Informal caregivers and older adults with chronic heart failure: a commentary

This invited commentary refers to ‘Dyadic relationships between informal caregivers and older adults with chronic heart failure: a systematic review and meta-synthesis’, by S.Q. Yoong et al., https://doi.org/10.1093/eurjcn/zvae093. Over recent decades, informal caregivers—such as partners, family members, friends, or neighbours—have taken on expanded caregiving responsibilities for heart failure (HF) patients. This includes providing more intensive care due to advances in treatments and technological devices for patients with HF. The influence of caregivers on HF patients’ outcomes has been documented in studies, showing increased quality of life, adherence, physical function, and emotional well-being, as well as decreased healthcare utilization.1 However, since 2018, the theory of dyadic illness management has highlighted the interdependent, dyadic team of informal caregivers and patients working together to optimize self-care and health outcomes of both members of the dyad.2 The present evidence on dyadic care in HF clarifies that patients and caregivers share the experience of HF and impact each other’s health. However, research is relatively limited and has mainly focused on quantitative studies.3 In the paper by Yoong et al.,4 the authors conducted an important review by synthesizing the qualitative evidence in both qualitative and mixed-methods studies. Out of 1851 studies identified in six databases, 24 met the inclusion criteria of dyadic relationship outside hospital, being adults ≥ 55 years old with chronic HF and their informal caregivers of any age. In the data synthesis, Sandelowski and Barroso’s two-step framework was used: (i) meta-summaries and inductive thematic analysis and (ii) meta-synthesis using the theory of dyadic illness management. This approach ensured solid methods and a transparent presentation of the analysis and results in tables and supplementary material. The meta-summary, consisting of four themes and nine subthemes, included (i) characteristics of dyad relationships, (ii) how both parts of the dyad care for each other, (ii) chronic HF and dyad relationships, and (iv) knowledge of managing chronic HF. In the second step, the meta-synthesis, the themes were reorganized into dyadic appraisal, dyadic management behaviours (subthemes: dyad typologies and use of technology to facilitate dyadic management), dyadic health) subthemes: health of dyad and impact of chronic HF on mental health), contextual factors affecting dyadic relationships and management behaviour (subthemes: individual factors, interaction between individual and dyadic factors, dyadic factors, and family and social factors that affect dyads’ abilities to cope with and manage chronic HF), and illness management as a dyadic phenomenon. A comprehensive comparison was performed across studies in this review. The knowledge from the content of the subthemes is important to comprehend the dyadic process between informal caregivers and patients with chronic HF, for example the interaction of individual and dyadic factors in managing HF. Moreover, the strength of the meta-synthesis is that all authors independently and critically reviewed the results and discussed the thematic framework until consensus was reached. Another strength of the meta-synthesis, using the theory of dyadic illness management, is that it allows discussion of results in accordance with the central elements of the theory. From a methodological perspective, the authors performed the meta-synthesis by re-organizing themes using the theory of dyadic illness management. This approach may increase the risk of confirmation bias in the process,5 as Braun and Clark6 describe the inductive analysis as ‘a process of coding the data without trying to fit it into a pre-existing coding frame’.6 The novelty of this review and its implications for future actions lie in the evidence that personalized care is needed. Although dyads collaborated on self-care, they coped differently with HF. The mental health of dyads overcoming obstacles improved both their relationship and mental health. Dyadic collaborations were strengthened through congruent perceptions of chronic HF and shared self-care. These findings are mainly supported by a new (2024) systematic review, meta-analysis, and meta-regression7 including 48 studies representing 9171 patient–caregiver dyads. The study demonstrated a significant effect on improved patients’ self-care maintenance (n = 10), self-care management (n = 9), and self-care confidence (n = 10), in addition to patients’ overall self-care. Moreover, they concluded that dyadic care interventions utilizing enabling and motivational strategies can effectively improve disease management and result in better health outcomes for both patients and caregivers. There are a limited number of studies, with heterogeneity in both qualitative/mixed-methods4 and quantitative7 studies. Future studies on the dyadic relationship between informal caregivers and adults with HF may be strengthened by using mixed-methods designs.8 Creswell8 underlines that mixed-methods research designs aim to provide a more comprehensive understanding to enhance the description and understanding of the phenomena. Combining quantitative and qualitative methods in research questions can improve both the understanding of the situation, the meaning, and values.8 It is therefore valuable that Yoong et al.4 included four mixed-methods studies (2018–23) in their review.9–12 Mixed-methods design can be seen aligned with Yoong et al.4 recommendations for future studies performing joint and individual pre-intervention interviews and/or questionnaires to assess chronic HF needs to customize intervention components. Irene Lie (Conceptualization [lead], Data curation [lead], Methodology [lead], Project administration [lead], Resources [lead], Software [lead], Writing—original draft [lead], Writing—review & editing [lead]), Christine Tørris (Methodology [supporting], Writing—original draft [supporting], Writing—review & editing [supporting]), and Stein Ove Danielsen (Methodology [supporting], Writing—original draft [supporting], Writing—review & editing [supporting]). No new data were generated or analysed in support of this research.