Mutuality and self-care in heart failure patient and caregiver dyads

With interest, we read the recently published article in the European Journal of Cardiovascular Nursing entitled ‘Mutuality and heart failure (HF) self-care in patients and their informal caregivers’ by Hooker and colleagues. ¹ To our knowledge, the above study is the first that has examined the relationship between mutuality and self-care in HF patient and caregiver dyads. In the above study, mutuality was defined as the positive quality of the relationship between a caregiver and a care-receiver. ² HF self-care was defined as those behaviours that patients and caregivers perform to maintain stable HF, monitor HF symptoms, adhere to prescribed treatment (self-care maintenance), consult a provider in case of symptoms and relieve symptoms (self-care management).^3–5 Self-care maintenance and management are influenced by confidence in performing the above behaviours. ⁶

In the USA, Hooker and colleagues enrolled a sample of 99 HF patient and caregiver dyads and tested two hypotheses: (a) higher patient and caregiver mutuality is associated with higher patient and caregiver confidence in self-care (both within and across the dyad) and (b) higher patient and caregiver confidence in self-care (both within and across the dyad) is associated with higher self-care maintenance. The analyses to test the above hypotheses were conducted using a structured equation modelling approach, which involved an actor-partner interdependence model.

We found the study to be very important and compelling for three main reasons. The first reason is that it is the first study that considers mutuality as an indicator of relationship quality in HF patient and caregiver dyads, and looks at the relationship between mutuality and HF self-care. In other populations, several studies have found that higher mutuality in patient and caregiver dyads is associated with better outcomes: for example, faster recovery in Parkinson’s disease patients, lower depression and aggression in dementia patients, higher life satisfaction in stroke survivors, lower stress and depression and improved health in caregivers. ⁷ Also, studies have shown that mutuality protects caregivers from adverse outcomes, especially when caregiving demands are high. ⁷ However, research on the influence of mutuality on HF patient and caregiver dyads is very limited. In our previous studies, we demonstrated that a good relationship between HF patients and caregivers was associated with better self-care^8–10 using a single item assessing the dyad relationship. Using a reliable and valid instrument such as the Mutuality Scale, ² Hooker and colleagues have unlocked a research field that has the potential to identify further predictors of HF self-care that could be modified with interventions.

The second reason the study is important is that the authors used a statistical approach (i.e. the actor-partner interdependence model) that controls for the interdependence within the dyad. Patient and caregiver dyads share the same living context, may think in a similar way and may influence each other. For example, it is not surprising that if a patient is depressed then his/her own caregiver is also depressed and vice versa. This interdependence should be ‘controlled’ in a statistical analysis involving dyads, as Hooker and colleagues have done.

The third reason we believe this study is important, is that, thanks to Hooker and colleagues, we have improved our understanding of caregiver contributions to HF self-care. Previously, we outlined the first conceptual framework on caregiver contribution to HF self-care. ¹¹ In this framework, caregiver self-care is influenced by caregiver variables (HF knowledge, perceived control, social support, education and anxiety), patient variables (education, cognition and HF duration) and dyad variables (patient and caregiver relationship). Now we know that mutuality also influences caregiver contributions to self-care, a variable that we can categorise amongst the dyad variables.

In Italy, mutuality is also becoming an important research area. One of our first steps in studying mutuality was conducting psychometric testing of the Mutuality Scale with its theoretical four-factor structure (i.e. love and affection, shared pleasurable activities, shared values and reciprocity) in stroke patient and caregiver dyads. ¹² We are currently testing the same scale in HF patient and caregiver dyads (paper under review). In another study, we are also looking at the influence of patient and caregiver mutuality on HF patient and caregiver self-care, as Hooker and colleagues have done, but differently. We are going to look at the influence of specific mutuality dimensions (e.g. reciprocity) on patient and caregiver self-care maintenance, management and confidence. We believe this approach can provide a detailed evaluation of the influence of mutuality on self-care that can illuminate future interventions to consequently improve mutuality and HF self-care. Also, we are going to look at the influence of mutuality on self-care management, something that Hooker et al.’s study did not consider.

Healthcare systems are being challenged by costs associated with the care of people with chronic conditions. Patient and caregiver dyads are also being challenged by chronic conditions that require them to manage multiple diseases. For healthcare providers and scientists, identifying predictors of self-care and strategies to improve self-care are the best ways to help people be autonomous and responsible for their health conditions and to empower their resources.