Search strategy

First, for this search we have used key words related to our wished objectives, according to Mesh and Decs terms: (Caregiver) OR (home nursing) AND (self-help group) OR (group structure) AND (family health). The search strategy used for each of the databases with their respective limiters and records obtained are shown in Table 1.

Table 1: Detailed search strategy. 

Selection process

To select articles, we considered next inclusion and exclusion criterions:

For the selection of articles, we have carried out different strategies to filter the total number of articles found after searching, and this one has been divided in two periods.

In the first filter, articles have been discarded by their title and their abstract. From 424 records found, 69 articles were selected.

Regarding the excluding criterions in this first selection phase, according to the title and abstract, they can be divided in:

In the second phase, filter was carried out by reading the complete text, getting 12 selected articles finally (from the 69 articles in the previous phase).

The exclusion criterions in this second period were:

The whole selection process is resumed in the next flow chart, Figure 1.

Figure 1: Summary of the item selection process. 

The variables of interest used in data extraction in these articles were the characteristics of SHG, the advantages of SHG on caregivers, the impact of SHG on family health, and the benefits of SHG for the dependent. The country was also taken into account, to know if it is developed in a western (individualist) and eastern (group) society. Once the articles that were finally included in the review were selected, they were analyzed using the CASPe (Critical Appraisal Skills Programme) method. It is a tool structured in: validity, results and applicability. The higher the score, the higher the quality of the study. ¹⁹Therefore, only two failures of the total item on the quality of the article were taken as a limit.

Mutual groups' characteristics

SHGs are based on the colleagues support, the group dynamics´ usage and the encouragement for participants to deal with their active life. Principally, they try to motivate participants to identify their strengths and improve their abilities to resolve problems. Besides, SHGs that offer an experience exchange, open discussion, information and advice achieve family caregivers´ requirements. ^{22 26}

Together with SHGs, they support families to be physical, metal and socially active, and promote knowledge to understand and manage the illness, which includes dimensions as helping patients and their caregivers to identify problems, their own abilities development and their self-efficiency to sort out problems and dominate their daily lives. By the other hand, they provide a sensation of having something in common with other caregivers, experiences validation and opportunities, that is, giving and receiving help. ²⁹

Besides, another way of SHG exists, as McKechnie V et al ²⁵, indicate, in his study, that is, caregivers support mediated on a computer.

This type of SHG offers a range of possible advantages in comparison with other traditional support groups, including the accessibility and the possibility of adapting the individual needs. It is specifically focused on online mutual support to caregivers looking after people with dementia, and it is used to ask for advice, share information, participate in discussions and feel supported.

These online self-help group´s participants referred an improvement in the relationship´s quality with the people with dementia. There was no change in users´ depression or anxiety during the study, but interviewed people informed about experiences and positive forum´s usage, in comparison with the traditional SHG.

In general, a significant improvement is observed, in comfort, obtaining a possible anonymity, anxiety and embarrassing produced by direct contact with other people reduction and exchange of ideas and feelings, much bigger than in traditional SHG.

Nevertheless, these online groups need much more investigation and time to obtain the same benefits than the face-to-face ones, as for example, the opportunity to offer health education by sanitary professionals. ¹¹

In conclusion, SHGs for caregivers must focus mainly in moderate care experiences discussion. They must integrate psych-educational elements, in particular, information about illness and available treatment, in order to know how to deal with patients' situation. To increase help groups' usage, all the family caregivers not only must been informed about the existence and accessibility to these offers, but also about the advantages to themselves. ²⁹

Family caregivers

In Wei Y-S study, et al ³⁰, it is been observed that a SHG for the dependent family caregivers is an efficient intervention to promote the physical and psychological health of caregivers, as well as their social support, to provide that network of social relationships that caregivers have been losing over time.

Wang L-Q, et al ²⁹, affirm that participants in mutual support groups had significant improvements in the anxiety and quality of life levels. These discoveries support the efficiency of the mutual support groups to offer psychosocial support to family caregivers. Therefore, it must be converted into a habitual component of people with dementia caregivers within the nursing cares. Besides, the results indicate the need of nurses (as care agent) to evaluate caregivers´ health later on in the process of caring and to be conscious of their relation with emotional support. Results also highlight the importance of caregivers establishing an appropriate self-care system that provides emotional support and physical help.

Rodriguez-Sanchez E, et al ²⁶, suggest that the implementation of a new psychological intervention improves mental health of family caregivers in charge, so, the fact that emotional discomfort doesn't increase and, even so it decreases significantly, can be consider as an important progress.

Laakkonen M-L, et al's study ²⁴, focused on disease management and saw how intervention helps accept the role of caregiver.

Finally, Candy B, et al ²⁰, affirm that the interventions that directly support family or friends can help them cope with their role as a caregiver and improve their quality of life.

Family health

The article written by Hemamalini M, et al ²³, talk about it.This article refers that SHGs have a deep impact into the family system, especially in its structure of roles and family functions. Family interventions' main objectives are reduce the immediate negative stress effects that members of the family feel, as well as mobilizing their confrontational skills adaptively. Family caregivers informed that the intervention met their support needs, reducing some of their care demands, increasing their confidence and capacity to face the dependent family situation. Therefore, the study concludes that SHG is an effective nursing intervention, recommended to caregivers taking care of dependent people to strengthen the family system.

In conclusion, as Chien WY, et al ²¹, affirm SHGs' participants indicated a significantly better improvement in family, in patient's functioning and in social support for families. Therefore, mutual support groups are an effective community intervention for caregivers looking after dependent people and their families.

Dependent people

According to different studies, named previously, we can affirm that stress and anxiety reduction in caregivers, feelings exchange, adding the information about this care, that SHGs offer to caregivers, has a direct repercussion into the patients looked after by them, having more capacity to improve the dependent patients' health status. Besides, a reduction in the number of relapses and symptoms is added, as well as a reduction in the sanitary services, thanks to the autonomy that caregivers gain by attending to SHGs. ^20,21,30

In other place, Theurer K, et al ²⁸, describe groups that target caregivers along with the dependents themselves that revealed, after evaluating structured interviews and observations, various topics, such as self-determination, giving and receiving help to other patients, discussions of their strengths and beliefs, and the expression of the challenges they face and how to better deal with them.

In addition, as if Secanilla E, et al ²⁷, describe the decision of taking dependent people into a residential centre is taken in a reflexive and more distant way, without that many negative emotions, thanks to the attendance of caregivers to SHGs. In addition, the group helps to exchange useful information about sick people's care and self-care matters, which allows the dependent patients' improvement.

Society

One third of the articles (four of the twelve) are developed in an eastern society, three of them in China and one in India. Cultural differences between an eastern and a western society have an impact on extrapolating the results. For example, the study of Chien WT, et al ²¹is carried out in China with male caregivers (2/3), against our environment where the caregiver role in women predominates. However, in Wang L-Q, et al's ^29),it was an advanced practice nurse who designed the protocol to guide the SHG process and the training of the facilitator and caregiver-moderator, based on evidence from the literature on family SHG in the western countries.

Limits and strengths

The above is one of the limitations of the study, although one of them is based on a western SHG. On the other hand, we only have included complete articles available, which implicates we may have not considered other important articles about this matter.

Three of the twelve selected articles are observational descriptive transversal and/or qualitative studies, which provides important and relevant information, but at the same time, they have a lower level of evidence than experimental studies or systematic revisions. Even so, in more than the half of them a high level of evidence methodology is used. In addition, this literature review has been conducted in pairs.