Journal of Cardiovascular Nursing

Vol. 32, No. 6, pp 576Y583 x Copyright B 2017 Wolters Kluwer Health, Inc. All rights reserved.

Family Caregiver Contribution to Self-care

of Heart Failure
An Application of the
Information-Motivation-Behavioral Skills Model
Yuxia Chen, BM, RN, MSN(c); Huijing Zou, BM, RN, MSN(c); Yanting Zhang, BSN, RN, MSN(c);
Wenjie Fang, BM, RN, MSN(c); Xiuzhen Fan, PhD, RN

Background: Adherence to self-care behaviors improves outcomes of patients with heart failure (HF). Caregivers
play an important role in contributing to self-care. Objective: We aimed to explore the relationships among HF
knowledge, perceived control, social support, and family caregiver contribution to self-care of HF, based on the
Information-Motivation-Behavioral Skills Model. Methods: Two hundred forty-seven dyads of eligible patients
with HF and family caregivers were recruited from a general hospital in China. Structural equation modeling was
used to analyze the data obtained with the Caregiver Contribution to Self-care of Heart Failure Index, the Heart
Failure Knowledge Test, the Control Attitudes Scale, and the Social Support Rating Scale. Results: In this model,
caregiver contribution to self-care maintenance was positively affected by perceived control (" = .148, P = .015)
and caregiver confidence in contribution to self-care (" = .293, P G .001). Caregiver contribution to self-care
management was positively affected by HF knowledge (" = .270, P G .001), perceived control (" = .140, P = .007),
social support (" = .123, P = .019), caregiver confidence in contribution to self-care (" = .328, P G .001), and
caregiver contribution to self-care maintenance (" = .148, P = .006). Caregiver confidence in contribution to
self-care was positively affected by HF knowledge (" = .334, P G .001). Conclusions: Heart failure knowledge,
perceived control, and social support facilitated family caregiver contribution to self-care of HF. Targeted
interventions that consider these variables may effectively improve family caregiver contributions to self-care.
KEY WORDS: caregivers, heart failure knowledge, perceived control, self-care, self-efficacy, social support

H eart failure (HF) is a particularly common syn-

drome worldwide, increasing in prevalence and
incidence because of the aging of the population.1 It
Yuxia Chen, BM, RN, MSN(c)
MSN Candidate, School of Nursing, Shandong University, Jinan,
PR China.
Huijing Zou, BM, RN, MSN(c)
MSN Candidate, School of Nursing, Shandong University, Jinan,
PR China.
Yanting Zhang, BSN, RN, MSN(c)
MSN Candidate, School of Nursing, Shandong University, Jinan,
PR China.
Wenjie Fang, BM, RN, MSN(c)
MSN Candidate, School of Nursing, Shandong University, Jinan,
PR China.
Xiuzhen Fan, PhD, RN
Professor, School of Nursing, Shandong University, Jinan, PR China.
This study was supported by Key Research and Development
Program of Shandong province (2016GSF201046).
The authors have no conflicts of interest to disclose.
Correspondence
Xiuzhen Fan, PhD, RN, School of Nursing, Shandong University,
44 Wenhua Xi Rd, Jinan, Shandong 250012, PR China
(fxiuzhen@sdu.edu.cn).
DOI: 10.1097/JCN.0000000000000398
is anticipated that, by 2030, more than 8 million people
will have HF in the United States.2 Moreover, between
2012 and 2030, the total direct medical costs of HF
are estimated to increase from $21 to $53 billion.2
The trajectory of HF is unpredictable, with a gradual
decline in physical function that is accompanied by
heavy symptom burden, a high hospitalization rate,
and poor quality of life.3,4 Previous studies have found
that adherence to self-care behaviors can prevent exacer-
bation and progression of HF and reduce the risk of
hospitalization and death.5,6 Nevertheless, self-care in
patients with HF is inadequate because of physiolog-
ical and psychological factors, such as high comorbid
burden, sleep disturbances, impaired cognition, and
depression.7Y9
Given the previously mentioned situation, the ad-
herence behaviors of complex medication, dietary, and
self-care regimens require the assistance of family care-
givers.10 Family caregivers were defined as laypersons
who provide unpaid care to a relative or friend to help
him/her take care of himself/herself.11 Family care-
givers as the proxy seem to be a fairly consistent substi-
tute for HF symptom assessment and management.12

576

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


Their decision making also contributed to self-care
maintenance and self-care confidence of patients with
HF.13 Therefore, family caregivers are now considered
as the members of healthcare team to assist patients
with health-promoting behaviors, medication adherence,
and symptom monitoring.14 Subsequently, Vellone et al11
proposed that caregiver contribution to self-care of heart
failure index (CC-SCHFI) was the extent to which a care-
giver contributed to a patient’s self-care maintenance and
management, as well as the caregiver’s confidence (self-
efficacy) in his/her ability to contribute to the patient’s
self-care. The CC-SCHFI contains 3 dimensions: (1) care-
giver contribution to self-care maintenance of HF index
(CC-SCHFI-maintenance), which included monitoring
patient’s symptoms and adhering to treatment; (2)
caregiver contribution to self-care management of HF
index (CC-SCHFI-management), which included recog-
nizing patient’s signs and symptoms of HF exacerbation,
implementing actions, and evaluating implemented treat-
ment; and (3) caregiver confidence in contribution to self-
care of HF index (caregiver confidence in CC-SCHFI),
which evaluated caregivers’ confidence in their abilities to
assist patients to engage in each phase of the self-care
process. However, there are few studies that have explored
CC-SCHFI with psychometrically sound instruments.15
The Information-Motivation-Behavioral (IMB) skills
model is a behavior-specific theoretical framework devel-
oped by Fisher et al.16 The Information-Motivation-
Behavioral model emphasizes that the performance of a
behavior requires information, motivation, and behav-
ioral skills. Information is accurate behavior-specific
knowledge. Motivation is an integrated function of
personal motivation and social motivation. Personal
motivation reflects an individual’s attitude or belief,
and social motivation rests on one’s perception of
social support. Behavioral skills include one’s self-
efficacy and objective skills for performing the behav-
ior. Individuals are more inclined to build behavior
skills with sufficient behavior-specific information and
motivation and then to engage in the targeted health
behavior.17 The Information-Motivation-Behavioral
model has been applied to predicting health-promoting
behaviors, such as diabetes medication adherence,
healthy behaviors for metabolic syndrome, and preven-
tion behaviors for sexually transmitted diseases.18Y20
Because information, motivation, and behavioral skills are
also important factors in HF caregiving, the Information-
Motivation-Behavioral model could help to explain
CC-SCHFI.
According to the Information-Motivation-Behavioral
model, we hypothesized that CC-SCHFI was explained
by the following: (1) information: HF knowledge served
as information in the hypothesized model. It includes
accurate knowledge about HF (eg, pathogen, symptoms,
medication, and diet selection), which was reported as a
determinant of self-care behavior in the perspective of
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Family Caregiver Contribution to Self-care of HF 577
patients and informal caregivers.21,22 (2) Motivation:
Perceived control and social support were regarded as
personal motivation and social motivation, respectively,
in the hypothesized model. Perceived control was the
self-generated belief or perception of control over
cardiovascular-related health.23 It was found to be an
important contributing factor to lower caregiver burden
and better psychological status.24,25 Hence, perceived
control might motivate family caregivers to make
contribution to self-care of HF. Social support was
defined as ‘‘an exchange of resources between at least
two individuals perceived by the provider or the
recipient to be intended to enhance the well-being of
the recipient.’’26 It was reported that family caregivers
required social support from families, communities,
and healthcare professionals.27 In addition, social sup-
port perceived by caregivers was significantly associ-
ated with CC-SCHFI-management and caregiving
burden.28,29 (3) Behavioral skills: Caregiver confidence
in CC-SCHFI was viewed as self-efficacy, and CC-SCHFI-
maintenance was viewed as an objective skill in the hypo-
thesized model. In a previous study, caregiver confidence
in CC-SCHFI was the primary determinant of CC-
SCHFI-maintenance and CC-SCHFI-management.30 (4)
Behavior: The CC-SCHFI-management represented as
behavior in the ditto model because the self-management of
HF was vital for disease management and prognosis.31
Accordingly, this study aimed to explore the effects
of HF knowledge (information), perceived control (per-
sonal motivation), and social support (social motiva-
tion) on CC-SCHFI (behavioral skills and behavior).
The ditto model is presented in Figure 1.
Methods
Sample and Procedure
A cross-sectional design was used in this study. The
convenience sample of 247 dyads of eligible patients
and their family caregivers were recruited from 3
cardiovascular units of a general university hospital in
China from October 2015 to May 2016. Permission to
conduct this study was obtained from the Medical
Ethics Committee of the participating site. Each en-
rolled patient and family caregiver received verbal
information about the study and signed an informed
consent form.
All enrolled patients met the inclusion criteria: (1)
18 years or older, (2) had a primary diagnosis of HF,
and (3) had at least 1 primary family caregiver. Patients
were excluded if they had an acute coronary event in
3 months before enrolment, a life-threatening disease,
or clear evidence of dementia. Each eligible patient
who agreed to participate in this study was asked to
appoint a primary family caregiver. The inclusion
criteria of family caregivers were (1) 18 years or older,
(2) designated as a primary caregiver, (3) an unpaid
578 Journal of Cardiovascular Nursing x November/December 2017

FIGURE 1. Hypothesized model of HF knowledge, perceived control, social support, and CC-SCHFI based on the Information-
Motivation-Behavioral model. Caregiver confidence in CC-SCHFI, caregiver confidence in contribution to self-care of HF
index; CC-SCHFI, caregiver contribution to self-care of HF index; CC-SCHFI-maintenance, caregiver contribution to self-
care maintenance of HF index; CC-SCHFI-management, caregiver contribution to self-care management of HF index; HF,
heart failure.

person who provided the most informal care to the
patient, and (4) able to provide informed consent.
All data were collected by a face-to-face interview
during the investigation. Among 247 dyads of eligible
patients and family caregivers, 241 dyads completed
valid questionnaires, and 6 dyads were excluded
because of missing data. The response rate was 96.8%.
Measurements
Demographic and Clinical Characteristics
The demographic information of patients and family
caregivers (age, gender, marital status, residence, edu-
cational level, patient’s relationship with family care-
giver, and family caregiver living with the patient or
not) was obtained from the interview. Clinical charac-
teristics of the patients (New York Heart Association
class and duration of diagnosis) were obtained from
medical records.
CC-SCHFI showed good internal consistency (9.80) and
test-retest reliability (9.90).14
Heart Failure Knowledge
Family caregivers’ HF knowledge was measured by
the Chinese version of Heart Failure Knowledge Test.
It was developed to assess the understanding of the
etiology of HF, symptoms of worsening HF, low-sodium
diet selection, medications, and self-management related
to weight monitoring, physical activity, and worsening
symptoms, for example, ‘‘Which of the following was
not the symptoms of HF?’’ 32 It consists of 10 single-
choice questions, 2 multiple-choice questions, and 2 fill-
in-the-blank items. One point is given for the correct
answer of each question. The number of correct answers is
the total score. A higher score indicates a higher level of
HF knowledge, with a range from 0 to 14. In this study,
the Cronbach’s ! was .63.

Caregiver Contribution to Self-care of Heart Failure Perceived Control

The CC-SCHFI was measured using the Chinese
version of Caregiver Contribution to Self-care of Heart
Failure Index (CC-SCHFI) developed from the SCHFI
v6.2.11 It is composed of 3 subscales with 22 items: CC-
SCHFI-maintenance (10 items, eg, ‘‘How often do you
recommend to the person you care for to check weight?’’),
CC-SCHFI-management (6 items, eg, ‘‘If the person you
care for has trouble breathing or ankle swelling, how likely
are you to recommend or do to reduce fluid intake?’’),
and caregiver confidence in CC-SCHFI (6 items, eg, ‘‘In
reference to the person you care for, how confident are
you that you can follow the given treatment advice?’’). The
standardized score for each subscale ranges from 0 to 100,
with a higher score indicating greater CC-SCHFI. The
Family caregivers’ perceived control was measured by
the Chinese version of Control Attitudes Scale-
Caregiver Version. The Control Attitudes Scale con-
sists of 4 items: two about perceived control and two
about helplessness, for example, ‘‘Regarding your
family member’s heart problems, how much control
or how helpless do you feel?’’33 The items for care-
givers are directed at the levels of control and help-
lessness they perceive and how much control and
helplessness they think patients have. Response state-
ments are scored from 1 (none) to 7 (very much). The
total score ranges from 4 to 28, with a higher score
reflecting greater perceived control. In this study, the
Cronbach’s ! was .74.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

 Family Caregiver Contribution to Self-care of HF 579

Social Support with patients. Most family caregivers (211, 87.5%)

Family caregivers’ social support was measured by the
Social Support Rating Scale, which has shown high
reliability and validity on a wide range of Chinese
populations, including family caregivers of patients
with chronic diseases.34,35 It contains 10 items and
measures 3 types of social supportVsubjective sup-
port (4 items; eg, I can ask my friends for help when
things go wrong), objective support (3 items; eg, I can
get economic assistance from family members, rela-
tives, friends, neighbors, or others when facing with
severe economic difficulties), and support availability
(3 items; eg, I can communicate with others about my
distress)Vto assess the various aspects of social support
individuals receive. These item scores are simply added
up, with the total score ranging from 12 to 66. A higher
score indicates stronger social support received by the
family caregiver. The Cronbach’s ! for this sample was .78.
were spouses or adult children of patients.
Mean Scores and Correlations of Construct
Variables
As Table 2 presented, the mean scores for CC-SCHFI-
maintenance, CC-SCHFI-management, and caregiver
confidence in CC-SCHFI were 52.41 (9.96), 55.62
(15.36), and 55.27 (16.38). The mean scores for HF
knowledge, perceived control, and social support of
family caregivers were 4.71 (2.11), 14.52 (4.62), and
41.84 (6.70). All scores for the previously mentioned
construct variables were significantly correlated with
each other (all Ps G .001), except the relationship between
HF knowledge and perceived control (r = 0.091, P 9 .05)
and the relationship between perceived control and
caregiver confidence in CC-SCHFI (r = 0.115, P 9 .05).

Statistical Analyses Path Analysis of the Hypothesized Model

The SPSS version 20.0 for Windows (IBM Corp, The pathway of the final model was depicted in Figure 2.
Armonk, New York) was used to perform statistical After modification, the fit indices were acceptable:
analyses. Descriptive statistics were used to summarize # 2 = 8.175, df = 4, # 2/df = 2.044 (P = .085); GFI, 0.989;
the demographics and clinical characteristics. The bi- AGFI, 0.942; TLI, 0.917; CFI, 0.978; and RMSEA, 0.066.
variate analysis provided the preliminary relationships
among construct variables of the hypothesis model. TABLE 1 Characteristics of Patients and Family
Subsequently, structural equation modeling was used Caregivers (N = 241 dyads)
to conduct path analyses of the hypothesis model using
Characteristics Patients Caregivers
SPSS Amos version 21.0. The # 2 test, goodness of fit
index (GFI), adjusted GFI (AGFI), Tucker-Lewis Index Age, mean (SD), y 62.71 (11.04) 48.40 (14.25)
Gender, n (%)
(TLI), comparative fit index (CFI), and root mean square Male 126 (52.3) 108 (44.8)
error of approximation (RMSEA) were calculated as Female 115 (47.7) 133 (55.2)
the fit indices of the final model. A structural model Partnered, n (%)
had good data fit if the # 2 was nonsignificant (P 9 .05); Yes 213 (88.4) 227 (94.2)
the GFI, AGFI, TLI, and CFI approached 1.0; and No 28 (11.6) 14 (5.8)
Education, n (%)
RMSEA was less than 0.08.36 The significance level QHigh school 65 (27.0) 125 (51.9)
was set at .05 with a 2-tailed test. GHigh school 176 (73.0) 116 (48.1)
Residence, n (%)
Rural 114 (47.3) 85 (35.3)
Results Urban 127 (52.7) 156 (64.7)
Sample Characteristics Patient characteristics
NYHA class, n (%)
As shown in Table 1, on average, family caregivers II 148 (61.4)
were approximately 14.3 years younger than patients III 72 (29.9)
IV 21 (8.7)
with HF, and there was a slightly smaller proportion Duration of diagnosis, n (%), y
of men (108, 44.8%) as family caregivers as opposed G0.5 149 (61.8)
to patients (126, 52.3%). Most family caregivers (227, 0.5Y3 44 (18.3)
94.2%) and patients (213, 88.4%) had a partner. 93 48 (19.9)
Family caregivers were more educated than patients, Caregiver characteristics
Living with patient, n (%)
with 51.9% of them having at least high school edu- Yes 154 (63.9)
cation. A higher proportion of family caregivers lived No 87 (36.1)
in urban areas (156, 64.7%), when compared with Relationship with patient, n (%)
patients (127, 52.7%). Most patients (220, 91.3%) Spouse 102 (42.3)
had NYHA class II or III, and 149 patients (61.8%) Adult child 109 (45.2)
Other relationship 30 (12.5)
were given a diagnosis of HF within half a year. More
than half of family caregivers (154, 63.9%) were living Abbreviation: NYHA, New York Heart Association.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

580 Journal of Cardiovascular Nursing x November/December 2017

TABLE 2 Mean Scores and Correlations of Construct Variables (N = 241)

Variable Mean (SD) 1 2 3 4 5
1. HF knowledge 4.71 (2.11)
2. Perceived control 14.52 (4.62) 0.091
3. Social support 41.84 (6.70) 0.218b 0.149a
4. CC-SCHFI-maintenance 52.41 (9.96) 0.194b 0.181b 0.165b
5. CC-SCHFI-management 55.62 (15.36) 0.441b 0.244b 0.280b 0.343b
6. Caregiver confidence in CC-SCHFI 55.27 (16.38) 0.334b 0.115 0.171a 0.309b 0.494b

Abbreviations: Caregiver confidence in CC-SCHFI, caregiver confidence in contribution to self-care of HF index; CC-SCHFI, caregiver contribution to
self-care of HF index; CC-SCHFI-maintenance, caregiver contribution to self-care maintenance of HF index; CC-SCHFI-management, caregiver
contribution to self-care management of HF index; HF, heart failure.
a
P G .05.
b
P G .01.

The path coefficients were shown in Table 3. As ex-
pected, CC-SCHFI-maintenance was positively influ-
enced by perceived control (" = .148, P = .015) and
caregiver confidence in CC-SCHFI (" = .293, P G
.001). The CC-SCHFI-management was positively
influenced by HF knowledge (" = .270, P G .001),
perceived control (" = .140, P = .007), social support
(" = .123, P = .019), caregiver confidence in CC-SCHFI
(" = .328, P G .001), and CC-SCHFI-maintenance (" =
.148, P = .006). Caregiver confidence in CC-SCHFI
was positively influenced by HF knowledge (" = .334,
P G .001). The final model accounted for 24.6% of the
variance in CC-SCHFI-maintenance, 67.6% of the var-
iance in CC-SCHFI-management, and 33.4% of the
variance in caregiver confidence in CC-SCHFI.
Discussion
To the best of our knowledge, this is the first study to
find the effects of HF knowledge, perceived control,
and social support on CC-SCHFI with psychometri-
cally sound instruments.
In this study, family caregivers’ HF knowledge had
indirect effects on CC-SCHFI-maintenance, both di-
rect and indirect effects on CC-SCHFI-management,
and direct effects on caregiver confidence in CC-SCHFI.
A previous study found that HF knowledge was
necessary but insufficient for effective self-care behav-
iors in patients and caregivers.37 Most patients and
caregivers expressed that healthcare providers
explained inadequate knowledge about HF, such as
its causes, symptoms, and medications, which was one
of the barriers to performing HF care.38 Although
patients could often recall healthcare providers’ self-
care information, they were unable to integrate the
practices into their daily lives.39 Therefore, theme-
based transitional care should include providing patients
and family caregivers with practical skills and services
to promote knowledge and engagement in self-care and

FIGURE 2. The final model of HF knowledge, perceived control, social support, and CC-SCHFI based on the Information-
Motivation-Behavioral model. Caregiver confidence in CC-SCHFI, caregiver confidence in contribution to self-care of HF
index; CC-SCHFI, caregiver contribution to self-care of HF index; CC-SCHFI-maintenance, caregiver contribution to self-
care maintenance of HF index; CC-SCHFI-management, caregiver contribution to self-care management of HF index; HF,
heart failure. Bold lines indicate significant regression paths. Dotted lines indicate nonsignificant regression paths. aP G .05.
b
P G .01. cP G .001.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


TABLE 3 The Path Coefficients of the Final Model (N = 241)
Path
CC-SCHFI-maintenance @ perceived control
CC-SCHFI-maintenance @ caregiver confidence in CC-SCHFI
CC-SCHFI-management @ HF knowledge
CC-SCHFI-management @ perceived control
CC-SCHFI-management @ social support
CC-SCHFI-management @ caregiver confidence in CC-SCHFI
CC-SCHFI-management @ CC-SCHFI-maintenance
Caregiver confidence in CC-SCHFI @ HF knowledge
Abbreviations: b, regression coefficient; ", standard regression coefficient; Caregiver confidence in CC-SCHFI, caregiver confidence in contribution to
self-care of HF index; CC-SCHFI, caregiver contribution to self-care of HF index; CC-SCHFI-maintenance, caregiver contribution to self-care
maintenance of HF index; CC-SCHFI-management, caregiver contribution to self-care management of HF index; HF, heart failure; SE, standard error.
stimulate active communication with healthcare
providers.40
Perceived control of family caregivers directly affected
CC-SCHFI-maintenance and both directly and indirectly
affected CC-SCHFI-management. Caregivers’ perceived
control about their family member’s heart problem was
a positive and important factor in the impact of care-
giving.41 In the previous studies, HF spouses or other
family members with higher perceived control had
less caregiver burden, higher emotional well-being, and
less emotional stress (eg, anxiety, depression, and
hostility).24,25,42,43 Therefore, interventions designed
specifically to increase the degree of perceived control
related to their caregiving tasks, caregiving burden, and
emotional status might improve CC-SCHFI-maintenance
and CC-SCHFI-management.
Social support of family caregivers only directly
influenced CC-SCHFI-management. This was con-
sistent with that better perceived social support for
caregivers was significantly associated with greater
CC-SCHFI-management.29 Although social support
from relatives, friends, and colleagues improved the
prognosis of patients with heart disease, their family
caregivers who experienced mental distress (eg,
caregiving stress, depression) also need emotional
support from others.44 In addition, the perceived social
support of family caregivers effectively reduced the
caregiving burden.28 A qualitative study reported that
family caregivers with lower social support perceived
their caregiver role as more burdensome and boring or
less rewarding than caregivers with higher social
support.41
In this study, the caregiver confidence in CC-SCHFI
had direct effects on caregiver CC-SCHFI-maintenance
and both direct and indirect effects on CC-SCHFI-
management. This was consistent with that caregiver
confidence in CC-SCHFI was the primary determinant of
CC-SCHFI-maintenance and CC-SCHFI-management.30
In addition, the CC-SCHFI-maintenance had direct ef-
fects on CC-SCHFI-management. These findings indi-
cated that the CC-SCHFI-management might be
improved through interventions targeted at caregiver
confidence and CC-SCHFI-maintenance.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Family Caregiver Contribution to Self-care of HF 581
b " SE P
0.128 .148 0.052 .015
0.296 .293 0.062 G.001
0.494 .270 0.101 G.001
0.117 .140 0.044 .007
0.071 .123 0.030 .019
0.323 .328 0.055 G.001
0.144 .148 .053 .006
0.621 .334 0.113 G.001
In this study, there was no direct relationship
between HF knowledge and CC-SCHFI-maintenance.
However, we found that the relationship was totally
mediated by caregiver confidence in CC-SCHFI. This
finding is of importance because it suggests that inter-
ventions on increasing family caregivers’ HF knowl-
edge may improve CC-SCHFI-maintenance through
strengthening caregiver confidence in CC-SCHFI. To
our knowledge, this mediating effect of caregiver con-
fidence in CC-SCHFI has not been reported among
family caregivers of patients with HF.
We also found that perceived control of family
caregivers had no direct effect on caregiver confidence
in CC-SCHFI. It is not in accordance with a previous
study on patients with HF, which reported that the
stronger perception of internal health control, the
higher confidence in the process of the management
of HF.45 It may result from the incongruence in
confidence of patient and caregiver contributions to
HF self-care.46 Furthermore, the determinants of con-
tribution to self-care of HF were not completely
identical in patient-caregiver dyadic.29,47 In our study,
family caregivers’ social support did not directly influ-
ence CC-SCHFI-maintenance. It is in line with the
finding that social support was not the significant
determinant of CC-SCHFI-maintenance in family
caregivers of patients with HF.29 Family caregivers’
social support was also found to have no direct
influence on caregiver confidence in CC-SCHFI in the
current study. It is comparable with the finding that
there was no effect of social support on confidence
for physical activity in family caregivers of cancer
survivors.48 Given the less evidence on CC-SCHFI,
further investigation is warranted.
Limitations
This study also has limitations. This was an analysis of
cross-sectional data, which allowed only the identifi-
cation of correlates or determinants of CC-SCHFI.
Future studies should use a longitudinal design to
identify true predictors of CC-SCHFI. In addition,
the findings are generalized to other countries with
582 Journal of Cardiovascular Nursing x November/December 2017
What’s New and Important
h Family caregivers’ HF knowledge, perceived
control, and social support were positively associated
with caregiver contribution to self-care of HF index
(CC-SCHFI).
h Both caregiver confidence in contribution to self-care
and CC-SCHFI-maintenance positively influenced
CC-SCHFI-management.
h The Information-Motivation-Behavioral modelYbased
interventions strengthening HF knowledge, perceived
control, and social support might improve family
CC-SCHFI.
caution because our sample only included Chinese
family caregivers of patients with HF. Sociocultural
aspects might influence how family caregivers take care
of their loved ones.
Conclusions
The Information-Motivation-Behavioral model was
used as a framework to evaluate critical prerequisites
to promote CC-SCHFI in this study. Heart failure
knowledge, perceived control, and social support were
contributors to CC-SCHFI. The higher caregiver confi-
dence in CC-SCHFI and better CC-SCHFI-maintenance
were linked to greater CC-SCHFI-management. There-
fore, Information-Motivation-Behavioral modelYbased
interventions or tailored educational programs might
include strategies to ensure that family caregivers pos-
sess appropriate knowledge of HF. Motivation might be
enhanced by targeting family caregivers’ perceived
control of HF and social support from family members
and healthcare services. These interventions would
effectively improve the behavioral skills and behavior
in CC-SCHFI.
Acknowledgments
The authors thank the staff of cardiovascular units of
the hospital who gave them permission to recruit pa-
tients and family caregivers for the study and patients
and family caregivers who willingly agreed to partic-
ipate in this study.
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