Analyzing Heart Failure Care by Actor-Partner Interdependence Model: Comparison
View Latest Version
Please note this is a comparison between Version 2 by Lindsay Dong and Version 1 by Agnieszka Olchowska-Kotala.

Heart failure (HF) is a complex, heterogeneous, increasingly prevalent cardiovascular disorder with high morbidity and mortality. Self-care behaviors are essential for the effective treatment of heart failure, and poor self-care may lead to adverse clinical events in patients with HF, including repeated hospitalizations, poor quality of life, and increased mortality. One of the most common approaches for analyzing data on HF self-care dyads is the Actor–Partner Interdependence Model (APIM). Studies using the APIM approach revealed interrelated patient and caregiver characteristics that influence self-care and explain many complex dyadic behaviors. 

  • heart failure
  • self-care behaviors
  • Actor–Partner Interdependence Model (APIM)
  • caregiver

1. Introduction

Heart failure (HF) is a complex, heterogeneous, increasingly prevalent cardiovascular disorder with high morbidity and mortality [1,2]. Self-care behaviors are essential for the effective treatment of heart failure, and poor self-care may lead to adverse clinical events in patients with HF, including repeated hospitalizations, poor quality of life, and increased mortality [3]. Several factors contribute to adequacy of self-care. Depression [4], sleep disturbances [5], impaired cognition, multiple comorbid conditions [6], and low level of awareness of illness decline all limit self-care [7]. The involvement of the partner, i.e., the informal caregiver who assists the patient with daily self-care, is crucial. Caregiver mental health, strain, and contributions to self-care predict patient clinical events in heart failure [8,9,10]. A caregiver is often someone very close to the patient, such as a spouse or an adult child, who helps the patient with daily functioning and has the potential to influence the trajectory of this chronic disease. Increasingly, researchers are using a dyadic approach to study self-care in HF because they have realized that self-care is a dyadic phenomenon in which patients and their caregivers are an interdependent team working within their life context and that the way they appraise illness as a team influences management of the disorder [11]. HF patients usually have a partner with whom they make day-to-day decisions about symptom management but also about diet and how to deal with worsening symptoms. Dyadic HF research has shown that good relationships with a partner and other people [12,13], knowledge regarding HF of each member of the dyad [14], congruence in symptom assessment, and agreement on who is providing self-care [15] influence HF behavior and may determine a patient’s outcome. Within this dyad, caregivers influence patient self-care and patients influence caregiver’s contribution to self-care. Patients struggle to perform self-care; therefore, the contribution of informal caregivers is fundamental, and a dyadic approach is necessary. Therefore, the dyadic approach to self-care allows a more accurate assessment the factors determining effective self-care in HF by including both the patient and the caregiver [16].
Studies conducted on caregiver participation in self-care in HF and other chronic conditions have shown that taking the caregiver role into account improves patient outcomes. Since HF patients and their caregivers influence each other in self-care, investigators have started to approach self-care studies using dyadic approaches because they allow controlling for the interdependence between patients and caregivers. The theoretical framework for research on dyadic care in HF is a combination of three theories: the Theory of Dyadic Illness Management (TDIM) [11], Situation-Specific Theory of Heart Failure Self-Care (SSTHFSC) [17,18], and the Situation-Specific Theory of Caregiver Contribution to Heart Failure Self-Care (SSTCCHFSC) [19]. The TDIM illustrates that management of disease is a dyadic process and describes the interdependency of the patient and the caregiver. The Situation-Specific Theory of Heart Failure Self-Care illustrates the unique aspects of self-care in patients with HF. The Situation-Specific Theory of Caregiver Contribution to Heart Failure Self-Care describes factors influencing caregiver contribution to HF self-care as well as outcomes of this contribution. Research on dyadic self-care in HF focuses on the joint management of this specific disease by the adult patient and caregiver. Many previous studies of self-care in HF have focused on either the patient [20,21,22,23] or the caregiver [9,24,25]. There are also studies investigating dyads with chronic illnesses, but their focus was more about dyadic appraisal and coping (i.e., spousal involvement and communication between dyadic partners) [26]. A dyadic approach to the care of a patient with HF emphasizes the joint efforts of both members in coping with the disease and the interdependency of the two members of the dyad on effectiveness of HF self-care.
HF is a heterogeneous disease, both in terms of patient health status as well as caregiver experience and tasks. The time required in HF caregiving is highly variable and depends on several factors, including the severity and stability of HF, the presence of comorbidities, impairments to physical and/or cognitive function, the complexity of the treatment regimen, and other situational aspects [27]. During the disease, as the disease advances, the experience of HF becomes characterized by continuous management of progressive and pervasive symptoms (e.g., dyspnea, fatigue, edema, insomnia) that severely compromise the quality of life [18,28]. Additionally, patients with advanced heart failure have an uncertain disease trajectory, and this places a significant burden on heart failure caregivers [29]. Higher levels of comorbid conditions are associated with family caregivers feeling fewer positive feelings about providing care [30], and higher patient with HF functional class (worse symptom severity) is significantly associated with greater caregiver anxiety and general stress [31]. Studies across caregiving contexts suggest that caregivers of patients with more severe illness may need the most support [32,33,34].

2. Theory of Dyadic Illness Management

2.1. The Situation-Specific Theory of Heart Failure Self-Care

The Situation-Specific Theory of HF self-care was created based on real-life experiences of caring for patients with HF. This theory was published in 2008 [17] and then updated in 2016 given recent empirical findings [18]. According to this theory, self-care includes three separate and interrelated processes: maintenance (adherence to recommendations and healthy behaviors, including taking medication, following low-salt diet, and maintaining physical activity), symptom perception (monitoring, detecting, interpreting, and labeling signals from the body), and management (a behavioral response to emerging symptoms). All processes require knowledge and skill, but the most demanding process is management. The SSTHFSC emphasizes that the “naturalistic decision-making” process occurs in real-life situations and dynamic environments with incomplete information, competing needs, time pressure, and high levels of stress due to the potentially life-threatening nature of the event. Patient decisions in self-care in HF are based on both objective data (e.g., weight gain) and subjective data (e.g., fatigue). The SSTHFSC identifies several factors that influence self-care decisions, including person-related factors (e.g., cultural identify, health literacy, socioeconomic status), problem-specific factors (e.g., co-morbidities, including cognitive impairment), and environmental factors (e.g., lack of social support). Given these factors, self-care decisions made by patients sometimes are inconsistent and even wrong.

2.2. The Situation-Specific Theory of Caregiver Contribution to HF Self-Care

The Situation-Specific Theory of Caregiver Contribution to HF Self-Care is based both on the SSTHFSC and the Middle Range Theory of Self-Care of Chronic Illnesses [36] and describe factors at caregiver (e.g., age), patient (e.g., cognition), and dyadic level (e.g., the relationship between the patient and the caregiver) that influence the extent to which caregivers contribute to support HF patient self-care. Similar to the SSTHFSC, caregiver contributions to HF self-care include the dimensions of caregiver contribution to self-care maintenance, symptom monitoring, and perception and self-care management. In addition, the theory includes a mediator, which is the caregiver’s self-efficacy that mediates the relationship between the contributors and caregiver contributions to self-care, and the outcomes, which can be related to patient (e.g., quality of life) and caregiver (e.g., self-esteem).

2.3. The Actor–Partner Interdependence Model

The interdependency between the patient and the caregiver needs to be taken into consideration when analyzing data on dyads. The Actor–Partner Interdependence Model (APIM) is the most current methodology for analyzing data on HF self-care dyads. The APIM is based on the Interdependence Theory [37], which assumes that people influence each other’s experiences by interacting with each other. Researchers emphasize the need to analyze the characteristics of both patient and caregiver since they are in a mutual, long-term interaction, and their reactions to events are dependent on each other. The APIM model for HF dyadic care studies is usually supported by paired regression analyses of the relationship within the couple, i.e., a regression method that does not require independent observations (see Appendix A, Figure A1). The APIM model specifies how the independent variable of an individual may impact their own dependent variable (actor effects) as well as the partner’s dependent variable (partner effects) [38]. There are three types of variables in the APIM model: (1) between-dyads variables, (2) within-dyads variables, and (3) mixed variables. Between-dyads variables are those that vary across dyads but are the same for both members of the dyad (e.g., years spent in a relationship). A within-dyads variable varies across the members of the dyad, but each dyad would have the same total score as all other dyads (e.g., if the study consists only of heterosexual couples, this variable will be gender: male and female). A mixed variable is one that has variation both within and between dyads (e.g., age of members). It is possible to estimate actor and partner effects for mixed variables only. Between- and within-dyads variables can be estimated as main effects. Additionally, various interactions can be tested based on the model [39]. An extended model of the APIM, the Actor–Partner Interdependence Mediation Model (APIMeM), allows to assess mediation in dyadic data [40].
To date, there has been little consistency in how data on HF care dyads have been analyzed. As mentioned above, researchers suggest analyzing dyadic data with the APIM model because it takes interactions between dyadic partners into consideration. In recent studies, APIM has been shown to be effective in identifying the determinants of effective dyadic coping with HF. Many authors emphasize the need to continue using this method of analysis [9,28,29]. Since dyadic analysis is becoming a new approach to studying HF self-care, a systematic review of these studies would help orientate future studies on this topic. The purpose of our article was to review the existing evidence on self-care in HF patient/caregiver dyads based on the APIM approach. Establishing the status of existing research in self-care in HF allowed us to systematize recent findings and point out potential areas worthy of further exploration.

3. Analyzing Heart Failure Care by Actor-Partner Interdependence Model 

3.1. Quality of Life and Emotional Aspects of Dealing with HF

Analysis of the dyadic studies demonstrates that managing HF can be very emotional for both the patient and the caregiver [42]. Both partners in the dyad experience high levels of emotional distress [43]; however, patients seem to experience more depressive symptoms than their spouses [41,51]. Greater emotional distress has been associated with poor quality of life. Two studies focused on the caregiver and provided evidence that quality of life of the patient is better if the care partner has no depressive symptoms or anxiety [42,43]. Sleep also is particularly important for caregivers. It has been empirically demonstrated that the presence of sleep disorders significantly affects the mental health of the caregiver [44]. What positively affects the caregiver’s quality of life is the patient’s adherence to therapy [48]. Better emotional well-being of the dyad also is associated with better relationship quality [41]; however, having a good relationship is not “protective” against anxiety and depression for caregivers [53]. If either member of the dyad senses that they are not in control over HF, the emotional well-being of the dyad may become worse [50]. Incongruent collaboration of partners in HF management also affects the emotional well-being of the dyad [51]. Studies on emotional state and quality of life in dyadic caring in HF conclude that interventions are needed to alleviate depressive symptoms in both dyadic partners [42,43]. It appears that nurses can increase dyadic caring by providing the dyadic partners with social support [49].

3.2. Dyadic HF Self-Care Confidence

Self-care confidence, or self-care self-efficacy, is the extent to which one feels able to perform regular self-care (patient) and contribute to patient self-care (caregiver) despite difficulties [47]. Research on dyadic self-care has shown that poor self-efficacy affects the ability of the patient and caregiver to engage. Patients with greater self-care confidence are more engaged in self-care behaviors [45]. Studies on dyadic care in HF also show that self-care confidence is not typically equal between the members of the dyad, with caregivers demonstrating greater self-care confidence than patients [16]. However, there has also been heterogeneity in confidence across the dyads, suggesting self-care confidence is adequate in some dyads but is insufficient to support self-care in others [16].

3.3. Maintenance and Management

Data from APIM studies show low levels of daily HF maintenance and management in both partners in HF self-care [46,47]. Not surprisingly, mild cognitive impairment in the patient reduces self-care [46]. Better self-care maintenance is usually achieved in dyads where the caregiver is a woman. Indeed, there is evidence that female gender of the caregiver was a significant predictor of better patient self-care maintenance [46]. This most likely arises from a traditional role of women, who mainly care about family health in many societies. There also is evidence that a caregiver is more likely to contribute to HF self-care management if the caregiver is not the patient’s spouse [46]. Involvement in self-care also is associated with the emotional state of the caregiver, the quality of the relationship between the HF patient and the caregiver [47,52,54], and the caregiver’s knowledge of self-care [47]. Patients are more adherent to recommendations when they have a decreased physical quality of life [48]. It seems, therefore, that a greater problem in engaging patients in self-care may arise in patients with a relatively high physical quality of life. Furthermore, an agreement between dyad partners who are responsible for performing self-care tasks may also be an important issue for self-care. Dyads that were congruent not only reported fewer psychosocial problems [55], but also in these dyads, the caregivers were more engaged in caregiving [47].

4. Conclusions

(1) a family-oriented approach can improve the functioning of a patient with heart failure condition, and (2) social support from caregivers significantly enhances patients’ adaptation to illness. Our work’s emerging view is that patient–caregiver interconnections are still enigmatic, and more studies are needed to provide a more complete and coherent picture of self-care in HF. Thus, further research should be carried out to clarify this concept and identify the most critical factors for effective dyadic functioning in HF.
 

References

  1. Friedman, M.M.; Quinn, J.R. Heart Failure Patients’ Time, Symptoms, and Actions before a Hospital Admission. J. Cardiovasc. Nurs. 2008, 23, 506–512. https://doi.org/10.1097/01.JCN.0000338928.51093.40.
  2. Hauptman, P.J.; Masoudi, F.A.; Weintraub, W.S.; Pina, I.; Jones, P.G.; Spertus, J.A. Variability in the Clinical Status of Patientswith Advanced Heart Failure. J. Card. Fail. 2004, 10, 397–402. https://doi.org/10.1016/J.CARDFAIL.2003.12.008.
  3. Lee, C.S.; Moser, D.K.; Lennie, T.A.; Riegel, B. Event-Free Survival in Adults with Heart Failure Who Engage in Self-Care Management.Hear. Lung J. Acute Crit. Care 2011, 40, 12–20. https://doi.org/10.1016/j.hrtlng.2009.12.003.
  4. Holzapfel, N.; Löwe, B.; Wild, B.; Schellberg, D.; Zugck, C.; Remppis, A.; Katus, H.A.; Haass, M.; Rauch, B.; Jünger, J.; Herzog,W.; Müller-Tasch, T. Self-Care and Depression in Patients with Chronic Heart Failure. Heart Lung 2009, 38, 392–397.https://doi.org/10.1016/J.HRTLNG.2008.11.001.
  5. Riegel, B.; Moelter, S.T.; Ratcliffe, S.J.; Pressler, S.J.; De Geest, S.; Potashnik, S.; Fleck, D.; Sha, D.; Sayers, S.L.; Weintraub, W.S.;Weaver, T.E.; Goldberg, L.R. Excessive Daytime Sleepiness Is Associated with Poor Medication Adherence in Adults with HeartFailure. J. Card. Fail. 2011, 17, 340–348. https://doi.org/10.1016/J.CARDFAIL.2010.11.002.
  6. Dickson, V.V.; Buck, H.; Riegel, B. A Qualitative Meta-Analysis of Heart Failure Self-Care Practices among Individuals withMultiple Comorbid Conditions. J. Card. Fail. 2011, 17, 413–419. https://doi.org/10.1016/J.CARDFAIL.2010.11.011.
  7. Jurgens, C.Y. Somatic Awareness, Uncertainty, and Delay in Care-Seeking in Acute Heart Failure. Res. Nurs. Health 2006, 29,74–86. https://doi.org/10.1002/NUR.20118.
  8. Bidwell, J.T.; Vellone, E.; Lyons, K.S.; D’Agostino, F.; Riegel, B.; Paturzo, M.; Hiatt, S.O.; Alvaro, R.; Lee, C.S. Caregiver Determinantsof Patient Clinical Event Risk in Heart Failure. Eur. J. Cardiovasc. Nurs. 2017, 16, 707–714. https://doi.org/10.1177/1474515117711305.
  1. Buck, H.G.; Harkness, K.; Wion, R.; Carroll, S.L.; Cosman, T.; Kaasalainen, S.; Kryworuchko, J.; McGillion, M.; O’Keefe-Mccarthy, S.; Sherifali, D.; Strachan, P.H.; Arthur, H.M. Caregivers’ Contributions to Heart Failure Self-Care: A Systematic Review. Eur. J. Cardiovasc. Nurs. 2015, 14, 79–89. https://doi.org/10.1177/1474515113518434. Int. J. Environ. Res. Public Health 2022, 19, 1919 16 of 18
  2. Nicholas Dionne-Odom, J.; Hooker, S.A.; Bekelman, D.; Ejem, D.; McGhan, G.; Kitko, L.; Strömberg, A.; Wells, R.; Astin, M.; Metin, Z.G.; Mancarella, G.; Pamboukian, S.V.; Evangelista, L.; Buck, H.G.; Bakitas, M.A. Family Caregiving for Persons with Heart Failure at the Intersection of Heart Failure and Palliative Care: A State-of-the-Science Review. Heart Fail. Rev. 2017, 22, 543–557. https://doi.org/10.1007/S10741-017-9597-4.
  3. Lyons, K.S.; Lee, C.S. The Theory of Dyadic Illness Management. J. Fam. Nurs. 2018, 24, 8–28. https://doi.org/10.1177/1074840717745669.
  4. Dunbar, S.B.; Clark, P.C.; Quinn, C.; Gary, R.A.; Kaslow, N.J. Family Influences on Heart Failure Self-Care and Outcomes. J. Cardiovasc. Nurs. 2008, 23, 258–265. https://doi.org/10.1097/01.JCN.0000305093.20012.B8.
  5. Graven, L.J.; Grant, J.S. Social Support and Self-Care Behaviors in Individuals with Heart Failure: An Integrative Review. Int. J. Nurs. Stud. 2014, 51, 320–333. https://doi.org/10.1016/J.IJNURSTU.2013.06.013.
  6. Bidwell, J.T.; Higgins, M.K.; Reilly, C.M.; Clark, P.C.; Dunbar, S.B. Shared Heart Failure Knowledge and Self-Care Outcomes in Patient-Caregiver Dyads. Hear. Lung J. Acute Crit. Care 2018, 47, 32–39. https://doi.org/10.1016/j.hrtlng.2017.11.001.
  7. Buck, H.G.; Hupcey, J.; Mogle, J.; Rayens, M.K. Caregivers’ Heart Failure Knowledge Is Necessary but Not Sufficient to Ensure Engagement With Patients in Self-Care Maintenance. J. Hosp. Palliat. Nurs. 2017, 19, 170–176. https://doi.org/10.1097/NJH.0000000000000326.
  8. Lyons, K.S.; Vellone, E.; Lee, C.S.; Cocchieri, A.; Bidwell, J.T.; D’Agostino, F.; Hiatt, S.O.; Alvaro, R.; Vela, R.J.; Riegel, B. A Dyadic Approach to Managing Heart Failure with Confidence. J. Cardiovasc. Nurs. 2015, 30, S64–S71. https://doi.org/10.1097/JCN.0000000000000234.
  1. Riegel, B.; Dickson, V.V. A Situation-Specific Theory of Heart Failure Self-Care. J. Cardiovasc. Nurs. 2008, 23, 190–196. https://doi.org/10.1097/01.JCN.0000305091.35259.85.
  2. Riegel, B.; Dickson, V.V.; Faulkner, K.M. The Situation-Specific Theory of Heart Failure Self-Care Revised and Updated. J. Cardiovasc. Nurs. 2016, 31, 226–235. https://doi.org/10.1097/JCN.0000000000000244.
  3. Vellone, E.; Riegel, B.; Alvaro, R. A Situation-Specific Theory of Caregiver Contributions to Heart Failure Self-Care. J. Cardiovasc. Nurs. 2019, 34, 166–173. https://doi.org/10.1097/JCN.0000000000000549.
  4. Ciere, Y.; Cartwright, M.; Newman, S.P. A Systematic Review of the Mediating Role of Knowledge, Self-Efficacy and Self-Care Behaviour in Telehealth Patients with Heart Failure. J. Telemed. Telecare 2012, 18, 384–391. https://doi.org/10.1258/jtt.2012.111009.
  5. Sousa, J.P.; Oliveira, C.; Pais-Vieira, M. Symptom Perception Management Education Improves Self-Care in Patients with Heart Failure. Work 2021, 69, 465–473. https://doi.org/10.3233/WOR-213491.
  6. Karimi, M.; Clark, A.M. How Do Patients’ Values Influence Heart Failure Self-Care Decision-Making?: A Mixed-Methods Systematic Review. Int. J. Nurs. Stud. 2016, 59, 89–104. https://doi.org/10.1016/j.ijnurstu.2016.03.010.
  7. Spaling, M.A.; Currie, K.; Strachan, P.H.; Harkness, K.; Clark, A.M. Improving Support for Heart Failure Patients: A Systematic Review to Understand Patients’ Perspectives on Self-Care. J. Adv. Nurs. 2015, 71, 2478–2489. https://doi.org/10.1111/jan.12712.
  8. Grant, J.S.; Graven, L.J. Problems Experienced by Informal Caregivers of Individuals with Heart Failure: An Integrative Review. Int. J. Nurs. Stud. 2018, 80, 41–66. https://doi.org/10.1016/j.ijnurstu.2017.12.016.
  9. Kim, E.Y.; Oh, S.; Son, Y.J. Caring Experiences of Family Caregivers of Patients with Heart Failure: A Meta-Ethnographic Review of the Past 10 Years. Eur. J. Cardiovasc. Nurs. 2020, 19, 473–485. https://doi.org/10.1177/1474515120915040.
  10. Berg, C.A.; Upchurch, R. A Developmental-Contextual Model of Couples Coping with Chronic Illness across the Adult Life Span. Psychol. Bull. 2007, 133, 920–954. https://doi.org/10.1037/0033-2909.133.6.920.
  11. Kitko, L.; McIlvennan, C.K.; Bidwell, J.T.; Dionne-Odom, J.N.; Dunlay, S.M.; Lewis, L.M.; Meadows, G.; Sattler, E.L.P.; Schulz, R.; Strömberg, A. Family Caregiving for Individuals with Heart Failure: A Scientific Statement from the American Heart Association. Circulation 2020, 141, e864–e878. https://doi.org/10.1161/CIR.0000000000000768.
  12. Lum, H.D.; Carey, E.P.; Fairclough, D.; Plomondon, M.E.; Hutt, E.; Rumsfeld, J.S.; Bekelman, D.B. Burdensome Physical and Depressive Symptoms Predict Heart Failure–Specific Health Status Over One Year. J. Pain Symptom Manage. 2016, 51, 963–970. https://doi.org/10.1016/J.JPAINSYMMAN.2015.12.328.
  13. Strömberg, A.; Luttika, M.L. Burden of Caring: Risks and Consequences Imposed on Caregivers of Those Living and Dying with Advanced Heart Failure. Current Opinion in Supportive and Palliative Care. 2015, pp 26–30. https://doi.org/10.1097/SPC.0000000000000111.
  1. Hwang, B.; Fleischmann, K.E.; Howie-Esquivel, J.; Stotts, N.A.; Dracup, K. Caregiving for Patients With Heart Failure: Impact on Patients’ Families. Am. J. Crit. Care 2011, 20, 431–442. https://doi.org/10.4037/AJCC2011472.
  2. Bidwell, J.T.; Hostinar, C.E.; Higgins, M.K.; Abshire, M.A.; Cothran, F.; Butts, B.; Miller, A.H.; Corwin, E.; Dunbar, S.B. Caregiver Subjective and Physiological Markers of Stress and Patient Heart Failure Severity in Family Care Dyads. Psychoneuroendocrinology 2021, 133, 105399. https://doi.org/10.1016/J.PSYNEUEN.2021.105399.
  1. Schulz, R.; Beach, S.R.; Czaja, S.J.; Martire, L.M.; Monin, J.K. Family Caregiving for Older Adults. Annu. Rev. Psychol. 2020, 4, 635-659. https://doi.org/10.1146/annurev-psych-010419-050754.
  2. Timonet Andreu, E.M.; Morales Asencio, J.M.; Canca Sanchez, J.C.; Sepulveda Sanchez, J.; Mesa Rico, R.; Rivas Ruiz, F. Effects and Consequences of Caring for Persons with Heart Failure: (ECCUPENIC Study) a Nested Case-Control Study. J. Adv. Nurs. 2015, 71, 2987–2997. https://doi.org/10.1111/jan.12732.
  3. Pressler, S.J.; Gradus-Pizlo, I.; Chubinski, S.D.; Smith, G.; Wheeler, S.; Sloan, R.; Jung, M. Family Caregivers of Patients with Heart Failure: A Longitudinal Study. J. Cardiovasc. Nurs. 2013, 28, 417–428. https://doi.org/10.1097/JCN.0b013e3182563877.
  4. Buck, H.G.; Hupcey, J.; Juárez-Vela, R.; Vellone, E.; Riegel, B. Heart Failure Care Dyadic Typology: Initial Conceptualization, Advances in Thinking, and Future Directions of a Clinically Relevant Classification System. J. Cardiovasc. Nurs. 2019, 34, 159– 165. https://doi.org/10.1097/JCN.0000000000000548.
  5. Riegel, B.; Jaarsma, T.; Strömberg, A. A Middle-Range Theory of Self-Care of Chronic Illness. Adv. Nurs. Sci. 2012, 35, 194–204. https://doi.org/10.1097/ANS.0B013E318261B1BA.
  6. Rusbult, C.E.; Van Lange, P.A.M. Interdependence, Interaction, and Relationships. Annu. Rev. Psychol. 2003, 54, 351–375. https://doi.org/10.1146/annurev.psych.54.101601.145059.
  7. Campbell, L.; Kashy, D.A. Estimating Actor, Partner, and Interaction Effects for Dyadic Data Using PROC MIXED and HLM: A User-Friendly Guide. Pers. Relatsh. 2002, 9, 327–342. https://doi.org/10.1111/1475-6811.00023.
  8. Rayens, M.K.; Svavarsdottir, E.K. Focus on Research Methods: A New Methodological Approach in Nursing Research: An Actor, Partner, and Interaction Effect Model for Family Outcomes. Res. Nurs. Heal. 2003, 26, 409–419. https://doi.org/10.1002/nur.10100.
  1. Ledermann, T.; Macho, S.; Kenny, D.A. Assessing Mediation in Dyadic Data Using the Actor-Partner Interdependence Model. Struct. Equ. Model. A Multidiscip. J. 2011, 18, 595–612. https://doi.org/10.1080/10705511.2011.607099.
  2. Lyons, K.S.; Sadowski, T.; Lee, C.S. The Role of Concealment and Relationship Quality on Patient Hospitalizations, Care Strain and Depressive Symptoms in Heart Failure Dyads. Eur. J. Cardiovasc. Nurs. 2020, 19, 118–124. https://doi.org/10.1177/1474515119863791.
  1. Thomson, P.; Howie, K.; Leslie, S.J.; Angus, N.J.; Andreis, F.; Thomson, R.; Mohan, A.R.M.; Mondoa, C.; Chung, M.L. Evaluating Emotional Distress and Healthrelated Quality of Life in Patients with Heart Failure and Their Family Caregivers: Testing Dyadic Dynamics Using the Actor-Partner Interdependence Model. PLoS One 2020, 15, e0227129. https://doi.org/10.1371/journal.pone.0227129.
  1. Chung, M.L.; Moser, D.K.; Lennie, T.A.; Rayens, M.K. The Effects of Depressive Symptoms and Anxiety on Quality of Life in Patients with Heart Failure and Their Spouses: Testing Dyadic Dynamics Using Actor-Partner Interdependence Model. J. Psychosom. Res. 2009, 67, 29–35. https://doi.org/10.1016/j.jpsychores.2009.01.009.
  1. Al-Rawashdeh, S.Y.; Lennie, T.A.; Chung, M.L. The Association of Sleep Disturbances with Quality of Life in Heart Failure Patient-Caregiver Dyads. West. J. Nurs. Res. 2017, 39, 492–506. https://doi.org/10.1177/0193945916672647.
  2. Hooker, S.A.; Schmiege, S.J.; Trivedi, R.B.; Amoyal, N.R.; Bekelman, D.B. Mutuality and Heart Failure Self-Care in Patients and Their Informal Caregivers. Eur. J. Cardiovasc. Nurs. 2018, 17, 102–113. https://doi.org/10.1177/1474515117730184.
  1. Bidwell, J.T.; Vellone, E.; Lyons, K.S.; D’Agostino, F.; Riegel, B.; Juárez-Vela, R.; Hiatt, S.O.; Alvaro, R.; Lee, C.S. Determinants of Heart Failure Self-Care Maintenance and Management in Patients and Caregivers: A Dyadic Analysis. Res. Nurs. Heal. 2015, 38, 392–402. https://doi.org/10.1002/nur.21675.
  2. Buck, H.G.; Mogle, J.; Riegel, B.; McMillan, S.; Bakitas, M. Exploring the Relationship of Patient and Informal Caregiver Characteristics with Heart Failure Self-Care Using the Actor-Partner Interdependence Model: Implications for Outpatient Palliative Care. J. Palliat. Med. 2015, 18, 1026–1032. https://doi.org/10.1089/jpm.2015.0086.
  3. Vellone, E.; Chung, M.L.; Cocchieri, A.; Rocco, G.; Alvaro, R.; Riegel, B. Effects of Self-Care on Quality of Life in Adults with Heart Failure and Their Spousal Caregivers: Testing Dyadic Dynamics Using the Actor-Partner Interdependence Model. J. Fam. Nurs. 2014, 20, 120–141. https://doi.org/10.1177/1074840713510205.
  4. Shamali, M.; Konradsen, H.; Stas, L.; Østergaard, B. Dyadic Effects of Perceived Social Support on Family Health and Family Functioning in Patients with Heart Failure and Their Nearest Relatives: Using the Actor–Partner Interdependence Mediation Model. PLoS One 2019, 14, e0217970. https://doi.org/10.1371/journal.pone.0217970.
  5. Strömberg, A.; Liljeroos, M.; Ågren, S.; Årestedt, K.; Chung, M.L. Associations Among Perceived Control, Depressive Symptoms, and Well-Being in Patients With Heart Failure and Their Spouses: A Dyadic Approach. J. Cardiovasc. Nurs. 2021, 36, 198– 205. https://doi.org/10.1097/JCN.0000000000000682.
  6. Lyons, K.S.; Hiatt, S.O.; Gelow, J.M.; Auld, J.; Mudd, J.O.; Chien, C.V.; Lee, C.S. Depressive Symptoms in Couples Living with Heart Failure: The Role of Congruent Engagement in Heart Failure Management. Aging Ment. Heal. 2018, 22, 1585–1591. https://doi.org/10.1080/13607863.2017.1381945.
  7. Vellone, E.; Chung, M.L.; Alvaro, R.; Paturzo, M.; Dellafiore, F. The Influence of Mutuality on Self-Care in Heart Failure Patients and Caregivers: A Dyadic Analysis. J. Fam. Nurs. 2018, 24, 563–584. https://doi.org/10.1177/1074840718809484.
  8. Dellafiore, F.; Chung, M.L.; Alvaro, R.; Durante, A.; Colaceci, S.; Vellone, E.; Pucciarelli, G. The Association between Mutuality, Anxiety, and Depression in Heart Failure Patient-Caregiver Dyads. J. Cardiovasc. Nurs. 2019, 34, 465–473. https://doi.org/10.1097/JCN.0000000000000599.
  1. Bugajski, A.; Buck, H.; Zeffiro, V.; Morgan, H.; Szalacha, L.; Alvaro, R.; Vellone, E. The Influence of Dyadic Congruence and Satisfaction with Dyadic Type on Patient Self-Care in Heart Failure. Eur. J. Cardiovasc. Nurs. 2020. https://doi.org/10.1177/1474515120960002.
  1. Kitko, L.A.; Hupcey, J.E.; Pinto, C.; Palese, M. Patient and Caregiver Incongruence in Advanced Heart Failure. Clin. Nurs. Res. 2015, 24, 388–400. https://doi.org/10.1177/1054773814523777.
  2. Bidwell, J.T.; Lyons, K.S.; Lee, C.S. Caregiver Well-Being and Patient Outcomes in Heart Failure a Meta-Analysis. J. Cardiovasc. Nurs. 2017, 32, 372–382. https://doi.org/10.1097/JCN.0000000000000350.
  3. Cameron, J.; Thompson, D.R.; Szer, D.; Greig, J.; Ski, C.F. Dyadic Incongruence in Chronic Heart Failure: Implications for Patient and Carer Psychological Health and Self-Care. J. Clin. Nurs. 2017, 26, 4804–4812. https://doi.org/10.1111/jocn.13836. Int. J. Environ. Res. Public Health 2022, 19, 1919 18 of 18
  4. Retrum, J.H.; Nowels, C.T.; Bekelman, D.B. Patient and Caregiver Congruence: The Importance of Dyads in Heart Failure Care. J. Cardiovasc. Nurs. 2013, 28, 129–136. https://doi.org/10.1097/JCN.0b013e3182435f27.
  5. Lee, C.S.; Mudd, J.O.; Auld, J.; Gelow, J.M.; Hiatt, S.O.; Chien, C.V.; Bidwell, J.T.; Lyons, K.S. Patterns, Relevance and Predictors of Heart Failure Dyadic Symptom Appraisal. Eur. J. Cardiovasc. Nurs. 2017, 16, 595–604. https://doi.org/10.1177/1474515117700760.
  1. Thompson, S.C.; Kyle, D.J. The Role of Perceived Control in Coping with the Losses Associated with Chronic Illness. In Loss and trauma: General and close relationship perspectives; Harvey, J.H., Miller, J.H., Eds.; Brunner-Routledge: Abingdon, UK, 2000; pp. 131–145.
  2. Olchowska-Kotala, A. Illness Representations in Individuals with Rheumatoid Arthritis and the Willingness to Undergo Acupuncture Treatment. Eur. J. Integr. Med. 2013, 5, 347–351. https://doi.org/10.1016/J.EUJIM.2013.03.008.
  3. Lowe, R.; Norman, P. Information Processing in Illness Representation: Implications from an Associative-Learning Framework. Health Psychol. 2017, 36, 280–290. https://doi.org/10.1037/HEA0000457.
  4. Rosenstock, I.M. The Health Belief Model and Personal Health Behavior. Health Educ. Monogr. 1974, 2, 354–386. https://doi.org/10.1177/109019817400200405.
  1. Jones, C.L.; Jensen, J.D.; Scherr, C.L.; Brown, N.R.; Christy, K.; Weaver, J. The Health Belief Model as an Explanatory Framework in Communication Research: Exploring Parallel, Serial, and Moderated Mediation. Health Commun. 2015, 30, 566. https://doi.org/10.1080/10410236.2013.873363.
  2. Hooker, S.A.; Grigsby, M.E.; Riegel, B.; Bekelman, D.B. The Impact of Relationship Quality on Health-Related Outcomes in Heart Failure Patients and Informal Family Caregivers: An Integrative Review. J. Cardiovasc. Nurs. 2015, 30, S52–S63. https://doi.org/10.1097/JCN.0000000000000270.
  3. Chung, M.L.; Lennie, T.A.; Mudd-Martin, G.; Dunbar, S.B.; Pressler, S.J.; Moser, D.K. Depressive Symptoms in Patients with Heart Failure Negatively Affect Family Caregiver Outcomes and Quality of Life. Eur. J. Cardiovasc. Nurs. 2016, 15, 30–38. https://doi.org/10.1177/1474515114535329.
  4. Timonet-Andreu, E.; Morales-Asencio, J.M.; Alcalá Gutierrez, P.; Cruzado Alvarez, C.; López-Moyano, G.; Mora Banderas, A.; López-Leiva, I.; Canca-Sanchez, J.C. Health-Related Quality of Life and Use of Hospital Services by Patients with Heart Failure and Their Family Caregivers: A Multicenter Case-Control Study. J. Nurs. Scholarsh. 2020, 52, 217–228. https://doi.org/10.1111/JNU.12545.
  1. Jorge-Samitier, P.; Durante, A.; Gea-Caballero, V.; Antón-Solanas, I.; Fernández-Rodrigo, M.T.; Juárez-Vela, R. Sleep Quality in Patients with Heart Failure in the Spanish Population: A Cross-Sectional Study. Int. J. Environ. Res. Public Health 2020, 17, 7772, 1–12. https://doi.org/10.3390/ijerph17217772.
  2. Aune, D.; Schlesinger, S.; Leitzmann, M.F.; Tonstad, S.; Norat, T.; Riboli, E.; Vatten, L.J. Physical Activity and the Risk of Heart Failure: A Systematic Review and Dose-Response Meta-Analysis of Prospective Studies. Eur. J. Epidemiol. 2021, 36, 367–381. https://doi.org/10.1007/S10654-020-00693-6.
  3. Lindgren, M.; Börjesson, M. The Importance of Physical Activity and Cardiorespiratory Fitness for Patients with Heart Failure. Diabetes Res. Clin. Pract. 2021, 176, 108833. https://doi.org/10.1016/J.DIABRES.2021.108833.
  4. Pinchera, B.; Delloiacono, D.; Lawless, C.A. Best Practices for Patient Self-Management: Implications for Nurse Educators, Patient Educators, and Program Developers. J. Contin. Educ. Nurs. 2018, 49, 432–440. https://doi.org/10.3928/00220124-20180813-09.
  5. Huntsinger, M.E.; Rabara, R.; Peralta, I.; Doshi, R.N. Current Technology to Maximize Cardiac Resynchronization Therapy Benefit for Patients With Symptomatic Heart Failure. AACN Adv. Crit. Care 2015, 26, 329–340. https://doi.org/10.1097/NCI.0000000000000113.

1. Introduction

Heart failure (HF) is a complex, heterogeneous, increasingly prevalent cardiovascular disorder with high morbidity and mortality [1][2]. Self-care behaviors are essential for the effective treatment of heart failure, and poor self-care may lead to adverse clinical events in patients with HF, including repeated hospitalizations, poor quality of life, and increased mortality [3]. Several factors contribute to adequacy of self-care. Depression [4], sleep disturbances [5], impaired cognition, multiple comorbid conditions [6], and low level of awareness of illness decline all limit self-care [7]. The involvement of the partner, i.e., the informal caregiver who assists the patient with daily self-care, is crucial. Caregiver mental health, strain, and contributions to self-care predict patient clinical events in heart failure [8][9][10]. A caregiver is often someone very close to the patient, such as a spouse or an adult child, who helps the patient with daily functioning and has the potential to influence the trajectory of this chronic disease. Increasingly, researchers are using a dyadic approach to study self-care in HF because they have realized that self-care is a dyadic phenomenon in which patients and their caregivers are an interdependent team working within their life context and that the way they appraise illness as a team influences management of the disorder [11]. HF patients usually have a partner with whom they make day-to-day decisions about symptom management but also about diet and how to deal with worsening symptoms. Dyadic HF research has shown that good relationships with a partner and other people [12][13], knowledge regarding HF of each member of the dyad [14], congruence in symptom assessment, and agreement on who is providing self-care [15] influence HF behavior and may determine a patient’s outcome. Within this dyad, caregivers influence patient self-care and patients influence caregiver’s contribution to self-care. Patients struggle to perform self-care; therefore, the contribution of informal caregivers is fundamental, and a dyadic approach is necessary. Therefore, the dyadic approach to self-care allows a more accurate assessment the factors determining effective self-care in HF by including both the patient and the caregiver [16].
Studies conducted on caregiver participation in self-care in HF and other chronic conditions have shown that taking the caregiver role into account improves patient outcomes. Since HF patients and their caregivers influence each other in self-care, investigators have started to approach self-care studies using dyadic approaches because they allow controlling for the interdependence between patients and caregivers. The theoretical framework for research on dyadic care in HF is a combination of three theories: the Theory of Dyadic Illness Management (TDIM) [11], Situation-Specific Theory of Heart Failure Self-Care (SSTHFSC) [17][18], and the Situation-Specific Theory of Caregiver Contribution to Heart Failure Self-Care (SSTCCHFSC) [19]. The TDIM illustrates that management of disease is a dyadic process and describes the interdependency of the patient and the caregiver. The Situation-Specific Theory of Heart Failure Self-Care illustrates the unique aspects of self-care in patients with HF. The Situation-Specific Theory of Caregiver Contribution to Heart Failure Self-Care describes factors influencing caregiver contribution to HF self-care as well as outcomes of this contribution. Research on dyadic self-care in HF focuses on the joint management of this specific disease by the adult patient and caregiver. Many previous studies of self-care in HF have focused on either the patient [20][21][22][23] or the caregiver [9][24][25]. There are also studies investigating dyads with chronic illnesses, but their focus was more about dyadic appraisal and coping (i.e., spousal involvement and communication between dyadic partners) [26]. A dyadic approach to the care of a patient with HF emphasizes the joint efforts of both members in coping with the disease and the interdependency of the two members of the dyad on effectiveness of HF self-care.
HF is a heterogeneous disease, both in terms of patient health status as well as caregiver experience and tasks. The time required in HF caregiving is highly variable and depends on several factors, including the severity and stability of HF, the presence of comorbidities, impairments to physical and/or cognitive function, the complexity of the treatment regimen, and other situational aspects [27]. During the disease, as the disease advances, the experience of HF becomes characterized by continuous management of progressive and pervasive symptoms (e.g., dyspnea, fatigue, edema, insomnia) that severely compromise the quality of life [18][28]. Additionally, patients with advanced heart failure have an uncertain disease trajectory, and this places a significant burden on heart failure caregivers [29]. Higher levels of comorbid conditions are associated with family caregivers feeling fewer positive feelings about providing care [30], and higher patient with HF functional class (worse symptom severity) is significantly associated with greater caregiver anxiety and general stress [31]. Studies across caregiving contexts suggest that caregivers of patients with more severe illness may need the most support [32][33][34].

2. Theory of Dyadic Illness Management

2.1. The Situation-Specific Theory of Heart Failure Self-Care

The Situation-Specific Theory of HF self-care was created based on real-life experiences of caring for patients with HF. This theory was published in 2008 [17] and then updated in 2016 given recent empirical findings [18]. According to this theory, self-care includes three separate and interrelated processes: maintenance (adherence to recommendations and healthy behaviors, including taking medication, following low-salt diet, and maintaining physical activity), symptom perception (monitoring, detecting, interpreting, and labeling signals from the body), and management (a behavioral response to emerging symptoms). All processes require knowledge and skill, but the most demanding process is management. The SSTHFSC emphasizes that the “naturalistic decision-making” process occurs in real-life situations and dynamic environments with incomplete information, competing needs, time pressure, and high levels of stress due to the potentially life-threatening nature of the event. Patient decisions in self-care in HF are based on both objective data (e.g., weight gain) and subjective data (e.g., fatigue). The SSTHFSC identifies several factors that influence self-care decisions, including person-related factors (e.g., cultural identify, health literacy, socioeconomic status), problem-specific factors (e.g., co-morbidities, including cognitive impairment), and environmental factors (e.g., lack of social support). Given these factors, self-care decisions made by patients sometimes are inconsistent and even wrong.

2.2. The Situation-Specific Theory of Caregiver Contribution to HF Self-Care

The Situation-Specific Theory of Caregiver Contribution to HF Self-Care is based both on the SSTHFSC and the Middle Range Theory of Self-Care of Chronic Illnesses [35] and describe factors at caregiver (e.g., age), patient (e.g., cognition), and dyadic level (e.g., the relationship between the patient and the caregiver) that influence the extent to which caregivers contribute to support HF patient self-care. Similar to the SSTHFSC, caregiver contributions to HF self-care include the dimensions of caregiver contribution to self-care maintenance, symptom monitoring, and perception and self-care management. In addition, the theory includes a mediator, which is the caregiver’s self-efficacy that mediates the relationship between the contributors and caregiver contributions to self-care, and the outcomes, which can be related to patient (e.g., quality of life) and caregiver (e.g., self-esteem).

2.3. The Actor–Partner Interdependence Model

The interdependency between the patient and the caregiver needs to be taken into consideration when analyzing data on dyads. The Actor–Partner Interdependence Model (APIM) is the most current methodology for analyzing data on HF self-care dyads. The APIM is based on the Interdependence Theory [36], which assumes that people influence each other’s experiences by interacting with each other. Researchers emphasize the need to analyze the characteristics of both patient and caregiver since they are in a mutual, long-term interaction, and their reactions to events are dependent on each other. The APIM model for HF dyadic care studies is usually supported by paired regression analyses of the relationship within the couple, i.e., a regression method that does not require independent observations. The APIM model specifies how the independent variable of an individual may impact their own dependent variable (actor effects) as well as the partner’s dependent variable (partner effects) [37]. There are three types of variables in the APIM model: (1) between-dyads variables, (2) within-dyads variables, and (3) mixed variables. Between-dyads variables are those that vary across dyads but are the same for both members of the dyad (e.g., years spent in a relationship). A within-dyads variable varies across the members of the dyad, but each dyad would have the same total score as all other dyads (e.g., if the study consists only of heterosexual couples, this variable will be gender: male and female). A mixed variable is one that has variation both within and between dyads (e.g., age of members). It is possible to estimate actor and partner effects for mixed variables only. Between- and within-dyads variables can be estimated as main effects. Additionally, various interactions can be tested based on the model [38]. An extended model of the APIM, the Actor–Partner Interdependence Mediation Model (APIMeM), allows to assess mediation in dyadic data [39]. To date, there has been little consistency in how data on HF care dyads have been analyzed. As mentioned above, researchers suggest analyzing dyadic data with the APIM model because it takes interactions between dyadic partners into consideration. In recent studies, APIM has been shown to be effective in identifying the determinants of effective dyadic coping with HF. Many scholars emphasize the need to continue using this method of analysis [9][28][29]. Since dyadic analysis is becoming a new approach to studying HF self-care, a systematic review of these studies would help orientate future studies on this topic.

3. Analyzing Heart Failure Care by Actor-Partner Interdependence Model 

3.1. Quality of Life and Emotional Aspects of Dealing with HF

Analysis of the dyadic studies demonstrates that managing HF can be very emotional for both the patient and the caregiver [40]. Both partners in the dyad experience high levels of emotional distress [41]; however, patients seem to experience more depressive symptoms than their spouses [42][43]. Greater emotional distress has been associated with poor quality of life. Two studies focused on the caregiver and provided evidence that quality of life of the patient is better if the care partner has no depressive symptoms or anxiety [40][41]. Sleep also is particularly important for caregivers. It has been empirically demonstrated that the presence of sleep disorders significantly affects the mental health of the caregiver [44]. What positively affects the caregiver’s quality of life is the patient’s adherence to therapy [45]. Better emotional well-being of the dyad also is associated with better relationship quality [42]; however, having a good relationship is not “protective” against anxiety and depression for caregivers [46]. If either member of the dyad senses that they are not in control over HF, the emotional well-being of the dyad may become worse [47]. Incongruent collaboration of partners in HF management also affects the emotional well-being of the dyad [43]. Studies on emotional state and quality of life in dyadic caring in HF conclude that interventions are needed to alleviate depressive symptoms in both dyadic partners [40][41]. It appears that nurses can increase dyadic caring by providing the dyadic partners with social support [48].

3.2. Dyadic HF Self-Care Confidence

Self-care confidence, or self-care self-efficacy, is the extent to which one feels able to perform regular self-care (patient) and contribute to patient self-care (caregiver) despite difficulties [49]. Research on dyadic self-care has shown that poor self-efficacy affects the ability of the patient and caregiver to engage. Patients with greater self-care confidence are more engaged in self-care behaviors [50]. Studies on dyadic care in HF also show that self-care confidence is not typically equal between the members of the dyad, with caregivers demonstrating greater self-care confidence than patients [16]. However, there has also been heterogeneity in confidence across the dyads, suggesting self-care confidence is adequate in some dyads but is insufficient to support self-care in others [16].

3.3. Maintenance and Management

Data from APIM studies show low levels of daily HF maintenance and management in both partners in HF self-care [49][51]. Not surprisingly, mild cognitive impairment in the patient reduces self-care [51]. Better self-care maintenance is usually achieved in dyads where the caregiver is a woman. Indeed, there is evidence that female gender of the caregiver was a significant predictor of better patient self-care maintenance [51]. This most likely arises from a traditional role of women, who mainly care about family health in many societies. There also is evidence that a caregiver is more likely to contribute to HF self-care management if the caregiver is not the patient’s spouse [51]. Involvement in self-care also is associated with the emotional state of the caregiver, the quality of the relationship between the HF patient and the caregiver [49][52][53], and the caregiver’s knowledge of self-care [49]. Patients are more adherent to recommendations when they have a decreased physical quality of life [45]. It seems, therefore, that a greater problem in engaging patients in self-care may arise in patients with a relatively high physical quality of life. Furthermore, an agreement between dyad partners who are responsible for performing self-care tasks may also be an important issue for self-care. Dyads that were congruent not only reported fewer psychosocial problems [54], but also in these dyads, the caregivers were more engaged in caregiving [49].

4. Conclusions

(1) a family-oriented approach can improve the functioning of a patient with heart failure condition, and (2) social support from caregivers significantly enhances patients’ adaptation to illness. The emerging view is that patient–caregiver interconnections are still enigmatic, and more studies are needed to provide a more complete and coherent picture of self-care in HF. Thus, further research should be carried out to clarify this concept and identify the most critical factors for effective dyadic functioning in HF.
© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/)
Video Production Service
Feedback