|Year : 2021 | Volume
| Issue : 2 | Page : 115-131
Effects of Dyadic Interventions on Quality of Life among Cancer Patients: An Integrative Review
Abha Sharma, Chongjit Saneha, Warunee Phligbua
Faculty of Nursing, Mahidol University, Thailand
|Date of Submission||16-Aug-2020|
|Date of Acceptance||16-Oct-2020|
|Date of Web Publication||29-Jan-2021|
PhD, RN Chongjit Saneha
Faculty of Nursing, Mahidol University
Source of Support: None, Conflict of Interest: None
Interventions delivered to cancer patients along with their caregiver as a unit of care indicates dyadic intervention. With the shift of care to home, dyadic interventions are being popular among cancer care. This review aims to identify the dyadic interventions targeting quality of life (QOL) of cancer patient. The current review examined different dyadic interventions for cancer patients from January 2009 to January 2020. PubMed, Psych-info, and CINAHL databases were searched, and 27 studies were included in the review. There were different dyadic interventions for cancer patients including skill based, psychosocial (psycho-educational, educational, counseling), yoga, mindfulness, coping, dance, writing, training along with education, and counseling. Interventions were different in mode of delivery, duration, and delivery personnel. Interventions had improved some aspects of QOL among cancer patients as well as caregivers. Although some aspects of QOL were improved, precise dose and use of different approaches together could be integrated to develop further interventions. Further intervention based on strong theoretical framework guided by the standard protocol is recommended.
Keywords: Cancer, dyadic interventions, quality of life
|How to cite this article:|
Sharma A, Saneha C, Phligbua W. Effects of Dyadic Interventions on Quality of Life among Cancer Patients: An Integrative Review. Asia Pac J Oncol Nurs 2021;8:115-31
|How to cite this URL:|
Sharma A, Saneha C, Phligbua W. Effects of Dyadic Interventions on Quality of Life among Cancer Patients: An Integrative Review. Asia Pac J Oncol Nurs [serial online] 2021 [cited 2021 Jun 20];8:115-31. Available from: https://www.apjon.org/text.asp?2021/8/2/115/308310
| Introduction|| |
Cancer journey is not just limited up to the patient, but it also includes patients along with their family caregiver mainly spouse., As the World Health Organization (WHO) estimated the rise to pile up reaching 18.1 million new cases of cancer and 9.6 million death in 2018, cancer has emerged as a burden of the 21st century. The aggregated 5-year survival rate for all cancers has increased from 50.3% to 67% from 1970–1977 to 2007–2013. At present, scenario with increasing number of long-term cancer survivors, family members being the main caregiver, and global shortage of healthcare providers has come up with a shift of care from hospital to community and home-based care for cancer patients and survivors putting crucial responsibility on family caregivers.,, Studies have supported the existence of relationship between illness experience in cancer patients and their family caregivers., Living with cancer reduces quality of life (QOL) of not only patient but also the QOL of family caregiver.
The disease process of cancer, its treatment, and side effects of treatment, results in remarkable distress among cancer patients and their family caregiver in physical,, psychological, social, and spiritual domains.,, These are the domains collectively referred as “QOL.” The WHO has defined QOL as “an individual's perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectation, standard, and concerns. QOL is dynamic and it changes as individual moves along the cancer continuum. Reflecting the data from developing countries, a study in India showed that majority of cancer patients (82.3%) had QOL score below average. Thus, maintaining “QOL” has been one of the main goals of cancer treatment.,,,
As caregiver provides care to the cancer patient in every possible dimensions of health: physical, emotional, social and goes through all the negative health consequences, caregiver and patient dyad is collectively viewed as a unit. When interventions are offered to the cancer patient and their family caregiver together as a unit of care, then it is patient–caregiver dyadic intervention. Couple-based/dyadic interventions for cancer patient and their partner have been found to enhance patient's psychological and social adjustment such as communication and relationship functioning. Dyadic intervention in cancer has potential for achieving success as it simultaneously addresses survivor, caregiver, and relationship factor that hinders effective symptom management, caregiving, and rehabilitation. However, other study concluded that family-involved interventions were not superior to usual care or active controls at improving cancer patient's outcome.
The objective of the study is to identify the dyadic interventions targeting QOL of cancer patient. Following review questions were used: What are the different types of dyadic interventions for cancer patients and their caregiver? What are the methodological features of interventions? Which domain of QOL is most influenced by the intervention?
| Methods|| |
Inclusion Criteria for the Study to be Considered for the Review
Type of studies included global studies with either pilot, randomized control trial, quasi-experimental with control group design, or pretest–posttest design. Peer-reviewed and full-text articles are included. All the published studies in English language between January 2009 and January 2020 were included. Studies that focused on adults diagnosed with any type of cancer and at any stage of cancer were included in the review. Any intervention directed toward the promotion of QOL of cancer patient, delivered by any mode including cancer patient and family caregiver, and given at any time during the cancer progression were included. The outcome of the interest is QOL of cancer patient.
Study search was conducted using following keywords, “Family” or “couple” or “spouse” or “partner” or “patient caregiver dyads” AND “intervention” or “treatment” or “therapy” or “program” or “strategy” AND “quality of life” or “well being” or “well-being” AND “cancer” or “neoplasm” or “carcinoma” or “malignancy.”
Search in CINAHL included “family or couple or spouse or partner or patient caregiver dyads” AND “intervention or treatment or therapy or program or strategy” AND “quality of life or well being or well-being” AND “cancer or neoplasm or carcinoma or malignancy.” Articles from January 2009 to January 2020, peer-reviewed, and English language were included. There were a total of 690 articles from which 14 were retrieved.
In PubMed, search included (family[Title/Abstract] OR couple[Title/Abstract] OR spouse[Title/Abstract] OR partner[Title/Abstract] OR patient caregiver dyads[Title/Abstract])) AND (intervention[Title/Abstract] OR treatment[Title/Abstract] OR therapy [Title/Abstract] OR program[Title/Abstract] OR strategy[Title/Abstract]) AND (quality of life[Title/Abstract] OR well being[Title/Abstract] OR well-being[Title/Abstract])) AND (cancer[Title/Abstract] OR neoplasm [Title/Abstract] OR carcinoma[Title/Abstract] OR malignancy[Title/Abstract]). Articles from January 2009 to January 2020, English language, and age 19+ years were included. Total articles were 820 out of which 29 articles were retrieved.
In Psych info, search included ab (family OR couple OR spouse OR partner OR patient caregiver dyads) AND ab (intervention OR treatment OR therapy OR program OR strategy) AND ab (quality of life OR well being OR well-being) AND ab (cancer OR neoplasm OR carcinoma OR malignancy). Articles from January 2009 to January 2020, English language, full text, and peer reviewed were included. There were 480 articles, among which 12 were retrieved.
Articles meeting the inclusion criteria were retrieved and evaluated for deciding its relevancy.
Assessment of Risk and Bias of Individual Studies
The three reviewers checked the quality of the methodologies for each of the studies used in the review. Scottish Intercollegiate Guidelines Network Methodological Checklist 2: Controlled Trials (version 2.0), was used for checking methodological quality. It was developed by the Scottish Intercollegiate Guideline Network (SIGN), Healthcare Improvement Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh EH 12 9EB. All the eligible articles were assessed independently by three researchers. Further, any disagreement between them was resolved in consensus. All the selected articles met the acceptable criteria.
Data were extracted in data extraction form by researcher and validated by 2 independent researchers. Discussion was made for the resolution of disagreement. A Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flowchart for the review is presented in [Figure 1].
|Figure 1: PRISMA 2009-2020 flow diagram. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis|
Click here to view
| Results|| |
Twenty-seven articles were confirmed on meeting the inclusion criteria and were included for the analysis. Characteristics of included studies are presented in [Table 1].
Design sampling method and sample size
Among 27 studies,,,,,,,,,,,,,,,,,,,,,,,,,,, 7 studies,,,,,, were pretest–posttest design. Mixed design was used in 3 studies,, and 17,,,,,,,,,,,,,,,, studies were randomized controlled trial. Majority, nineteen studies,,,,,,,,,,,,,,,,,, were conducted in the USA while two each in the Netherlands,, the United Kingdom,, and China., Finally, one study each was conducted in Indonesia and Chile.
Almost half of the studies,,,,,,,,,,,,, were conducted in multi-sites and the remaining [31,,,,,,,,,,,, in one site. Sample size of 3 studies,, was less than or equal to ten dyads, while sample size was between 11 and 20 dyads in 3 studies,,, 21 and 30 dyads in 4 studies,,,, 31 and 40 dyads in 5 studies,,,, 41 and 50 dyads in 2 studies,, 61–70 dyads in 1 study, 71 and 80 dyads in 3 studies,,, 91 and 100 in 1 study, 100 and 200 dyads in 2 studies,, 200 and 300 dyads in 2 studies,, and above 300 dyads, i.e., 302 dyads in one study. Sample size calculation was shown in only four studies.,,,
Regarding the type of cancer included, 6 studies,,,,, included patients with lung cancer, 6 studies,,,,, included different types and stages of cancer, 5 studies,,,, included breast cancer, 3 studies,,, included prostate cancer, 2 studies, included terminal cancer, 2 studies, included gastrointestinal cancer, 1 study included ovarian cancer, and 1 study included high-grade glioma (brain cancer). In 18 studies, the eligibility age was mentioned to be 18 years or more for providing consent. While five studies had eligibility age being 21 years or more and the age eligibility was not indicated in four studies.,,,
Characteristics of the interventions in studies included in the review are presented in [Table 2].
Among all the included studies, intervention of studies included skill development;,,,, psychoeducation, i.e., Family involvement, Optimistic attitude, Coping effectiveness, Uncertainty reduction, and Symptom management (FOCUS) program;,,,, yoga based;,,, mindfulness based;,, and coping.,, Studies,, tested between counseling and education. One study each had intervention education, dance, writing, and training along with education and counseling.
Interventions focused in skill development
In reflexology intervention, caregivers were trained by reflexologists in two home visits; 9 reflexes on foot with thumb walking pressure were provided. Reflexologist coached caregiver and adjusted as needed. Caregiver delivered session for 2 weeks. Intimacy enhancing therapy (IET) focused on improving couples' ability to share thoughts, share feelings regarding cancer, promote mutual understanding, and support, enhance, and maintain emotional intimacy. IET comprised of five couple sessions with skill practice and home practice. Another intervention was multimedia instructional program in touch-based techniques focusing on touch and massage methods. Instructional digital versatile disc (DVD) was developed featuring dyads of different ethnic group and relationship. Content included safety precautions related to touch, communication, manual techniques for comfort and relaxation, acupressure, anxiety, and nausea. DVD had a multilingual voice and captions and was given with manual. They practice at least three times/week for 20 min. Enhanced couple group included expression of feelings about the cancer experience, constructive communication skills, expressing support needs, creating a “Wish List” for positive acts for their spouse to do for them, being a good support to one's partner, stress management and sexual intimacy, and created an intimacy deck, problem-solving, and emotion-focused coping. Skills practice included focused-breathing relaxation induction, progressive muscle relaxation as a group, guided imagery, and cognitive restructuring practice. This also assisted couples for preparing “survivorship” phase. Basic skill training (BST) educational package included video and a module of five chapters on assisting a bedridden patient with bathing, providing oral hygiene, hair washing, assisting with urination and bowel movements, and managing feeding orally and using a nasogastric tube. Three training sessions were given at the hospital and home where caregivers observed a demonstration by the nurse educators, watched the video, and then practiced the skills. After 2 weeks, nurse educator did home visits and assist them in developing skills.
All the yoga interventions were given to dyads over 5–6 weeks of radiotherapy. Vivekananda Yoga,, included: (1) Joint loosening with breath synchronization; (2) postures (asanas) and a deep relaxation technique; (3) breath energization (pranayama) with sound resonance; and (4) meditation. Another study had five main components: (1) deep breathing awareness with visualization; (2) breath retention exercises; (3) mindfulness and focused attention through guided meditation; (4) Tsa Lung movements; and (5) a brief compassion-based meditation. Sessions 1–4 focused on introducing practices while further sessions focused on refining practice.
Mindfulness meditation was delivered through audio (MP3), preloaded with eight mindfulness meditation tracks and a study booklet with practice diary. Mindfulness-based stress reduction program (MBSR), was delivered by mindfulness trainer. Program contained 8 sessions along with silent day and home assignments. Psychoeducation about grief and stress was added.
Psychoeducational-Family involvement, Optimistic attitude, Coping effectiveness, Uncertainty reduction, and Symptom management program
Studies, included the original FOCUS program. In a previous study, to determine the optimal dose, original 5-session program was revised into brief (three contacts) and extensive versions (six contacts) and was delivered by a nurse over 10 weeks while intervention in previous study by licensed social worker, family therapist. Study was web-based format, including only family involvement module. Content included cancer effect on family, value of teamwork, family strength, family concerns, addressing problems, communication tips, types of support, and finding meaning in illness, looking to the future. Tailored e-mail with the summary of key content was sent in alternate weeks. Personalization, tailored feedback, and content matching were used as tailoring strategies. Prostate Cancer Education and Resources for Couples (PERC) integrated the family involvement and symptom management modules from the FOCUS program and guidelines for symptom management. PERC website included seven education modules: 2 mandatory (teamwork and survivorship issues) and 5 optional (symptom management). Couple care, optimistic outlook, navigating the journey, new normality, empowering self, change lifestyle, target setting (CONNECT) was based on FOCUS, including discussions on symptom management, sexual and urinary dysfunction, uncertainty management, positive thinking, and healthy lifestyles delivered as 3 group and 2 individualized telephone sessions.
Health education compared with counseling
Patients received eight weekly sessions and partners received four sessions every other week. Telephone interpersonal counseling (TIP-C) was compared with health education attention condition (HEAC) in a study. Telephone health education (THE) was compared to TIP-C while with telephone counseling (T-C) or videophone interpersonal counseling (V-C) in a study.
Wellness education included education in physical therapy, coping and communication strategies, mental health (MH), spirituality, social needs, knowledge about lung cancer, TKI treatment, nutrition, physical activity, symptom, and pain management. It was delivered in hospital.
Partners in Coping Program (PICP) included assessment of couple's relationship, social support network, integrating tasks of illness into a couples daily routine, caring for children when mother has cancer, personal coping and preserving physical and psychological health, learning new coping skills, enhancing the couple's communication, promoting supportive exchanges, enhancing intimacy and sexual functioning, and living with cancer. PICP was compared with standard social work services. Study compared peer helping + coping skills group (Dyads helped to create an informational resource for other dyads coping with cancer. Therapist introduced topics, e.g., physical symptoms, stress, social changes, and asked experiences and advice. Dyad indicated helpful skills to others, followed by in-session practice of one or more coping skills) with coping skills group (dyads discussed the same topics but did not help create an informational resource). Another study compared individual coping intervention (ICI) with couple-based coping intervention (CBCI). Both group patients received cognitive, behavioral, and psychological intervention. In the CBCI group, partners attended training sessions, accompanied patients over 3 h a day, and helped patients to adopt an active coping style.
Humanized nursing accompaniment included home visits for training family caregiver on seeking palliative care from the nursing setting, teaching care as per need. Nursing counseling at home (through 3 home visits per month per family), on-line counseling with educational platform supported by audiovisual content, and telephone service to solve unforeseen inquiries were also used.
The Restoring Health in You (and Your Partner) through Movement (RHYTHM) project is a ballroom dance intervention including 10 private and 2 group lessons. Couples learned Foxtrot, Waltz, Cha-Cha, and East Coast Swing.
The Guided Disclosure Protocol for written emotional disclosure had 3-day writing protocol including describing the diagnosis and treatment chronologically, describing feelings and impact of diagnosis on life, current feelings, and coping similar situations. It was compared to neutral writing where couple wrote about what the patient did the previous day.
Theoretical Framework behind Intervention
Humanized nursing accompaniment was based on care factors by Jean Watson, PICP on cognitive-behavioral framework. IET was based on cognitive-behavioral and behavioral marital therapy; FOCUS was guided by stress-coping theory. Interventions TIP-C and THE,, were based on stress process model whereas TIP-C,, developed from the standard interpersonal psychotherapy combined with cancer education. All the dyadic yoga interventions,,, were based on the principles of interconnectedness, interdependence: reciprocal support, teamwork, and equity. The MBSR intervention, was based on the original MBSR program as developed by Kabat-Zinn. The written emotional disclosure used the cognitive processing hypothesis and the social interaction hypothesis. The RHYTHM project was based on cognitive interaction and intimacy model. Peer helping + coping skills were based on the helper therapy principle.
Majority, 13 studies,,,,,,,,,,,, had retention between 70% and 80%, while 7 studies,,,,,, was between 80% and 90%. Retention rate above 90% was in three studies;,, in reading intervention condition and Yoga, there was 100% retention while retention was not given in two studies.,
Significant findings for patients/survivors
Majority, 18 studies,,,,,,,,,,,,,,,,, had significant improvements in some aspects of QOL of cancer patients. Overall QOL/global health was improved in five studies.,,,, HEAC group of study had improvement in all the aspects of QOL, while study had an improvement in all aspects of QOL except spiritual well-being. Spiritual well-being was found to be improved in five studies,,,, (counseling groups). Emotional QOL was found to be increased in four studies.,,, Social QOL was increased in three studies,, (counseling group). Further, three studies had improvements in physical QOL,,, functional QOL,,, MH of QOL.,, In a study, although all the aspects of QOL decreased from preoperative to 2 months' postoperative and 6 months' postoperative, there was a significant difference; CBCI group had higher mean score in vitality (VT), social functioning (SF), emotional problems (RE), and MH than ICI at both follow-ups. Overall well-being improved in a study. Significant improvement in symptom was present in six studies,,,,, while five studies each had significant reduction in distress,,,, and anxiety.,,,, Similarly, four studies,,, had significant decrease in depression.
Significant findings for caregivers
Ten studies,,,,,,,,, reported significant increase in overall QOL or some aspects of QOL among caregivers. Anxiety, depression, and/or negative feelings were found to be decreased in seven studies.,,,,,, Distress was found to be reduced in 5 studies,,,,, fatigue in 3,,, burden in 3,,, and increase in self-efficacy in 3.,, Decreased physical symptoms were in two studies, while one study each had decreased in sleep disturbance, anger hostility, intrusive thoughts, increase in confidence and comfort, partner's perception of patient's cancer symptoms, agreement and happiness, and benefit finding.
Fidelity was reported in four studies (87.4%, 88%–98%, 99%, and 85%). Studies,,,,,,,, mentioned the interventions to be feasible. Interventions were rated as beneficial/useful/satisfied in six studies.,,,,,
| Discussion|| |
The main aim of this review was to explore existing dyadic/family interventions for cancer dyads and to identify the effectiveness of intervention on patient QOL outcome. This review provides future direction for family-based intervention. The review provides crucial suggestions for developing interventions. There are different dyadic interventions focusing on QOL of cancer patients. Eighteen studies had significant improvements in some aspects of QOL of cancer patients. However, social well-being was not improved in majority of studies. Among skill-based interventions, reduction in symptom severity was observed as in reflexology group. Significantly greater decrease in pain, nausea, and other self-reported symptoms was seen for patients in the massage condition (multimedia instructional program in touch-based techniques). On a BST, educational package, patient's global health status/QoL, functional scales, EF and SF, improved significantly. Further, reduction in fatigue, pain, dyspnea, insomnia, appetite loss, constipation, and financial issue were also noted.
Although yoga intervention was feasible, the sample size included in the studies were smaller and studies had clinical significance in many outcomes while one study had statistically significant decrease in fatigue and anxiety among patients and had significant increase in spiritual well-being.
FOCUS program had significant effect on emotional QOL, total QOL, physical QOL, symptoms; as well, in one study, improvement in social QOL was observed among patient as well as caregiver. While mindfulness-based interventions were successful in reducing distress, anxiety, and depression. Coping skill interventions were successful in decreasing both patient's and caregiver's fatigue and caregiver's distress.
HEAC for prostate cancer had significant improvement in patient's psychological, social, physical, and spiritual well-being as well as partner's depression, fatigue, social well-being, and spiritual well-being in comparison to dyads in TIP-C condition. While the health education (THE) compared to TIP-C delivered by telephone or video call among breast cancer dyads, both the intervention yield significant improvements in measures of QOL (physical, social, and psychological), but superiority of intervention could not be determined. In these studies, QOL and its domains were assessed using many tools as presented in [Table 1]. Wellness education also gained significant improvement in emotional well-being. RHYTHM significantly improved physical activity, functional capacity, in the mental component of QOL, VT, SF, and MH. Humanized nursing accompaniment gained significant improvement in the global health subscale in 3-month posttest. In addition, improvement in symptom of constipation, fatigue, dyspnea, and anorexia was found.
Majority of the studies included in this review had a sample size<100; another review also mentioned that most dyadic intervention studies have sample size (N < 100), indicating that they are less powerful in examining changes in multiple outcome that were considered which could have contributed to small-to-moderate effect sizes.
As adolescent and young adults with cancer have problems with the maintenance and development of family/peer relationships, intimate/marital relationship, and peer support, this desire of patient for social well-being could be addressed through more structured dyadic intervention.
Among the included studies, two studies, did follow-up data until 6 months where some outcome improvements were found in 3 months' follow-up while only few were sustained till 6 months. One study did 1-year follow-up data where well-being was found to be improved until 1-year follow-up. Thus, dyadic interventions seem to have short-term as well as long-term benefit, but more rigorous study is required for concluding its long-term benefit.
All the yoga intervention could be integrated with radiotherapy treatment as it was feasible. The study conducted by Budin compared psycho-education and psycho-education plus telephone counseling; both were superior to standard care but superiority among intervention was not significant as seen in this review. In one study, 33 patients and 20 caregivers participated which does not address patient and caregiver as a dyad. Further studies included in the review had caregiver comprising spouse, family members, or even member of social network in the studies.
As majority of the studies included here were conducted in the USA, this limits knowledge of dyadic characteristics and efficacy of dyadic intervention, with regard to diverse culture, ethnicity, healthcare systems, and socioeconomic status. Some studies included in the review still lack theoretical framework as stated in another review, many dyadic interventions lacked theoretical framework, while others used either individual stress and coping theories or resource theories or dyadic models as in this review.
Findings of the review should be considered along with its limitations. This review included only published studies. There remains possibility that studies without significant treatment effects were never published. Further studies published in only English language were focused. Further, we did not perform quantitative analysis or assess the quality of results reviewed but presented the interventions in descriptive way.
For future dyadic intervention, focus on dyad as a unit should be given. For future research, theoretical framework incorporating cancer dyad as a unit and approaches of interventions and outcome measure should be well defined. As evident in this review, single intervention could not address all the QOL dimensions, so integrating some skill along with psychoeducational could be conceptualized. As dyads are the sample, family and social integration can also be considered for developing new intervention as social well-being seems to be not highlighted among the review studies. Precise dose must be planned as retention rate decreases as the doses of intervention increases. Intervention, as well as its mode of delivery, should depend on and be accepted culturally and economically and should synchronize with the lifestyle and technology adaptation of the dyad. Well-trained and intervention specific workforce should be utilized for delivering the intervention.
For healthcare practices, addressing cancer patient and caregiver as a unit throughout cancer journey could foster dyadic adoption and adjustment with chronic illness like cancer.
As dyadic interventions seem to be feasible and beneficial for cancer patients and their caregiver, healthcare system should include dyads at community and household level for addressing different issues concerning cancer journey.
| Conclusions|| |
This review showed that dyadic interventions in the context of cancer are feasible and can bring about a significant positive outcome in some domains of QOL. More rigorous study with precise dose, integrating different approaches is needed. Further intervention with a strong theoretical framework and guided by standard protocol and in diverse group of population has to be conducted.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]