies found that caregiver contributions to patient self-care caused a significant reduction in readmission, hospitalization, and mortality of patients. Clinical implication: The findings from this review have encouraged providers to conduct interventions that focus on quality of patient-caregiver relationships (e.g., mutuality).

Self-care is initiated by HF patients with varied levels of support from informal caregivers (CGs) such as family members or friends. Wingham, et al. [9] noted that caregivers need to have a clear picture of the patients they care for; caregiv-patient outcomes. The reason behind choosing this condition is because HF is a chronic condition that significantly impacts the quality of life of patients living with the disease. Approximately one in five adults in the United States have HF; and approximately 50% of people who develop HF die during the first five years of diagnosis [8]. Heart failure presents a major challenge for health policy makers in primary and secondary intervention care [9] and has a significant impact on the physical and mental health of caregivers who provide personal care and support for self-care planning [10]. Self-report Self-report Self-report Objective Self-report Self-report Self-report Self-report Self-report Self-report Self-report 63 full-text articles excluded • 30 did not measure self-care as an outcome variable. • 13 were not full text-articles • 5 lacked complete instrument development • 1 was a systematic review • 1 was not in English • 1 was an integrative review • 1 was a mixed method • 6 were qualitative studies 12 of the studies included in qualitative synthesis Figure 1: Flow Diagram of the Selection Process of the Studies "Self-management OR self-care" AND "family caregivers OR informal caregivers OR relatives OR family" AND "heart failure." The same search strategy was followed with the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Psych Info. The search was limited to English, peer-reviewed, year of publication, and full text research articles. There were no limitations on geographical location or type of patient outcomes because this systematic review aimed to identify all possible self-care outcomes and to involve all possible studies for the purpose of this review.

Eligibility Criteria
Studies were included in the systematic review if they (a) Used a quantitative methodology; (b) Included participants with HF who were > 18 years old; (c) included an informal caregiver; (d) explicitly measured patient outcomes. Studies were excluded in the systematic review if they (a) used a qualitative methodology; the traditional way for systematic review is only including empirical study with statistical outcomes [15]; (b) Included formal caregivers.

Review Process
All screened articles were organized and retrieved using a Microsoft word document and RefWorks reference management software. Articles titles and abstracts were assessed for ers need to know how to participate in care giving activities. The care activities should include monitoring and planning for daily life activities, providing complex medications that may require modification, and adherence to dietary restriction.
Furthermore, caregivers should be involved in discussions about care to develop their abilities to support self-maintenance and self-management experiences. The National Institute of Health and Care Excellence Clinical Guidelines 108 for HF [5] recommended that caregivers be involved in discussion about self-care management plan. Most caregivers, however, have little knowledge about how to expand their competence to support self-care [9]. Researchers agree that it is critical to engage caregivers in self-care activities to achieve positive health outcomes for HF patients [6,7,[9][10][11].

Methods
This Systematic Review way was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [13]. PRISMA ensures the transparent and thorough reporting of systematic review [14]. The search was conducted for years 2014 to 2019 utilizing three databases: CINHAL, PubMed, and Psych INFO. This five-year period was chosen to synthesize the current findings of literature with evidence-based practice. To extract the appropriate articles, the following key words were used in PubMed: • Patient and caregiver levels of confidence were significantly higher when the patient rated the quality of the relationship higher, the caregiver experienced greater mental health, and the patient had lower levels of cognitive impairment (p=0.001).
Self-care confidence of the patients:Men with HF reported lower levels of confidence than women.
Patients may be risk for some low of lower confidence whey cared for by spouse. In this study souse caregiver had significantly poorer physical health than adult-child caregiver. Spouse caregiver may focus on their own health and are not likely engage in patient self-management.

Study characteristics
The 12 studies reviewed for this paper were published between 2014 and 2019 ( Table 2). The study samples' sample size ranged from 83 to 1192 participants. The samples represented four countries: Italy (n = 5), Lebanon (n = 1), Thailand (1), and the United States (n = 5). Studies from the United States involved White, African American, and Hispanic or Latino. The mean age for participants included in the review ranged, for patients, from 52 to 76 years old and for caregivers from 33 to 64 years old. Both male and female caregivers including spouses/partners, children, and sisters were included in the review, with a dominant percentage of females ranging from 50% to 90%. Six studies (60%) had a cross-sectional design. Of these 12 studies, six studies had an RCT (randomized eligibility after removing duplicates. Then, the full-text articles were retrieved and extracted into a table. The data were extracted based on the following methods: Authors' name, year of publication, country name, design and sample size, purpose, key variables and instruments, and findings. The validity of the studies was assessed using the Systematic Review of Observational Studies (QATSO) checklist Quality Evaluation Tool [16], which was slightly updated to suit the analysis ( Table 1). The QATSO consists of items for assessing external validity, bias, and confounding, and the validity/reliability of outcomes measurement. The total quality score is the total score divided by 100 items multiplied by the total number. Studies were referred to as bad (0-33%), satisfactory (34-66%), and good (67-100%) [16].

Selection of the studies
The electronic search extracted 379 articles ( Figure 1); 51 duplicate articles were removed. The remaining 328 articles and abstracts were screened for eligibility and 253 articles were excluded because of inclusion and exclusion criteria. The remaining full-text articles (75) were further screened for eligibility. Of these, 63 articles were excluded because these Bidwell  • Caregiver strain was not a predictor of caregiver contribution to patient self-care.
• Social support were predictors of caregiver contribution to patient self-care.

Randomized study N=117
Examine (1) association of family functioning and the self-care antecedents of perceived confidence and treatment self-regulation (autonomous and controlled) and (2) whether participants exposed to an FPI had greater confidence scores for diet, medications and treatment self-regulation at baseline, four and eight months compared to participants exposed to patient-family education (PFE) intervention or usual care (UC) • Family support • Perceived confidence: PCS Family function:Family functioning was related to self-care confidence for diet (p=0.02).
• The family partnership intervention group significantly improved confidence (p=0.05) and motivation (medications (p=0.004; diet p=0.012) at four months; patient-family education group and usual care did not change.
Citation: Alnomasy NR (2020) Impact of Caregiver Support on Patient Self-Care Outcomes with Heart Failure: A Systematic Review. J Nurs Pract 3( • Perceived caregiver burden: ZBI-SF. • The more likely mutual care the more confident level (r=.33*).
• Patients and caregivers who perceived better mutuality also reported more confidence in patient self-care, and for patients, those who were more confident also reported better maintenance.

• Patients in the inconsistent and compensato-
ry dyadic archetype of contributions to heart failure self-care had fewest limitations in performing activities of daily living and more of them had hospitalizations for heart failure in the past year, compared with the other archetypes. (p=0.035).
• Expert and collaborative heart failure dyadic archetype: Patients of this archetype also had the worst mental and physical QOL and the greatest limitations to activities of daily living compared with the other archetypes.
Citation: Alnomasy NR (2020) Impact of Caregiver Support on Patient Self-Care Outcomes with Heart Failure: A Systematic Review. J Nurs • Caregiver QOL: Caregiver health related QOL in this sample was generally lower than national norms, and especially low in the "Knowledge Gap" group.
Citation: Alnomasy NR (2020) Impact of Caregiver Support on Patient Self-Care Outcomes with Heart Failure: A Systematic Review. J Nurs • In the caregiver version the strongest correlation was between Shared • Pleasurable Activities and Reciprocity dimensions (r = .814); but the lowest correlation was between Love and Affection and Reciprocity (r = .508).
• Regarding the love and affection dimension, the only actor effect that we found was on self-care confidence; a higher score on the love and affection dimension was associated with higher caregiver self-care confidence (B = 7.369, p < .001).
• • Patients with LHL had significantly lower HF knowledge (p < .001) and their FMs also had significantly lower HF knowledge (p = .001) than those with HHL.
• Patients with LHL also trended to have lower medication adherence (p = .077), and their 24-hr urinary sodium levels were higher by 650.4 mg compared with patients with HHL, although both did not reach significant level (p = .072).
• When both patient and FM had LHL, both the patient and FM HF knowledge was significantly lower (both ps< .001), and the patient medication adherence was significantly lower (p = .026) than the HHL and DHL groups.
• It is possible that when both HF patients and FMs have LHL, they both have less understanding of HF and treatment that cause more difficulty understanding and following medication instructions and which may be one factor leading to patient medication nonadherence.
in this study had poor physical and mental health compared to adult-children caregivers. However, in the same study also found that the level of confidence among patients mediated the high level of medication adherence and diet [24].

Caregiver and patient health related quality of life
Four studies reported the relationship between caregiver contribution to patient self-care and health related quality of life [17,20,25,26]. For example, two studies reported the inverse relationship between caregiver contributions to selfcare and patient physical and mental health related quality of life (p = 0.77, 0.25) respectively [17,26]. However, two studies found the health quality of life related to emotional symptoms was a significant determinant of better self-care from caregivers to their recipients [25,26].

Relationship between caregiver contribution and patient self-management outcomes
The systematic review revealed that caregivers contribute to self-care and patient confidence. Five studies reported a level of confidence for health behavior (exercise, medication adherence, and diet) as a significant predictor for caregiver contributions to patient self-care [17,18,[21][22][23]. One study found that patients who were cared for by their spouses experienced a risk for a low level of confidence compared to adults-children caregivers [24]. This was because the spouse caregivers of age. As a result, this discrepancy in findings suggested that caregivers' experiences may differ across age groups, populations, patient comorbidities, and cultures, indicating the need to understand the perceptions of caregivers about their contribution to HF self-care.

Limitations
These findings demonstrate the limitations of the studies reviewed. First, the majority of the studies used secondary data analysis with cross-sectional design. Most of the studies in this review lack probability sampling, which confines causality and generalizability of the findings to populations with heart failure. Furthermore, a plurality of the studies used self-report measures of caregiver contributions to patient self-care, which could present recall bias and a misestimate of caregiver contributions. Also, these studies used dissimilar definition criteria for caregiver contributions to patient self-care. As a result, more studies are needed to measure caregiver contributions to patient self-care objectively and consistently.
Moreover, this review is susceptible to assorted limitations, which are deep-rooted in the systematic review. This review is subject to selection and reporting bias because this systematic review was confined to English full-text studies, year of publication, and only quantitative studies retrieved from three electronic databases. As a result, non-English reviews, books, theses or dissertations, and studies obtained through a manual search or references list were not included.

Implications for Clinical Practice and Future Research
The findings from this review have various implications for the clinical and research arena. Clinically, we need to educate healthcare providers about the importance of involvement of caregivers in patient self-care activities and all educational sessions. Also, it is imperative to encourage providers and practitioners to conduct interventions that focus on quality of patient-caregiver relationships (e.g., mutuality) to improve patient self-care and caregiver contributions to self-care. Most of the studies included in this analysis used secondary data analysis with cross-sectional designs and various measures of self-care. Therefore, future studies are needed to measure caregiver contributions to patient self-care using objective measures; longer follow-up periods are also essential to assess long-term self-care activities on outcomes, such as readmission, mortality, and quality of life. More longitudinal studies are needed to examine the impact of caregiver contributions to patient self-care on outcomes.

Conclusion
This systematic review sought to incorporate findings of quantitative studies to examine the impact of caregiver contributions to self-care on HF patient outcomes. Findings showed that caregiver strains, gender, and caregiver quality of life were related to greater caregiver contributions to patient self-care. Also, findings showed mixed results concerning the relationship between caregiver roles regarding symp-

Caregiver and patient clinical outcomes
Three studies reported the impact of involvement of caregivers on patient self-care caused a significant reduction in readmission, hospitalization, and mortality of patients (p = 0.02) [17,26,27]. Also, the study by Deek, et al. [17] in their study found patients who involved their family centered-self-care intervention had lower readmission rates and fewer major vascular events (heart attack, cerebral vascular) than control group patients (p = 0.01).

Caregiver patient motivation for medication adherence and diet
Two studies reported the relationship between caregiver contributions to patient self-care and patient motivation for medication adherence and diet [18,19]. For example, the study by Stamp, et al. [18] showed that the motivation for medication and diet was significant among patients. Dunbar, et al. [19] found an inverse relationship between poor family function and high level of Na in diet among patients with heart failure. Patient-caregiver Dyads and self-care Outcomes. Five studies demonstrated the influence of mutuality on self-care outcomes for HF patients [21,[23][24][25]28]. Specifically, among the six studies, Vellone, et al. [21] investigated the three dimensions of self-care including self-maintenance, management and confidence.

Discussion
The purpose of this systematic review was to examine the impact of caregivers' contributions to self-care on patient outcomes. The findings revealed a link between the contribution of caregivers to patient self-care and patient outcomes. These findings are consistent with those of other reviews conducted among patients with other chronic diseases [28][29][30][31].
The findings of this review demonstrate the evolution of self-care science in the contribution of caregivers to HF selfcare. These findings indicate that patients' physical and psychological health determines patients' self-care outcomes [27]. These findings from our review are consistent with findings from other reviews of family care and their impact on the physical and mental health of the patient [32]. As far as the caregiver is concerned, the strain, the quality of life, and social support are linked to the caregiver in the context of self-care [25]. Health care providers should take caregivers' situation into account when they are involved in patient selfcare. The review also highlighted the importance of a dyadic approach to interventions such as educational supplements and archetypes of dyadic caregivers. These findings indicate that the dyadic approach plays a significant role in patient self-care outcomes [26,27].
Overall, although the studies involved in this systematic review showed a significant impact on patient self-care outcomes, there was a discrepancy between the results. There are three causes that explain the discrepancy in findings. First, there are differences in the cultural background of the populations studied. Second, the sample size ranges from 83 to 1192 participants. Third, age ranging from 52 to 76 years toms and the treatment evaluation process. Furthermore, the findings highlighted that self-confidence mediates and moderates the relationship between patient self-care and outcomes. The findings of this systematic review accentuate the significance of the caregiver role, specifically the dyadic approach and mutuality. Given these findings, it is important to merge interventions focusing on a dyadic approach.