Journal of

Clinical Medicine

Systematic Review
Telehealth in Informal Caregivers of Stroke Survivors:
A Systematic Review
Juan Carlos Zuil-Escobar 1, * , Jose Antonio Martín-Urrialde 1 , Juan Andrés Mesa-Jiménez 1 ,
Rocío Palomo-Carrión 2 and Carmen Belén Martínez-Cepa 1, *

1 Departamento de Fisioterapia, Facultad de Medicina, Universidad San Pablo-CEU, CEU Universities,

Urbanización Montepríncipe, 28668 Alcorcón, Spain; [email protected] (J.A.M.-U.); [email protected] (J.A.M.-J.)
2 Physiotherapy Department, Universidad de Castilla-La Mancha, 45071 Toledo, Spain; [email protected]
* Correspondence: [email protected] (J.C.Z.-E.); [email protected] (C.B.M.-C.)

Abstract: Background: There has been an increase in people with disabilities who require continuous
care, which often falls to informal carers (ICs). Stroke is one of the conditions where ICs are most
needed. Therefore, it is necessary for ICs to improve their caregiving skills and self-care capacity.
Telehealth (TH) can facilitate them. The aim of this systematic review is to summarize the evidence of
the effects of interventions on ICs of stroke patients. Methods: The search was conducted in Pubmed,
Scopus, Web of Science, CINALH, Psychology and Behavioral Sciences Collection, and APA PsycInfo.
Key search terms included “stroke”, “informal caregiver” and “telemedicine”. Only randomised
clinical trials were included. Results: A total of 2031 articles were found in the databases, 476 were
screened and 19 clinical trials met the eligibility criteria. Different TH programmes have evaluated
many outcomes related to physical and emotional health. The TH tools included phone, videophone,
web-based interventions, and social media. The most investigated outcome was depression; although
contradictory results were found, the TH may have helped to prevent an increase in depressive
symptoms. There were inconsistent results on the caregiving burden and the preparedness of the IC.
However, TH has positive effects on the health of the ICs, reducing the number of unhealthy days,
anxiety, task difficulty perception, and improving psychological health. Conclusions: TH may be a
useful tool to improve the abilities and health of ICs of SS. No adverse effects have been reported.
Citation: Zuil-Escobar, J.C.; Martín-
More quality studies evaluating the effects of telemedicine on the ICs of stroke survivors, as well as
Urrialde, J.A.; Mesa-Jiménez, J.A.;
the most appropriate doses, are needed.
Palomo-Carrión, R.; Martínez-Cepa,
C.B. Telehealth in Informal Caregivers
Keywords: caregiver; caregiver burden; stroke; telemedicine
of Stroke Survivors: A Systematic
Review. J. Clin. Med. 2024, 13, 1810.
https://doi.org/10.3390/jcm13061810

Academic Editors: Silvia Cimino,

1. Introduction
Georgios Tsivgoulis and Deirdre
A. Lane
In recent years, there has been an increase in life expectancy, which will continue in
the coming decades [1]. Globally, the number of people aged 60 and over will increase by
Received: 20 January 2024 56% by 2030, and by 2050, the global elderly population is expected to reach 1.5 billion [2].
Revised: 12 March 2024 Longer life expectancy has led to an increase in the number of chronically ill and disabled
Accepted: 19 March 2024 people [3]. Their management has become a challenge for society and the healthcare system.
Published: 21 March 2024
Dependent persons require continuous care over time, which is often provided by
an informal caregiver (IC) [4]. An IC is a person responsible for the unpaid care of a sick
or elderly person who is unable to perform the activities of daily living on their own [5].
Copyright: © 2024 by the authors.
They provide physical, emotional, and sometimes financial support, and spend most of the
Licensee MDPI, Basel, Switzerland. day with them [6,7]. The IC is usually a close family member [7] who has no specialised
This article is an open access article training [8]. However, caregiving takes a significant toll on ICs, affecting both their physical
distributed under the terms and and psychological health, as well as their social, professional, and economic spheres [9–11].
conditions of the Creative Commons The IC often puts the needs of the person they care for before their own personal needs and
Attribution (CC BY) license (https:// lifestyle preferences [12]. Half of them report some form of caregiving overload [13] and
creativecommons.org/licenses/by/ 17% suffer from significant health problems, particularly neuropsychiatric disorders [14],
4.0/). which also affect their ability to care [4].

J. Clin. Med. 2024, 13, 1810. https://doi.org/10.3390/jcm13061810 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2024, 13, 1810 2 of 20

In the United States, it is estimated that there are 17.7 million people providing
informal care to people over the age of 65 years [7]. There is therefore a need to develop
interventions to support them in their role and improve their health. Although ICs are
aware of the need to look after their health, many find it difficult to find the time to do so
or to follow the advice given by healthcare professionals [15].
Stroke is the third leading cause of disability worldwide [16] and its prevalence con-
tinues to increase [17]. One-third of stroke survivors (SS) suffer permanent disability [18],
while 40% of SS require care, with the IC playing a key role in their recovery [19] and
in preventing further episodes [20]. The ICs of SS do not have the skills to manage the
disease [21]. In addition, most of these ICs are older people with other health problems [22].
For example, up to 50% of them show depressive symptoms, a percentage that rises to 80%
in the acute phase of the disease [23]. The perceived burden of IC is mainly determined
by the functional status of the caregiver, the duration of care, the number of hours of
caregiving per day, and self-efficacy [24]. One of the challenges for health systems and
society is to improve the knowledge of ICs about the pathology and their ability to care, as
well as to provide them with adequate tools for self-care [25]. It is therefore necessary that
ICs in stroke have resources available to them during the post-discharge process, as well as
regular communication and support from healthcare professionals [26].
Telehealth (TH) can help in the workplace [27] by facilitating access to services without
the need to travel, improving adherence to interventions and facilitating care [28]. For ICs,
it helps them by reducing absenteeism [12] and financial costs and facilitating access to
interventions [29]. The TH has been shown to have a positive effect on the emotional and
psychosocial state of ICs in chronic patients [4,12]. In the case of Alzheimer’s disease, TH
has been shown positive effects on the health of ICs, helping them with the disease process
and in their caregiving role [30].
Several TH programmes have been used for stroke. Therefore, telerehabilitation
programmes have shown similar results to conventional rehabilitation programmes in
improving patients’ activities of daily living, motor function, balance, and quality of
life [31,32]. In addition, two systematic reviews on the use of telerehabilitation in stroke
care showed that these programmes have positive health outcomes for ICs [33,34].
TH can help solve some of the problems faced by ICs of stroke patients. They use
internet tools, such as Google, to search for information about their unmet needs and to
connect with other caregivers [35]. Similarly, there are also a number of mobile applications
available to support these ICs. A scoping review found that these apps provide help in three
main areas: caregiver support, barriers, and informal caregiver support [36]. In addition, the
mHealth tools for ICs of stroke survivors include several functionalities such as information
resources, risk assessment, remote monitoring, data sharing or reminders [37]. However,
no systematic reviews were found that evaluated the effects of TH programmes specifically
targeted at ICs of stroke survivors.
The aim of this systematic review is to summarize the evidence of the effects of
interventions on ICs of patients who have suffered a stroke.

2. Materials and Methods

2.1. Information Sources
A search was conducted to identify relevant papers evaluating the effects of TH
on ICs of SS in the following databases: Web of Science, Scopus, Pubmed, CINAHL,
Psychology and Behavioral Sciences Collection, and APA PsycInfo. The systematic review
was conducted according to the PRISMA principles [38]. This systematic review was not
registered in any public database.

2.2. Eligibility Criteria

The search strategy includes terms related to IC, TH, and stroke. The following
inclusion was defined by criteria according to the PICO framework [39]:
Population: IC of SS. Both males and females were included.
J. Clin. Med. 2024, 13, 1810 3 of 20

Interventions: TH interventions in IC of SS.

Comparison: conventional interventions.
Outcomes: indicators of caregiver burden (fatigue, burnout, etc.), physical and emo-
tional health (depression, general health, quality of life), self-efficacy, etc.
In terms of study design, only randomised clinical trials were included. Conference ab-
stracts were excluded, as were reviews and books. There were no time restrictions applied,
and articles published in both English and Spanish were included. If the interventions
focused on SS, although the ICs were involved, the studies were also excluded.

2.3. Search Strategy

Concerning the search keywords, terms (both MeSH and plain language) related to
“stroke”, “informal caregiver” and “telehealth” were used.
The following filters were used in the different databases:
- Pubmed, article type: “clinical trial”, “controlled clinical trial”, “randomized clinical
trial”; language: “English”, “Spanish”.
- Web of Science: “English”, “Spanish”, “clinical trial”.
- Scopus: “English”, “Spanish”, “article”.
- CINALH, Psychology and Behavioral Sciences Collection and APA PsycInfo: “English”.
Appendix A shows the search strategy for each database.

2.4. Selection Process and Data Collection

After performing the bibliographic search in the above-mentioned databases, we used
the filtering tools of each of them to eliminate the articles that did not meet the inclusion
criteria. In addition, we searched the selected articles for relevant bibliographical references.
We also searched for the results of the identified clinical trial protocols.
All references were exported to Mendeley Reference Manager, where duplicates were
removed. Next, the titles and abstracts of the included articles were read and those that
did not meet the objectives or criteria of the study were excluded. Finally, the full text of
the selected articles was read and those that did not meet the objectives of the systematic
review or did not meet the inclusion criteria were excluded.
A PRISMA flowchart [38] was used to organize the information, including the number
of studies removed by the automatic tools of the databases, duplicates, and selected studies.
The initial selection of articles was carried out by two independent reviewers according to
the defined inclusion criteria, based on the reading of titles and abstracts only. Subsequently,
the articles that were selected or for which the title and abstract did not provide sufficient
information underwent a second phase of full-text review. The two reviewers performed
the assessment independently according to the eligibility criteria. A consensus meeting
was held in case of disagreement.

2.5. Data Extraction

Data extraction was performed using an Excel form designed for this systematic
review. One independent reviewer extracted data, including article information, population
information, interventions, comparisons, outcomes, results, and conclusions. A second
reviewer checked all the extracted data. A consensus meeting was held if there was
disagreement between the reviewers.
A critical review of the included articles was performed, analysing the main aspects:
participants (age, gender), interventions, comparisons, outcome measures, and results. In
terms of outcomes, variables related to caregiver burden (stress, burnout, burden, strain,
etc.), physical (general health, unhealthy days, etc.), mental health (depression, anxiety,
etc.), quality of life, ability to cope with caregiving tasks and self-perception of caregiving
were collected.
J. Clin. Med. 2024, 13, 1810 4 of 20

2.6. Risk of Bias

The risk of bias was assessed using version 2 of the Cochrane risk-of-bias tool for ran-
domised trials (RoB 2) [40]. This tool measures the risk of bias in the results of randomised
trials. To identify potential bias in the results, this tool is divided into five domains:
(1) Bias arising from the randomisation process.
(2) Bias due to deviations from the intended interventions.
(3) Bias due to missing outcome data.
(4) Bias in the outcome measurement of the outcome.
(5) Bias in the selection of the reported outcome.
A separate score is given for each domain, and an overall score is calculated. The
final rating is “low risk” when all domains indicate low risk. If there are concerns in any
domain, the final rating will reflect “some concerns”. If there is a high risk in any domain,
the overall result is categorised as “high risk”.
Two independent reviewers assessed the methodological quality and the risk of bias
in the selected articles.

2.7. Quality Assessment

The JADAD scale was used to assess their methodological quality. This scale consists
of five items and RCTs are of good quality if they score 3 or higher [41]. This scale has been
shown to have good reliability [42].

2.8. Data Synthesis

A narrative synthesis of the data was carried out. Descriptive tables were used to
compare the studies, including sample size, age and gender of participants, characteristics
of interventions, duration of interventions, outcome measures, follow-up, and main results.
In the case of missing data, the authors were contacted to obtain unreported data. Effect
measures included Student’s t-test and ANOVA or non-parametric equivalent tests.
The review was carried out from December 2023 to February 2024.

3. Results
3.1. Study Selection
Figure 1 shows the PRISMA flowchart describing the selection process for this system-
atic review. Two thousand and thirty-one preliminary articles were found in the databases.
After removing duplicates and records marked as ineligible by automated tools, 476 articles
were scanned for title and abstract, and 429 were excluded. A total of 47 articles were
read in full, and 28 articles were excluded. Nineteen articles [43–61] met the eligibility
criteria and were included in the final review. No further articles were found by searching
other sources.

3.2. Sample Size and Participant Characteristics (Age and Number of Women per Study) of the
Articles Reviewed
A total of 1483 ICs were included in all the articles reviewed. Table 1 shows the main
characteristics of the population included in the articles reviewed.

Table 1. Population.

Article n Age Women

30
IG: 10
Grant et al., 1999 [43] 56 years 21
CG: 10
PAG: 10
Grant et al., 2002 [44] 74 56 ± 12 years 67
J. Clin. Med. 2024, 13, 1810 5 of 20

Table 1. Cont.

Article n Age Women

40
IG: 56.43 ± 9.61 IG: 13
Bakas et al., 2009 [45] IG: 21
CG: 57.84 ± 11.8 CG: 16
CG: 19
103
IG: 54 ± 12.2 IG: 25
Pierce et al., 2009 [46] IG: 51
CG: 55 ± 13.1 CG: 30
CG: 52
Perrin et al., 2010 [47] 61 58.5 ± 12.0 56
32
IG: 55.3 ± 6.9
Smith et al., 2012 [48] IG: 19 NI
CG: 54.9 ± 12.9
CG: 19
36
IG: 49.8 ± 14.8
Kim et al., 2013 [49] IG: 18 NI
CG: 57.3 ± 11.5
CG: 18
122
IG: 66.7 ± 9.9 IG: 46
Pfeiffer et al., 2014 [50] IG: 60
CG: 65.6 ± 10.1 CG: 49
CG: 62
49
Bishop et al., 2014 [51] IG: 23 56.8 ± 16. 32
CG: 26
254
IG: 54.0 ± 12.5 IG: 96
Bakas et al., 2015 [52] IG: 123
CG: 4.7 ± 11.4 CG: 103
CG: 131
128
IG: 49.08 ± 12.09 IG: 50
Cheng et al., 2018 [53] IG: 64
CG: 49.11 ± 12.90 CG: 46
CG: 64
152
IG: 49.04 ± 14.96
Goudarzian et al., 2019 [54] IG: 76 90
CG: 49.48 (15.05)
CG: 76
53
IG 4 weeks: 13
LeLaurin et al., 2021 [55] IG 8 weeks: 13 60.3 ± 10.1 49
CG: 13
AG: 14
110
IG: 35 (25–55) IG: 42
Elsheikh et al., 2022 [56] IG: 55
CG: 35 (25–57) CG: 40
CG: 55
40
IG: 45.61 ± 12.14 IG: 9
Mou et al., 2022 [57] IG: 20
CG: 48.10 ± 12.20 CG: 10
CG: 20
63
IG: 35.48 ± 10.77 IG: 27
Demir et al., 2023 [58] IG: 33
CG: 36.07 ± 10.88 CG: 27
CG: 30
80
IG: 54.61 ± 11.73 IG: 70.6%
Bitek et al., 2023 [59] IG: 40
CG: 51.60 ± 14.18 CG: 71.4%
CG: 40
75
IG: 46.1 ± 11.3 IG: 25
Hussin et al., 2023 [60] IG: 38
CG: 45.6 ± 12.8 CG: 24
CG: 37
84
IG: 46.16 ± 11.32 IG: 27
Mohammadi et al., 2023 [61] IG: 42
CG: 46.1 ± 10.5 CG: 25
CG: 42
Population characteristics. AG: attention group; CG: control group; IG: intervention group; NI: no information;
PAG: personal attention group.
J. Clin. Med.
Med. 2024,
2024, 13, x1810
FOR PEER REVIEW 5 6of
of 21
20

Figure 1. Prisma Flowchart showing the review process.

FigureThe
1. Prisma
largestFlowchart showing
sample size was the
for review process.
the article by Goudarzian et al. [54], which included
152 ICs. On the other hand, Grant et al. [43] included 30 participants.
3.2. Sample Size
In terms ofand Participant
gender, Characteristics
the majority of the ICs(Age
are and Number
women of Women per Study)
[43–47,50–56,58–61] and of
in the
most
Articles Reviewed
articles, the IC was the spouse or the daughter/son of the SS [43–45,47,49,50,52,55,60]. The
A total
average ageofof1483 ICs is
the ICs were included
over 50 years,inwith
all the articles
the reviewed.
exception Table 1 shows
of Goudarzian et al.the
[54]main
and
Mohammadi et
characteristics ofal.
the[61], Mou et included
population al. [57], and Hussin
in the et al.
articles [60], where it is over 45 years.
reviewed.
Only Elsheikh et al. [56] and Demir et al. [59] included ICs below 40 years old.
Table 1. Population.
3.3. Interventions
Article n Age Women
Table 2 shows the characteristics of the interventions and the outcomes of the articles
30
included in this systematic review. In terms of interventions, the reviewed articles included
specific
Grantintervention programmes IG:
et al., 1999 [43]
10 telephone [43–45,50–55,57–59,61], videophone [47],
using 56 years 21
web-based interventions [46,48,49,52,59],CG: 10 mobile applications [60], and social media [61].
PAG: 10
Grant
Table et al., 2002 [44]
2. Interventions 74
(both in the intervention 56 ±groups),
and control 12 years 67
main outcome measures, and
40
follow-up carried out in the articles reviewed.
IG: 56.43 ± 9.61 IG: 13
Bakas et al., 2009 [45] IG: 21
Article Interventions CG: 57.84 ± 11.8 Measurement 16
CG:
CG: 19 Outcomes Times

103General health (SF-36)

IG: telephone contact IG: 54
Problem-solving skills ± 12.2
(PSI) IG:025
Week
Pierce et al., 2009 [46] IG: 51
CG: control Satisfaction (CSQ)
CG: 55 ± 13.1 Week
CG:2 30
Grant et al., 1999 [43] CG: 52
PAG: home visit Depression (CES-D) Week 5
Perrin et 12 al.,weeks
2010 [47] 61
Caregiver 58.5(PCS)
preparedness ± 12.0 Week 56
13
Caregiving burden (CBS)
32
IG: 55.3 ± 6.9
IG: social
Smith problem-solving
et al., 2012 [48] General health (SF-36)
IG: 19 NI
telephone partnerships Problem-solving CG:
skills54.9
(PSI)± 12.9 Week 0
CG: 19
CG: usual discharge Satisfaction (CSQ) Week 2
Grant et al., 2002 [44] 36 Depression (CES-D)
planning services IG: 49.8 ± 14.8 Week 5
SG:Kim
shamettelephone
al., 2013 intervention
[49] IG: 18
Caregiver preparedness (PCS) WeekNI
13
CG: 57.3 ± 11.5
12 weeks CG:Caregiving
18 burden (CBS)
Pfeiffer et al., 2014 [50] 122 IG: 66.7 ± 9.9 IG: 46
J. Clin. Med. 2024, 13, 1810 7 of 20

Table 2. Cont.

Article Interventions Outcomes Measurement Times

Caregiver optimism (LOT-R)
Perceived difficulty with
IG: TASK (phone intervention) Week 0
tasks (OCBS)
CG: attention control group Week 4
Bakas et al., 2009 [45] Threat appraisal (ACS)
(including phone calls) Week 8
Depression (PHQ-9)
8 weeks Week 12
Caregiver life changes (BCOS)
General health (SF-36)
Week 0
IG: web-based intervention Month 3
Depression (CES-D)
Pierce et al., 2009 [46] CG: usual care Month 6
Satisfaction (SWLS)
12 months Month 9
Month 12
IG: transition assistance program, Caregiver burden (CSI)
Week 0
including 4 videophones Depression (CES-D)
Perrin et a. 2010 [47] Week 4
CG: standard care Caregiver satisfaction
Week 12
6 weeks (VACCHTPSS)
Depression (CES-D and PHQ-9)
IG: web-based intervention Mastery (Mastery Scale)
(online information, educational Self esteem (SES) Week 0
Smith et al., 2012 [48] videos, chat sessions, e-mail) Social support (MOS social Week 11
CG: relevant online information support survey) Week 15
11 weeks Treatment credibility, reported
effort, and perceived benefit
IG: web-based intervention
Week 0
Kim et al., 2013 [49] CG: usual care Caregiver mastery (CGMS)
Month 3
9 weeks
IG: telephone-based
Week 0
problem-solving intervention Depression (CES-D)
Pfeiffer et al., 2014 [50] Month 3
CG: information letters Caregiving competence (SCQ)
Month 12
3 months
FIIT: family intervention
Functional independence (FAI) Week 0
telephone tracking
Bishop et al., 2014 [51] Depression (GDS) Month 3
CG: standard medical follow-up
Family functioning (FAD) Month 6
6 months
Week 0
IG: TASK II (phone intervention)
Depression (PHQ-9) Week 8
CG: information, support, and
Bakas et al., 2015 [52] Caregiver life changes (BCOS) Week 12
referral (phone)
Unhealthy days Week 24
12 weeks
Week 52
Caregiving competence (CGS)
IG: strength-oriented
Caregiver burden (CSI) Week 0
psychoeducational programme
Problem-solving skills (PSI) Week 26
Cheng et al., 2018 [53] (six 30 min phone sessions)
Depression (CES-D) Week 32
CG: usual care
General health (SF-12) Week 40
26 weeks
Social support (SSQ)
IG: phone consultation
Depression (BDI) Week 0
Goudarzian et al., 2019 [54] CG: usual care
Anxiety (BAI) Month 3
3 moths
IG: RESCUE programme:
web-based and phone Week 0
Depression (CES-D)
LeLaurin et al., 2021 [55] intervention Week 5 or 9
Caregiver burden (ZBISF)
CG: usual care Week 21 or 25
4–8 weeks
J. Clin. Med. 2024, 13, 1810 8 of 20

Table 2. Cont.

Article Interventions Outcomes Measurement Times

IG: multiple methods, including 6
Quality of life Week 0
phone calls
Elsheikh et al., 2022 [56] (WHOQOL-BREF) Month 3
CG: institutional booklet
Care burden (ZBISF) Month 6
6 months
IG: patient–caregiver dyads Caregiver burden (CSI)
education (telephone calls) Family functioning (F-COPES) Week 0
Mou et al., 2002 [57]
CG: usual care Caregiving competence (CCS) Week 4
4 weeks Anxiety (GAD-7)
IG: discharge training and
telephone counselling (4 sessions) Week 0
Betik et al., 2023 [58] Caregiver burden (ZCBS)
CG: routine care Month 3
12 weeks
IG: transitional care model
(education via web and Caregiving competence (CCS)
phone calls) Caregiver preparedness (PCS)
Week 0
Demir et al., 2023 [59] CG: usual care Caregivers’ e-Health
Week 12
12 weeks Literacy (eHLS)
CG: routine care Caregiver burden (MBIGF)
12 weeks
IG: stroke riskometer application
Lifestyle changes (LS7) Week 0
Hussin et al., 2023 [60] CG: usual care
Caregiver’s stroke risk Week 12
12 weeks
IG: phone and social media
Week 0
Mohammadi et al., 2023 [61] CG: usual care General health (SF-36)
Week 12
12 weeks
ACS: Appraisal of Caregiving Threat Subscale; BAI: Beck Anxiety Inventory; BCOS: Bakas Caregiving Outcomes
Scale; BDI: Beck Depression Index; CBS: Caregiving Burden Scale; CG: control group; CCS: Caregiving Competence
Scale; CES-D: Centre For Epidemiologic Studies Depression Scale; CGMS: Caregiving Mastery Scale; CSI: Caregiver
Strain Index; CSQ: Client Satisfaction Questionnaire; eHLS: e-Health Literacy Scale; F-COPES: Family Crisis-
oriented Personal Evaluation Scale; FAD: Family assessment device; FAI: Frenchay activities index; GAD-7:
Generalised anxiety disorder scale-7; GDS: geriatric depression scale; IG: intervention group; LS7: Lifestyle 7 scores;
LOT-R: revised life orientation test; MBIGF: Maslach Burnout Inventory-General Form; OCBS: Oberst Caregiving
Burden Scale Difficulty Subscale; PAG: personal attention group; PCS: Preparedness For Caregiving Scale;
PHQ-9: Patient Health Questionnaire Depression Scale; PSI: problem-solving inventory; SES: Self-esteem Scale;
SSQ: Six-item Social Support Questionnaire; SWLS: Satisfaction with Life Scale; TASK: Telephone Assessment
and Skill Building Kit; VACCHTPSS: VA Care Coordination and Home Telehealth Patient Satisfaction Survey;
WHOQOL-BREF: WHO Quality of Life-BREF; ZBISF: Zarit Burden Interview-Short Form; ZCBS: Zarit Caregiver
Burden Scale.

Comparisons included home visits [43], sham telephone calls [44,52], usual care [44–
47,49,51,53–55,57–61], online basic information [48], and information letters [50] and book-
let [56].
In addition to the heterogeneity of the interventions, there was also wide variation in
the duration of the interventions and the follow-up.

3.4. Outcomes
The interventions focused on different aspects of the CI, and the studies that were
reviewed were concerned with the effects of interventions on the health of ICs. Depression
was one of the most important outcomes evaluated [43–48,50–53,55]. General health
perceptions were assessed in six articles [43–45,53,59,61]. The burden of the care was also
evaluated in nine articles [43,44,47,53,55–59]. Changes in the lifestyle of the CIs have also
been studied [60].
Other outcomes assessed were the CI’s ability to cope with the tasks [43–45,53] and
the caregiver’s preparedness [43,44,48–50,53,58,59], satisfaction [43,44,46,47], and func-
tional independence [51]. The impact of caregiving on the life of the CI [45,56], the num-
J. Clin. Med. 2024, 13, 1810 9 of 20

ber of unhealthy days [52], self-esteem [48], threat appraisal [45], anxiety [53,54] or the
caregiver’s stroke risk [60], social support [48,53], and the family functioning were also
evaluated [51,57].

3.5. Results
Table 3 shows the main outcomes of the studies.

Table 3. Main results of the articles reviewed.

Article Outcomes Results

CES-D week 2 = ß = 1.63 (p < 0.01) The IG scored statistically significantly better on
CES-D week 5 = ß = 0.91 (p = 0.05) depression, problem-solving skills, and caregiving
Grant et al., 1999 [43] PSI week 2 = ß = −2.26 (p < 0.01) preparedness during the intervention (weeks 2 and 5)
PSI week 5 = ß = −2.14 (p < 0.05) compared to the other two groups. It also improved,
PCS week 1 = ß = 1.36 (p < 0.01) although without significant results, after the
PCS week 5 = ß = 0.73 (p < 0.05) intervention (weeks 13).
PCS = IG = 19.12 ± 1.61 (p < 0.01); CG = 0.01 ± 1.65
(p > 0.05); SG = 0.78 ± 1.63 (p > 0.05) The IG showed better problem-solving skills, greater
Grant et al., 2002 [44] CES-D = IG = 14.68 ± 1.61 (p < 0.01); CG = 0.08 ± 1.65 caregiver preparedness, and less depression
(p > 0.05); SG = 3.56 ± 1.63 (p > 0.05) compared to SG and CG (p < 0.05). No differences
PSI = IG = −7.2 ± 1.59 (p < 0.05); GC = 1.91 ± 1.65 were found in the caregiving burden.
(p > 0.05); SG = 0. ± 1.62 (p > 0.05)
LOT-R week 4 = 18.34 ± 0.92 vs. 14.78 ± 0.97 (p < 0.05)
LOT-R week 8 = 18.14 ± 0.84 vs. 14.85 ± 0.89 (p < 0.05)
LOT-R week 12 = 17.61 ± 1 vs. 13.59 ± 1.06 (p < 0.05) The IG showed significant increases in optimism
OCBS week 4 = 22.87 ± 1.38 vs. 27.94 ± 1.47 (p < 0.05) (weeks 4, 8, 12), improvement in task difficulty (week
Bakas et al., 2009 [45] OCBS week 8 = 22.61 ± 1.39 vs. 26.07 ± 1.48 (p > 0.05)
OCBS week 12 = 22.34 ± 1.41 vs. 24.63 ± 1.49 (p > 0.05) 4), and threat appraisal (weeks 8 and 12) compared
ACS week 4 = 31.55 ± 1.83 vs. 34.5 ± 1.94 (p > 0.05) to the CG.
ACS week 8 = 28.38 ± 1.86 vs. 35.48 ± 1.98 (p < 0.05)
ACS week 12 = 30.64 ± 2.84 vs. 38.92 ± 1.87 (p < 0.05)

Pierce et al., 2009 [46] CES-D = 12.3 ± 9.8 vs. 9 ± 9.1 (p > 0.05) No statistical difference between groups was found
SWLS = 21.7± 6.7 vs. 24.6± 6 (p > 0.05) in depression and satisfaction.

CSI 1–3 months a = −1.64 ± 3.31 vs. 2 ± 6.26 (p < 0.05) The IG shows significantly lower caregiver strain at
Perrin et al., 2010 [47] 3 months. The IG showed also less depression than
CES-D = −1.81 b (p > 0.05) the CG, but without statistical significance.
The IG showed significantly lower depression than
Smith et al., 2012 [48] CES-D week 11 = 13.9 ± 2 vs. 19.7 ± 1.8 (p < 0.05) the CG in weeks 11 and 15. No significant differences
CES-D week 15 = 13.4 ± 1.6 vs. 24.1 ± 0.5 (p < 0.05)
were found for other variables.
Kim et al., 2013 [49] CGMS = (19.7 ± 2.8 vs. 22.8 ± 2.5) (p < 0.05) The IG improved significantly in mastery.
The IG showed significantly lower levels of
Pfeiffer et al., 2014 [50] CES-D months 3 = 17.3 ± 7.55 vs. 20.4 ± 9.44 (p < 0.05) depressive symptoms after both 3 and 12 months. No
CES-D months 12 = 2.4 ± 7.52 vs. 18.2 ± 10.87 (p < 0.05)
significant differences were found for other variables.
FAD months 3 = 2.4 ± 4.6 vs. −2.5 ± 3.5 (p < 0.05) The IG showed an improvement in both
Bishop et al., 2014 [51] FAD month 6 = 2.7 ± 6.4 vs. −2.8 ± 4 (p < 0.05) independence functioning in months 3 and 6 and
FAI month 3 = −0.65 ± 5.4 vs. 2.13 ± 3.72 (p < 0.05)
FAI month 6 = −0.84 ± 4.5 vs. 1.74 ± 3.8 (p < 0.05) family functioning in months 3 and 6.
PHQ-9 weeks 1–8 = −3.6 ± 0.8 vs. −0.9 ± 0.7 (p < 0.05)
PHQ.9 weeks 1–12= −3.9 ± 0.8 vs. −2 ± 0.7 (p < 0.05) There was a statistically significant reduction in
PHQ-9 weeks 1–24 = −3.6 ± 0.7 vs. −1.6 ± 0.6 (p < 0.05) depression in weeks 8, 12, 24, and 52; an
Bakas et al., 2015 [52] PHQ-9 weeks 1–52 = −4 ± 0.8 vs. −1.1 ± 0.7 (p < 0.05)
BCOS weeks 1–8 = 2.9 ± 1.3 vs. 1.2 ± 1.2 (p < 0.05) improvement in life changes in week 8 and a
Unhealthy days weeks 1–8 = −1.1 ± 0.9 vs. 1.8 ± 0.9 reduction in unhealthy days in week 8 in the IG.
(p < 0.05)
CGS week 26 = 12.02 ± 1.79 vs. 11.16 ± 2.35
CGS week 32 = 12.31 ± 1.46 vs. 10.65 ± 2.07 The IG improved, compared to CG, throughout the
CGS week 40 = 12.48 ± 1.28 vs. 10.65 ± 2.10 (p < 0.05) study in caregiving competence problem-solving
PSI week 26 = 94.69 ± 12.56 vs. 103.67 ± 19.08 (p < 0.05) coping abilities (T0–T1: −5.93 (−11.08, −6.81);
Cheng et al., 2018 [53] PSI week 32 = 93.96 ± 13.89 vs. 106.70 ± 20.12 (p < 0.05) T0–T2: −8.74 (−13.81, −3.67); T0–T3: −12.34
PSI week 40 = 92.59 ± 10.82 vs. 108.08 ± 18.61 (p < 0.05) (−17.88, −6.81) and social support satisfaction
SSQ week 26 = 5.15 ± 0.55 vs. 4.90 ± 0.84 (p < 0.05) (T0–T1: 0.28 (0.08, 0.47); T0–T1: 0.42 (0.20, 0.64);
SSQ week 32 = 5.23 ± 0.51 vs. 4.83 ± 0.88 (p < 0.05) T0–T3: 0.33 (0.10, 0.55) (p < 0.01).
SSQ week 40 = 5.11 ± 0.49 vs. 4.81 ± 0.80 (p < 0.05)

Goudarzian et al., 2019 [54] BAI = 30.18 ± 5.53 vs. 33.59 ± 6.4 (p < 0.05) The IG statistically improved in anxiety, but not
BDI = 35.41 ± 9.34 vs. 35.85 ± 7.8 (p > 0.05) (p > 0.05) in depression.
J. Clin. Med. 2024, 13, 1810 10 of 20

Table 3. Cont.

Article Outcomes Results

CES-D week 5/9 = 9.4 ± 6.1 vs. 16.4 ± 8.6 vs. 16.2 ± 10.4
vs. 13.7 ± 12.5
CES-D week 21/25 = 12 ± 6.3 vs. 12.9 ± 10.4 vs. 12.7 ± 11.1 Although the study was not powered for significance
LeLaurin et al., 2021 [55] vs. 11.6 ± 10.7 testing, no statistically significant findings
ZBISF week 5/9 = 9.4 ± 6.1 vs. 16.4 ± 8.6 vs. 16.2 ± 10.4 vs.
13.7 ± 12.5 were found.
ZBISF week 21/25 = 12.6 ± 12.4 vs. 12.9 ± 10.4 vs.
12.7 ± 11.1 vs. 11.6 ± 10.7
WHOQOL-BREF psychological month 3 = 43.41 ± 19.93 vs.
42.73 ± 18.89
WHOQOL-BREF psychological month 6 = 43.86 ± 19.88 vs. Although the effects of group and time interaction on
42.35 ± 19.04 both the psychological and social relationship
Elsheikh et al., 2022 [56] WHOQOL-BREF social month 3 = 71.06 ± 15.45 vs. domains were significant (p < 0.05), no significant
70.91 ± 14.77 differences within groups or between groups for all
WHOQOL-BREF social month 6 = 72.12 ± 15.57 vs. domains of QoL were found. No differences were
69.85 ± 16.08 found between groups in care burden.
ZBISF month 3 = 34.38 ± 7.09 vs. 32.53 ± 7.96 (p > 0.05)
ZBISF month 6 = 34.60 ± 7.07 vs. 33.24 ± 7.83 (p > 0.05)
CBI = 32.45 ± 15.86 vs. 44.4 ± 16.5 (p < 0.05) The caregiver burden was significantly reduced in
Mou et al., 2022 [57] CCS = 11.75 ± 2.51 vs. 11.4 ± 1.35 (p < 0.05)
F-COPES = 98.75 ± 7.65 vs. 93.4 ± 8.52 (p > 0.05) the IG compared to the CG. The IG also improved
GAD-7 = 3.45 ± 3.39 vs. 4.65 ± 4.07 (p > 0.05) caregivers’ competence.

The caregiver´s burden was significantly lower in

Bitek et al., 2023 [58] ZCBS = 32.14 ± 15.4 vs. 34.27 ± 14.2 (p < 0.05)
the IG compared to the CG after the intervention.
CCS = 13.48 ± 2.31 vs. 11.37 ± 2.48 (p < 0.001)
PCS = 28.48 ± 4.74 vs. 20.93 ± 7.10 (p < 0.001)
eHLS = 34.42 ± 4.74 vs. 26.93 ± 8.53 (p < 0.001) After the intervention, the IG exhibited significantly
MBIGF emotional exhaustion = 7.24 ± 3.27 vs. 8.90 ± 3.58 better caregiver competence, preparation for care,
Demir et al., 2023 [59] (p < 0.05) and e-health literacy than the CG. The IG showed
MBIGF personal accomplishment = 10.45 ± 4.13 vs. also better results in emotional exhaustion and
16.93 ± 5.10 (p < 0.05) personal accomplishment.
MBIGF depersonalization= 6.03 ± 2.38 vs. 6.43 ± 2.70
(p > 0.05)

LS7 c = 9.29 (1.59) vs. 8.41 (1.87) (p < 0.05) The IG showed a better improvement in LS7 than CG
Hussin et al., 2023 [60] Stroke risk 5 years c = 2.04 (1.21) vs. 2.57 (1.70) (p > 0.05) at 3 months (median difference = (95% CI) = 0.88
(1.68–0.08) (p < 0.05). No differences were found in
Stroke risk 10 years c = 3.53 (2.50) vs. 4.34 (3.28) (p > 0.05) the risk of stroke (p > 0.05).
SF-36 psychological subscale = 64.4 ± 14.53 vs. The IG showed significant differences in the
Mohammadi et al., 2023 [61] 51.09 ± 14.07 (p < 0.05) psychological subscale of the SF-36 compared to the
SF-36 physical subscale = 80.98 ± 17.06 vs. 77.71 ± 15.21
(p > 0.05) CG, but not in the physical domain.

ACS: Appraisal of Caregiving Threat Subscale; BAI: Beck Anxiety Inventory; BCOS: Bakas Caregiving Outcomes
Scale; BDI: Beck Depression Index; CBI: Caregiver Burden Inventory; CBS: Caregiving Burden Scale; CCS:
Caregiving Competence Scale; CES-D: Centre For Epidemiologic Studies Depression Scale; CGMS: Caregiving
Mastery Scale; CGS: Caregiving competence; CSI: Caregiver Strain Index; ; eHLS: e-Health Literacy Scale; F-COPES:
Family Crisis-oriented Personal Evaluation Scale; FAD: Family assessment device; FAI: Frenchay activities index;
GAD-7: Generalised anxiety disorder scale-7; LOT-R: revised life orientation test; LS7: Lifestyle 7 scores; MBIGF:
Maslach Burnout Inventory-General Form; OCBS: Oberst Caregiving Burden Scale Difficulty Subscale; PCS:
Preparedness For Caregiving Scale; PHQ-9: Patient Health Questionnaire Depression Scale; PSI: problem-solving
inventory; SSQ: Six-item Social Support Questionnaire; SWLS: Satisfaction with Life Scale; WHOQOL-BREF:
WHO Quality of Life-BREF; ZBISF: Zarit Burden Interview-Short Form; ZCBS: Zarit Caregiver Burden Scale.
a : mean differences (standard deviation); b : t-statistic; c : medians (interquartile range).

Depression was assessed in most of the articles. Some articles showed that the TH
interventions led to an improvement in the depressive symptoms of the CIs compared
to control interventions [43,44,48,50,52,55]. However, other articles found no significant
improvement [45–47,51,53,54].
There are conflicting results regarding caregiver burden. Perrin et al. [47] showed
that the intervention reduced burden at 3 months and LeLaurin et al. [55], Mou et al. [57],
and Betik et al. [58] also found a reduction in burden. However, Grant et al. [43,44] and
Elsheikh [56] did not find a reduction in caregiver burden.
The TH has a positive effect on the lives of CIs, reducing the number of unhealthy
days [52], anxiety [54], functional independence and family functioning [51], and increasing
lifestyle changes [60]. In terms of general health perception, only Mohammady et al. [61]
found an improvement in the psychological domain of the SF-36.
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 12 of 21
J. Clin. Med. 2024, 13, 1810 11 of 20

3.6.
3.6. Risk
Risk of
of Bias
Bias
Nine
Nine articles have
articles have aa low
low risk
risk of
of bias
bias [48–53,55,57,59],
[48–53,55,57,59], nine
nine have
have some
some concerns
concerns [44–
[44–
47,54,56,58,60,61]
47,54,56,58,60,61] and one study has a high risk of bias [43]. Figure 2 shows the
and one study has a high risk of bias [43]. Figure 2 shows the results of
results of
the RoB2 scale.
the RoB2 scale.

Figure
Figure 2.
2. RoB
RoB assessments
assessments for
for each
each study.
study. The
The plus
plus sign
sign means
meanslow
lowrisk
riskor
orbias;
bias;the
thequestion
questionmark
mark
moderate RoB and minus sign denotes high risk of bias and [43–61].
moderate RoB and minus sign denotes high risk of bias and [43–61].

3.7. Quality Assessment

Sixteen of
Sixteen ofthe
thearticles included
articles includedin this systematic
in this review
systematic are of good
review are ofquality
good [45–53,55,61],
quality [45–
with a score
53,55,61], ofa3score
with on the
of 3JADAD scale. Only
on the JADAD scale.three
Onlyarticles were of
three articles lowofmethodological
were low methodo-
quality, two withtwo
logical quality, a score
withof a 2score
[44,54]
of and one with
2 [44,54] and aone
score of a0 score
with [43]. Appendix B shows the
of 0 [43]. Appendix B
JADAD Scale.
shows the JADAD Scale.

4. Discussion
4. Discussion
Nineteen clinical
Nineteen clinicaltrials
trialswere
wereincluded
includedinin
this systematic
this systematicreview. It should
review. be noted
It should that
be noted
a variety of TH tools were used, in particular the use of telephone calls; video conferencing,
that a variety of TH tools were used, in particular the use of telephone calls; video confer-
messaging, and mobile applications were also used. These interventions may be helpful
encing, messaging, and mobile applications were also used. These interventions may be
to ICs to support them in their caregiving role. In all cases, these systems have shown no
helpful to ICs to support them in their caregiving role. In all cases, these systems have
worse results than conventional interventions, and in some trials have been superior to
shown no worse results than conventional interventions, and in some trials have been
them. No adverse effects have been reported.
superior to them. No adverse effects have been reported.
ICs need tools and interventions that enable them both to improve their capacity to
ICs need tools and interventions that enable them both to improve their capacity to
provide care and to improve their own health [62]. Therefore, it is necessary that ICs of
provide care and to improve their own health [62]. Therefore, it is necessary that ICs of SS
SS have resources available to them during the post-discharge process, as well as regular
have resources available to them during the post-discharge process, as well as regular
communication and support from health professionals [26].
communication and support from health professionals [26].
The use of TH in IC can serve several purposes: education, counselling, therapy, social
The use of TH in IC can serve several purposes: education, counselling, therapy, so-
support, and data monitoring [4,27]. There are several TH technologies that can be used to
cial support,
perform theseand data monitoring
functions, [4,27]. There
including telephone calls,are several TH technologies
videoconferencing, that canand
text messaging, be
J. Clin. Med. 2024, 13, 1810 12 of 20

the use of web-based interventions or mobile applications [4]. There is also a wide choice
of providers. Piran et al. [63] identified 843 mobile applications on iTunes in 2019. These
apps had different functions: communication, stroke risk calculation, speech therapy, motor
recovery, etc. Lobo et al. [37] identified 47 apps for IC stroke survivors. They focused on
several functionalities, such as educational resources, risk assessment, remote monitoring,
data sharing, and reminders. However, there was no single application that covered all
these aspects.

4.1. Population
One of the most important issues in the design and use of HT in SS ICs is the consider-
ation of their demographic characteristics. Previously, it has been noted that in most cases,
the IC is a close relative, with this role mainly falling to the spouse and/or children of the
caregiver [7]. In the studies included in this systematic review, the CI has a direct family
relationship with the SS, being mainly the spouse or daughter/son [43–45,47,49,50,52,55].
In terms of age, previous studies have shown that the ICs are usually older people [22], as
we found in our systematic review; ICs were over 45 years old, with the majority of articles
being over 50 years old [43–52,55,58]. And it is worth noting that there are more women
than men in most studies [43–47,50,52–55,58–61].
ICs do not have specialised training to perform their role [7], but they are willing to
improve their caring function [8]. This may also be one of the points where TH can help
the ICs.

4.2. Interventions
The studies reviewed included specific care programmes for ICs using different types
of TH, including telephone [43–45,50,51,53,56–59], videophone [47], web-based interven-
tions [46,48,59], mobile applications [60], and social media [61]. ICs’ familiarity with TH
tools may facilitate their acceptance, thereby improving adherence to these interventions.
However, even if ICs are unfamiliar with the technology, they can adhere to the pro-
gramme properly if they receive the right support [46]. TH can improve the interventions
received by ICs by facilitating access, limiting travel problems, and improving adherence
to programmes [28].
In addition to TH, the studies reviewed included specific care programmes for ICs,
aimed at meeting their needs. Thus, the use of the TH tool in isolation, without including a
programme tailored to the needs of the ICs, did not show significant effects on some of the
CGs [45,48,52]. When the programme allows the IC to contact a health professional [54],
adherence is higher than 96%.
Although new technologies can be challenging for ICs [64], many ICs find that TH
helps them in their care work [65], offering new opportunities for care and improving
their own health [66]. It is also noteworthy that the ICs find TH to be very positive and
useful and recommend its use [67–70]. In fact, in some cases, they have higher ratings than
face-to-face interventions [71]. Even if users have no previous experience, they can use the
tools if there is adequate technical support [69,70,72,73]. Users should be given appropriate
information, and it should not be assumed that they are familiar with the tools, even if they
are similar to those they use in their daily lives [73].

4.3. Outcomes
The articles included in this systematic review assessed several outcomes. One of the
most important outcomes was depression. Depressive symptoms were assessed in most
articles, using the Centre for Epidemiologic Studies Depression Scale [43,44,46–48,50,53,55].
Other instruments used were the Patient Health Questionnaire Depression Scale [45,48,52]
or the Beck Depression Index [54]. Caregiving burden was assessed using the Caregiving
Burden Scale [43,44], the Caregiver Strain Index [47,53], the Zarit Burden Interview-Short
Form [55,56,58] or the Caregiver Burden Inventory [57].
J. Clin. Med. 2024, 13, 1810 13 of 20

Self-perceived general health was assessed using one instrument, the SF-36 [43–45,61]
or the SF-12 [53]. The WHO-Quality of Life was used in one article [56]. However, for other
outcomes, the articles used different instruments. For example, the ability of the CI to cope
with the tasks was assessed using the problem-solving inventory [43,44,53] or the Perceived
Difficulty with Tasks [45]. Caregiver preparedness was assessed using the Preparedness for
Caregiving Scale [43,44,59], the Mastery Scale [48], the Caregiving Mastery Scale [49], the
Caregiving Competence Scale [53,59], and the Sense of Competence Questionnaire [50]. IC
satisfaction was assessed using the Client Satisfaction Questionnaire [43,44], the VA Care
Coordination and Home Telehealth Patient Satisfaction Survey [47] and the Satisfaction
with Life Scale [46]. The fact that the reviewed articles used different assessment tools
makes it difficult to compare their results. The anxiety was evaluated using the Beck
Anxiety Inventory [54] or the generalised anxiety disorder scale-7 [57]. Social support was
also evaluated [48,53] as well as family functioning [51,53].
Some outcomes were only assessed in one article: the impact of caregiving on the life
of the CI (using the Caregiving Outcomes Scale) [45], the number of unhealthy days [52],
self-esteem [48], threat appraisal [45], functional independence [51] or the caregiver´s
stroke risk [60].

4.4. Results
One of the most investigated outcomes in the articles was depression. The results
found were contradictory, with some studies showing a reduction in depressive symp-
toms [43,44,48], and others not [45,47]. Of particular interest are the results of Pfeiffer
et al. [50] and Bakas et al. [52], who found that improvements in depressive symptoms
were sustained for up to 12 months. TH programmes may be useful in the prevention of
depression. For example, although Perrin et al. [47] did not find a statistically significant
reduction in depression, they suggest that the telehealth intervention may have helped to
prevent an increase in depressive symptoms in those ICs who did not suffer from depres-
sion at baseline. Pierce et al. [46] found that ICs did not increase depressive symptoms after
1 year of web-based intervention; however, they suggested that the main reason was that
the ICs were not depressed at baseline.
There were also inconsistent results on caregiver mastery and preparedness, with
statistically significant differences found in some studies [44,46,53,57,59] but not in oth-
ers [43,48,50].
The effects of the TH in the lives of ICs have also been studied, and it has been
found that TH reduces the number of unhealthy days [52] and anxiety [54] and improves
the psychological domain of the SF-36 [61], the functional independence, and the family
functioning [51]. The TH helps also the CIs to modify their lifestyle [60]. The TH has
also been found to have a positive effect on task difficulty perception [45] and threat
appraisal [45]. However, TH has not shown positive effects on IC satisfaction [43,44,46,47].
An important point to consider in TH programmes is the real needs of the ICs. It
has been shown that the needs identified by ICs differ from those perceived by health
professionals and/or those designing HT tools [65,74]. If TH programmes are not aligned
with the real needs of end-users, their use and adherence will be hampered [75]. For this
reason, it is necessary to involve all of them in the design of health technology tools [65].
No adverse effects have been found in any case, showing that TH programmes may
be at least as appropriate as the usual care received by ICs of SS.

4.5. Risk of Bias

Almost half of the reviewed articles have a low risk of bias [48–53,55,57,59]. Of the
studies with some concerns, most of them are related to the domain “measurement of
the outcome” [44–47,54,56,58,60,61]. The main limitation is the unblinding of the outcome
assessors. LeLaurin et al. [55] evaluated the blinding procedure in their pilot clinical trial.
The assessors were asked which group they thought the clinical trial participants had
been allocated to. There was a significant association between the pattern of responses for
J. Clin. Med. 2024, 13, 1810 14 of 20

group allocation and the guess of the data collectors. This could be due to participants
commenting in a way that could alert the assessors to the intervention that the caregivers
were receiving. It is therefore necessary to monitor the correct blinding of the evaluators.

4.6. Quality Assessment

Only three of the articles [43,44,54] included in the systematic review had a score of
less than 3 on the JADAD scale. In those studies with good methodological quality, the
main problem was the lack of double blinding [45–53,55–61]. Given the characteristics of
the interventions, it is difficult to achieve blinding of both researchers and participants.

4.7. Limitations
This review contributes to improving the knowledge about the TH in ICs of stroke
patients. However, there is a potential for selection bias because we did not include
conference abstracts or any other grey literature. We have tried to include as many studies
as possible; we have screened the references of the papers included in the review and we
have searched whether the protocols of the clinical trials found in the databases have been
carried out.
Another limitation is that we did not conduct a meta-analysis of the trials included in
the review.
There is great variability in the objectives of the articles reviewed, in the intervention
programs, and in the outcome measures, which limits the comparability of their results.
Another limitation to be considered is the lack of studies evaluating which of the
ST systems is the most appropriate. There were no studies comparing different TH tools.
The opinion of the ICs on the most appropriate TH system could be assessed before the
development of the TH interventions [76].
There is also no clear evidence on the most appropriate dosage of ST programs. Only
LeLaurin et al. [55] compared the feasibility and use of a ST programme with different
dosages. In addition, studies of TH that extend interventions over time are rare; only one
study [50] was found to maintain the programme for one year. Although the needs of ICs
are known at the time of discharge [77], stroke is a chronic condition, and needs change
over time [78]. Similarly, no long-term follow-up of outcomes has been found.
The results of this systematic review show that telemedicine can help the ICs of
patients who have had a stroke. Although contradictory results were found for some of
the variables studied, in no case were the groups receiving telemedicine services shown to
have worse outcomes than the control groups, with results at least similar to those of the
control interventions [43–61]. As stroke is a pathology that requires survivor care, which
often falls to ICs, it is necessary to consider this type of intervention. In addition, there
may be interventions that reduce the cost of caring for these patients, as has been shown in
other pathologies [30,79]. However, more controlled clinical trials are needed to investigate
the most appropriate tools and doses. It is also necessary to use technologies that are
user-friendly and do not require sophisticated equipment. This will help to overcome
barriers to technology use [80]. Involving users of these technologies in the development
of telehealth programmes can also be an important element in facilitating adherence and
success. [81].

5. Conclusions
Based on the results of this systematic review, TH may be a useful tool to improve the
abilities and health of ICs of SS. Although there are contradictory results on the effects of
TH on depression and caregiver burden, positive effects have been found on the health
of ICs as well as on their ability to care. No adverse effects have been reported in any of
the articles.
More quality studies evaluating the effects of telemedicine on the ICs of stroke sur-
vivors are needed. These studies should also assess which tools are most useful, as well as
the most appropriate doses.
J. Clin. Med. 2024, 13, 1810 15 of 20

Author Contributions: Conceptualisation, J.C.Z.-E., C.B.M.-C., J.A.M.-U., R.P.-C. and J.A.M.-J.;

methodology, J.C.Z.-E. and C.B.M.-C.; software, J.C.Z.-E. and C.B.M.-C.; validation, J.C.Z.-E. and
C.B.M.-C.; formal analysis, J.C.Z.-E. and C.B.M.-C.; investigation, J.C.Z.-E., C.B.M.-C., J.A.M.-U.,
R.P.-C. and J.A.M.-J.; resources, J.C.Z.-E. and C.B.M.-C.; data curation, J.C.Z.-E. and C.B.M.-C.;
writing—original draft preparation, J.C.Z.-E. and C.B.M.-C.; writing—review and editing, J.C.Z.-E.,
C.B.M.-C., J.A.M.-U., R.P.-C. and J.A.M.-J.; project administration, J.C.Z.-E., C.B.M.-C., J.A.M.-U.,
R.P.-C. and J.A.M.-J. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflicts of interest.

Appendix A
Search strategy: Pubmed
((“stroke”[MeSH Terms] OR “stroke”[All Fields] OR “strokes”[All Fields] OR “stroke
s”[All Fields] OR (“cerebrovascular”[All Fields] AND “accident”[All Fields]) OR “cere-
brovascular accident”[All Fields] OR “cva”[All Fields] OR (“cerebrovascular”[All Fields]
AND (“event”[All Fields] OR “event s”[All Fields] OR “events”[All Fields])) OR “cve”[All
Fields])
AND
(“caregiver s”[All Fields] OR “caregivers”[MeSH Terms] OR “caregivers”[All Fields]
OR “caregiver”[All Fields] OR “caregiving”[All Fields] OR (“informal”[All Fields] AND
“caregiver”[All Fields]) OR “informal caregiver”[All Fields] OR “family”[MeSH Terms]
OR “family”[All Fields] OR “relative”[All Fields] OR “relatives”[All Fields] OR “relative
s”[All Fields] OR “relatively”[All Fields] OR (“family”[All Fields] AND “members”[All
Fields]) OR “family members”[All Fields] OR “caregiver burden” [MeSH Terms] OR (“care-
giver”[All Fields] AND “burden”[All Fields]) OR “caregiver burden”[All Fields] OR (“care-
giver”[All Fields] AND “stress”[All Fields]) OR “caregiver stress”[All Fields] OR “caregiver
fatigue”[All Fields] OR ((“caregiver s”[All Fields] OR “caregivers”[MeSH Terms] OR “care-
givers”[All Fields] OR “caregiver”[All Fields] OR “caregiving”[All Fields]) AND (“fatigua-
bility”[All Fields] OR “fatiguable”[All Fields] OR “fatigue”[MeSH Terms] OR “fatigue”[All
Fields] OR “fatigued”[All Fields] OR “fatigues”[All Fields] OR “fatiguing”[All Fields]
OR “fatigability”[All Fields])) OR (“caregiver”[All Fields] AND “burden”[All Fields]) OR
“caregiver burden”[All Fields] OR (“caregiver”[All Fields] AND “burnout”[All Fields]) OR
“caregiver burnout”[All Fields]))
AND
(“mobile applications”[MeSH Terms] OR (“mobile”[All Fields] AND “applications”[All
Fields]) OR “mobile applications”[All Fields] OR (“mobile”[All Fields] AND “applica-
tion”[All Fields]) OR “mobile application”[All Fields] OR (“mobile”[All Fields] AND
“app”[All Fields]) OR “mobile app”[All Fields] OR “mhealth s”[All Fields] OR “telemedicine”
[MeSH Terms] OR “telemedicine”[All Fields] OR “mhealth”[All Fields] OR “ehealth”[All
Fields] OR “internet based intervention”[MeSH Terms] OR (“internet based”[All Fields]
AND “intervention”[All Fields]) OR “internet based intervention”[All Fields] OR (“web”[All
Fields] AND “based”[All Fields] AND “intervention”[All Fields]) OR “web based inter-
vention”[All Fields] OR (“internet”[All Fields] AND “based”[All Fields] AND “interven-
tion”[All Fields]) OR “internet based intervention”[All Fields] OR “telehealth s”[All Fields]
OR “telehealth”[All Fields] OR “telemonitor”[All Fields] OR “telemonitored”[All Fields] OR
“telemonitoring”[All Fields] OR “telemonitors”[All Fields] OR “telepractice”[All Fields] OR
“telenursing”[MeSH Terms] OR “telenursing”[All Fields] OR “telecare”[All Fields] OR “com-
puters, handheld”[MeSH Terms] OR (“computers”[All Fields] AND “handheld”[All Fields])
OR “handheld computers”[All Fields] OR (“computer”[All Fields] AND “handheld”[All
Fields]) OR “computer handheld”[All Fields] OR “telerehabilitation”[MeSH Terms] OR
“telerehabilitation”[All Fields] OR (“tele”[All Fields] AND “rehabilitation”[All Fields]) OR
J. Clin. Med. 2024, 13, 1810 16 of 20

“tele rehabilitation”[All Fields] OR (“virtual”[All Fields] AND “rehabilitation”[All Fields])

OR “virtual rehabilitation”[All Fields] OR (“remote”[All Fields] AND “rehabilitation”[All
Fields]) OR “remote rehabilitation”[All Fields] OR “mobile applications”[MeSH Terms] OR
(“mobile”[All Fields] AND “applications”[All Fields]) OR “mobile applications”[All Fields]
OR (“mobile”[All Fields] AND “app”[All Fields]) OR “mobile app”[All Fields] OR (“mo-
bile”[All Fields] AND “application”[All Fields]) OR “mobile application”[All Fields] OR
“smartphone”[MeSH Terms] OR “smartphone”[All Fields] OR “smartphones”[All Fields]
OR “smartphone s”[All Fields] OR “cell phone”[MeSH Terms] OR (“cell”[All Fields] AND
“phone”[All Fields]) OR “cell phone”[All Fields] OR “telephone”[MeSH Terms] OR “tele-
phone”[All Fields] OR “telephones”[All Fields] OR “telephoned”[All Fields] OR “tele-
phonic”[All Fields] OR “telephonically”[All Fields] OR “telephoning”[All Fields] OR “hot-
lines”[MeSH Terms] OR “hotlines”[All Fields] OR (“hot”[All Fields] AND “lines”[All Fields])
OR “hot lines”[All Fields] OR “patient portals”[MeSH Terms] OR (“patient”[All Fields]
AND “portals”[All Fields]) OR “patient portals”[All Fields] OR “videoconferenced”[All
Fields] OR “videoconferencing”[MeSH Terms] OR “videoconferencing”[All Fields])
Search strategy: Scopus
TITLE-ABS-KEY ((“stroke*” OR “cerebrovascular accident” OR “cva” OR “cerebrovas-
cular event” OR “cve”) AND (“caregiv*” OR “informal caregiv*” OR “famil* caregiv*”
OR “relativ* caregiv*” OR “caregiv* burden” OR “caregiv* stress” OR “caregiv* fatigu*”
OR “caregiv* burnout”) AND (“mobile app*” OR “mhealth*” OR “telemedicine” OR
“ehealth*” OR “internet based intervention*” OR “web based intervention*” OR “tele-
health*” OR “telemonitor*” OR “telepractic*” OR “telenurs*” OR “telecare” OR “handheld
computer*” OR “telerehabilitation” OR “virtual rehabilitation” OR “remote rehabilitation”
OR “Smartphone*” OR “cell phone*” OR “telephon*” OR “hot line*” OR “patient* portal*”
OR “videoconferenc*”))
Search strategy: Web of Science
(TS = stroke* OR TS = cerebrovascular accident OR TS = cva OR TS = cerebrovascular
event* OR TS = cve) AND (TS = caregiv* burden OR TS = caregiv* stress OR TS = caregiv*
fatigu* OR TS= caregiv* burnout) AND (TS = mobile app* OR TS = mhealth* OR TS =
telemedicine OR TS = ehealth* OR TS = internet based intervention* OR TS = web based
intervention* OR TS = telehealth* OR TS = telemonitor* OR TS = telepractic* OR TS =
telenurs* OR TS = telecare OR TS = handheld computer* OR TS = telerehabilitation OR
TS = virtual rehabilitation OR TS = remote rehabilitation OR TS = Smartphone* OR TS
= cell phone* OR TS = telephon* OR TS = hot line* OR TS = patient* portal* OR TS =
videoconferenc*)
Search strategy: CINAHL, Psychology and Behavioral Sciences Collection, APA
PsycInfo
(“stroke*” OR “cerebrovascular accident” OR “cva” OR “cerebrovascular event” OR
“cve”) AND (“caregiv*” OR “informal caregiv*” OR “famil* caregiv*” OR “relativ* caregiv*”
OR “caregiv* burden” OR “caregiv* stress” OR “caregiv* fatigu*” OR “caregiv* burnout”)
AND (“mobile app*” OR “mhealth*” OR “telemedicine” OR “ehealth*” OR “internet based
intervention*” OR “web based intervention*” OR “telehealth*” OR “telemonitor*” OR
“telepractic*” OR “telenurs*” OR “telecare” OR “handheld computer*” OR “telerehabilita-
tion” OR “virtual rehabilitation” OR “remote rehabilitation” OR “Smartphone*” OR “cell
phone*” OR “telephon*” OR “hot line*” OR “patient* portal*” OR “videoconferenc*”).
J. Clin. Med. 2024, 13, 1810 17 of 20

Appendix B
Table A1. JADAD scale for each article.

Appropriated Appropriated Description of

Randomisation Blinded
Paper Randomisation Blinded Withdrawals Total
Present Present
Utilised Utilised and Dropouts
Grant et al., 1999 [43] 0 0 0 0 0 0
Grant et al., 2002 [44] 1 0 0 0 1 2
Bakas et al., 2009 [45] 1 1 0 0 1 3
Pierce et al., 2009 [46] 1 1 0 0 1 3
Perrin et al., 2010 [47] 1 1 0 0 1 3
Smith et al., 2012 [48] 1 1 0 0 1 3
Kim et al., 2013 [49] 1 1 0 0 1 3
Pfeiffer et al., 2014 [50] 1 1 0 0 1 3
Bishop et al., 2014 [51] 1 1 0 0 1 3
Bakas et al., 2015 [52] 1 1 0 0 1 3
Cheng et al., 2015 [53] 1 1 0 0 1 3
Goudarzian et al., 2019 [54] 1 1 0 0 0 2
LeLaurin et al., 2021 [55] 1 1 0 0 1 3
Elsheikh et al., 2022 [56] 1 1 0 0 1 3
Mou et al., 2022 [57] 1 1 0 0 1 3
Betik et al., 2023 [58] 1 1 0 0 1 3
Demir et al., 2023 [59] 1 1 0 0 1 3
Hussin et al., 2023 [60]
Mohammadi et al., 2023 [61] 1 1 0 0 1 3

References
1. Beard, J.R.; Officer, A.; de Carvalho, I.A.; Sadana, R.; Pot, A.M.; Michel, J.-P.; Lloyd-Sherlock, P.; Epping-Jordan, J.E.; Peeters,
G.M.E.E.G.; Mahanani, W.R.; et al. The World report on ageing and health: A policy framework for healthy ageing. Lancet 2016,
387, 2145–2154. [CrossRef]
2. Maresova, P.; Javanmardi, E.; Barakovic, S.; Barakovic Husic, J.; Tomsone, S.; Krejcar, O.; Kuca, K. Consequences of chronic
diseases and other limitations associated with old age—A scoping review. BMC Public Health 2019, 19, 1431. [CrossRef]
3. Pache, B.; Vollenweider, P.; Waeber, G.; Marques-Vidal, P. Prevalence of measured and reported multimorbidity in a representative
sample of the Swiss population. BMC Public Health 2014, 15, 65.
4. Chi, N.C.; Demiris, G. A systematic review of telehealth tools and interventions to support family caregivers. J. Telemed. Telecare
2015, 21, 37–44. [CrossRef]
5. Kent, E.E.; Rowland, J.H.; Northouse, L.; Litzelman, K.; Chou, W.Y.; Shelburne, N.; Timura, C.; O’Mara, A.; Huss, K. Caring for
caregivers and patients: Research and clinical priorities for informal cancer caregiving. Cancer 2016, 122, 1987–1995. [CrossRef]
6. Zapata-Sampedro, M.A.; Matute-Caballero, M.N.; Gómez-Reina, M.V. Plan de cuidados enfermeros al cuidador informal: Caso
clínico. Enferm. Clin. 2007, 17, 157–161. [CrossRef] [PubMed]
7. Pristavec, T.; Luth, E.A. Informal Caregiver Burden, Benefits, and Older Adult Mortality: A Survival Analysis. J. Gerontol. B
Psychol. Sci. Soc. Sci. 2020, 75, 2193–2206. [CrossRef] [PubMed]
8. Pakenham, K.I.; Chiu, J.; Bursnall, S.; Cannon, T. Relations between social support, appraisal and coping and both positive and
negative outcomes in young carers. J. Health Psychol. 2007, 12, 89–102. [CrossRef] [PubMed]
9. Winter, K.H.; Bouldin, E.D.; Andresen, E.M. Lack of choice in caregiving decision and caregiver risk of stress, North Carolina,
2005. Prev. Chronic Dis. 2010, 7, A41.
10. Ornstein, K.; Gaugler, J.E. The problem with “problem behaviors”: A systematic review of the association between individual
patient behavioral and psychological symptoms and caregiver depression and burden within the dementia patient-caregiver
dyad. Int. Psychogeriatr. 2012, 24, 1536–1552. [CrossRef]
11. Christian, L.M.; Wilson, S.J.; Madison, A.A.; Prakash, R.S.; Burd, C.E.; Rosko, A.E.; Kiecolt-Glaser, J.K. Understanding the health
effects of caregiving stress: New directions in molecular aging. Ageing Res. Rev. 2023, 92, 102096. [CrossRef]
12. Graven, L.J.; Boel-Studt, S.; Buck, H.G.; Abbott, L.; Grant, J.S. Heart Failure Caregiver Self-Care: A Latent Class Analysis. Clin.
Nurs. Res. 2021, 30, 625–635. [CrossRef]
13. Riffin, C.; Van Ness, P.H.; Wolff, J.L.; Fried, T. Multifactorial Examination of Caregiver Burden in a National Sample of Family and
Unpaid Caregivers. J. Am. Geriatr. Soc. 2019, 67, 277–283. [CrossRef]
14. Cheng, S.T. Dementia Caregiver Burden: A Research Update and Critical Analysis. Curr. Psychiatry Rep. 2017, 19, 64. [CrossRef]
[PubMed]
J. Clin. Med. 2024, 13, 1810 18 of 20

15. Joling, K.J.; van Marwijk, H.W.; Veldhuijzen, A.E.; van der Horst, H.E.; Scheltens, P.; Smit, F.; van Hout, H.P. The two-year
incidence of depression and anxiety disorders in spousal caregivers of persons with dementia: Who is at the greatest risk? Am. J.
Geriatr. Psychiatry 2015, 23, 293–303. [CrossRef] [PubMed]
16. Regenhardt, R.W.; Das, A.S.; Lo, E.H.; Caplan, L.R. Advances in Understanding the Pathophysiology of Lacunar Stroke: A Review.
JAMA Neurol. 2018, 75, 273–1281. [CrossRef] [PubMed]
17. Feigin, V.L.; Forouzanfar, M.H.; Krishnamurthi, R.; Mensah, G.A.; Connor, M.; Bennett, D.A.; Moran, A.E.; Sacco, R.L.; Anderson,
L.; Truelsen, T.; et al. Global and regional burden of stroke during 1990–2010: Findings from the global burden of disease study
2010. Lancet 2014, 383, 245–255. [CrossRef] [PubMed]
18. Mackay, J.; Mensah, G. The Atlas of Heart Disease and Stroke; WHO: Geneva, Switzerland, 2004.
19. Winstein, C.J.; Stein, J.; Arena, R.; Bates, B.; Cherney, L.R.; Cramer, S.C.; Deruyter, F.; Eng, J.J.; Fisher, B.; Harvey, R.L.; et al.
Guidelines for adult stroke rehabilitation and recovery. Stroke 2016, 47, e98–e169. [CrossRef] [PubMed]
20. Larson, J.; Franzén-Dahlin, A.; Billing, E.; Arbin, M.; Murray, V.; Wredling, R. The impact of a nurse-led support and education
programme for spouses of stroke patients: A randomized controlled trial. J. Clin. Nurs. 2005, 14, 995–1003. [CrossRef] [PubMed]
21. Rodgers, H.; Atkinson, C.; Bond, S.; Suddes, M.; Dobson, R.; Curless, R. Randomized controlled trial of a comprehensive stroke
education program for patients and caregivers. Stroke 1999, 30, 2585–2591. [CrossRef] [PubMed]
22. Hickenbottom, S.L.; Fendraick, J.M.; Kutcher, J.S.; Kabeto, M.U.; Katz, S.J.; Langa, K.M. A national study of the quantity and cost
of informal caregiving for the elderly with a stroke. Neurology 2002, 58, 1754–1759. [CrossRef]
23. Visser-Meily, A.; Post, M.; van de Port, I.; Maas, C.; Forstberg-Warleby, G.; Lindeman, E. Psychosocial functioning of spouses with
patients with stroke from initial rehabilitation to 3 years post-stroke: Course and relations with coping strategies. Stroke 2009, 40,
1399–1404. [CrossRef]
24. Boonsin, S.; Deenan, A.; Wacharasin, C. Factors Influencing the Burden of Family Caregiving for Survivors of Stroke. Pac. Rim Int.
J. Nurs. Res. 2021, 25, 102–113.
25. Pindus, D.M.; Mullis, R.; Lim, L.; Wellwood, I.; Rundell, A.V.; Azah Abd Aziz, N.; Mant, J. Stroke Survivors’ and Informal
Caregivers’ Experiences of Primary Care and Community Healthcare Services—A Systematic Review and Meta-Ethnography.
PLoS ONE 2018, 13, e0192533.
26. Martinsen, R.; Kirkevold, M.; Sveen, U. Young and midlife stroke survivors’ experiences with the health services and long-term
follow-up needs. J. Neurosci. Nurs. 2015, 47, 27–35. [CrossRef]
27. Bashshur, R.L.; Shannon, G.; Krupinski, E.A.; Grigsby, J. Sustaining and realizing the promise of telemedicine. Telemed. e-Health
2013, 19, 339–345. [CrossRef] [PubMed]
28. Aldehaim, A.Y.; Alotaibi, F.F.; Uphold, C.R.; Dang, S. The impact of technology-based interventions on informal caregivers of
stroke survivors: A systematic review. Telemed. J. e-Health 2016, 22, 223–231. [CrossRef] [PubMed]
29. Glueckauf, R.L.; Davis, W.S.; Willis, F.; Sharma, D.; Gustafson, D.J.; Hayes, J.; Stutzman, M.; Proctor, J.; Kazmer, M.M.; Murray, L.;
et al. Telephone-based, cognitive-behavioral therapy for African American dementia caregivers with depression: Initial findings.
Rehabil. Psychol. 2012, 57, 124–139. [CrossRef] [PubMed]
30. Martínez-Alcalá, C.I.; Pliego-Pastrana, P.; Rosales-Lagarde, A.; Lopez-Noguerola, J.S.; Molina-Trinidad, E.M. Information and
Communication Technologies in the Care of the Elderly: Systematic Review of Applications Aimed at Patients With Dementia
and Caregivers. JMIR Rehabil. Assist. Technol. 2016, 3, e6. [CrossRef] [PubMed]
31. Chen, J.; Jin, W.; Zhang, X.X.; Xu, W.; Liu, X.N.; Ren, C.C. Telerehabilitation Approaches for Stroke Patients: Systematic Review
and Meta-analysis of Randomized Controlled Trials. J. Stroke Cerebrovasc. Dis. 2015, 24, 2660–2668. [CrossRef] [PubMed]
32. Tchero, H.; Tabue Teguo, M.; Lannuzel, A.; Rusch, E. Telerehabilitation for Stroke Survivors: Systematic Review and Meta-Analysis.
J. Med. Internet Res. 2018, 20, e10867. [CrossRef] [PubMed]
33. Johansson, T.; Wild, C. Telerehabilitation in stroke care—A systematic review. J. Telemed. Telecare 2011, 17, 1–6. [CrossRef]
[PubMed]
34. Sun, W.-J.; Song, Y.-Y.; Wang, C.; Jiang, Y.; Cui, W.-Y.; Liu, W.-J.; Liu, Y. Telerehabilitation for Family Caregivers of Stroke Survivors:
A Systematic Review and Meta-Analysis. J. Nurs. Manag. 2023, 2023, 3450312. [CrossRef]
35. Denham AM, J.; Wynne, O.; Baker, A.L.; Spratt, N.J.; Bonevski, B. The unmet needs of carers of stroke survivors: An evaluation of
Google search results. Health Inform. J. 2020, 26, 934–944. [CrossRef] [PubMed]
36. Firmawati, E.; Setyopanoto, I.; Pangastuti, H.S. Mobile Health Application to Support Family Recurrent Stroke Prevention:
Scoping Review. Open Access Maced. J. Med. Sci. 2021, 9, 142–151. [CrossRef]
37. Lobo, E.H.; Frølich, A.; Kensing, F.; Rasmussen, L.J.; Livingston, P.M.; Grundy, J.; Abdelrazek, M. mHealth applications to support
caregiver needs and engagement during stroke recovery: A content review. Res. Nurs. Health 2021, 44, 213–225. [CrossRef]
38. Page, M.J.; Moher, D. Evaluations of the uptake and impact of the preferred reporting items for systematic reviews and meta-
analyses (PRISMA) statement and extensions: A scoping review. Syst. Rev. 2017, 6, 263. [CrossRef]
39. Munn, Z.; Stern, C.; Aromataris, E.; Lockwood, C.; Jordan, Z. What kind of systematic review should I conduct? A proposed
typology and guidance for systematic reviewers in the medical and health sciences. BMC Med. Res. Methodol. 2018, 18, 5.
[CrossRef]
40. Oremus, M.; Wolfson, C.; Perrault, A.; Demers, L.; Momoli, F.; Moride, Y. Interrater reliability of the modified Jadad quality scale
for systematic reviews of Alzheimer’s disease drug trials. Dement. Geriatr. Cogn. Disord. 2001, 12, 232–236. [CrossRef]
J. Clin. Med. 2024, 13, 1810 19 of 20

41. Sterne, J.A.C.; Savović, J.; Page, M.J.; Elbers, R.G.; Blencowe, N.S.; Boutron, I.; Cates, C.J.; Cheng, H.Y.; Corbett, M.S.; Eldridge,
S.M.; et al. RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ 2019, 366, l4898. [CrossRef]
42. Clark, H.; Wells, G.A.; Huët, C.; McAlister, F.A.; Salmi, L.R.; Fergusson, D.; Laupacis, A. Assessing the quality of randomized
trials: Reliability of the Jadad scale. Control. Clin. Trials 1999, 20, 448–452. [CrossRef] [PubMed]
43. Grant, J.S. Social problem-solving partnerships with family caregivers. Rehabil. Nurs. 1999, 24, 254–260. [CrossRef] [PubMed]
44. Grant, J.S.; Elliott, T.R.; Weaver, M.; Bartolucci, A.A.; Giger, J.N. Telephone intervention with family caregivers of stroke survivors
after rehabilitation. Stroke 2002, 33, 2060–2065. [CrossRef]
45. Bakas, T.; Farran, C.J.; Austin, J.K.; Given, B.A.; Johnson, E.A.; Williams, L.S. Stroke caregiver outcomes from the Telephone
Assessment and Skill-Building Kit (TASK). Top. Stroke Rehabil. 2009, 16, 105–121. [CrossRef]
46. Pierce, L.L.; Steiner, V.L.; Khuder, S.A.; Govoni, A.L.; Horn, L.J. The effect of a Web-based stroke intervention on carers’ well-being
and survivors’ use of healthcare services. Disabil. Rehabil. 2009, 31, 1676–1684. [CrossRef] [PubMed]
47. Perrin, P.B.; Johnston, A.; Vogel, B.; Heesacker, M.; Vega-Trujillo, M.; Anderson, J.; Rittman, M. A culturally sensitive Transition
Assistance Program for stroke caregivers: Examining caregiver mental health and stroke rehabilitation. J. Rehabil. Res. Dev. 2010,
47, 605–617. [CrossRef]
48. Smith, G.C.; Egbert, N.; Dellman-Jenkins, M.; Nanna, K.; Palmieri, P.A. Reducing depression in stroke survivors and their informal
caregivers: A randomized clinical trial of a Web-based intervention. Rehabil. Psychol. 2012, 57, 196–206. [CrossRef]
49. Kim, J.I.; Lee, S.; Kim, J.H. Effects of a web-based stroke education program on recurrence prevention behaviors among stroke
patients: A pilot study. Health Educ. Res. 2013, 28, 488–501. [CrossRef]
50. Pfeiffer, K.; Beische, D.; Hautzinger, M.; Berry, J.W.; Wengert, J.; Hoffrichter, R.; Becker, C.; van Schayck, R.; Elliott, T.R. Telephone-
based problem-solving intervention for family caregivers of stroke survivors: A randomized controlled trial. J. Consult. Clin.
Psychol. 2014, 82, 628–643. [CrossRef]
51. Bishop, D.; Miller, I.; Weiner, D.; Guilmette, T.; Mukand, J.; Feldmann, E.; Keitner, G.; Springate, B. Family Intervention: Telephone
Tracking (FITT): A pilot stroke outcome study. Top. Stroke Rehabil. 2014, 21 (Suppl. S1), S63–S74. [CrossRef]
52. Bakas, T.; Austin, J.K.; Habermann, B.; Jessup, N.M.; McLennon, S.M.; Mitchell, P.H.; Morrison, G.; Yang, Z.; Stump, T.E.; Weaver,
M.T. Telephone Assessment and Skill-Building Kit for Stroke Caregivers: A Randomized Controlled Clinical Trial. Stroke 2015, 46,
3478–3487. [CrossRef] [PubMed]
53. Cheng, H.Y.; Chair, S.Y.; Chau, J.P.C. Effectiveness of a strength-oriented psychoeducation on caregiving competence, problem-
solving abilities, psychosocial outcomes and physical health among family caregiver of stroke survivors: A randomised controlled
trial. Int. J. Nurs. Stud. 2018, 87, 84–93. [CrossRef] [PubMed]
54. Goudarzian, M.; Fallahi-Khoshknab, M.; Dalvandi, A.; Delbari, A.; Biglarian, A. Effect of Telenursing on Levels of Depression
and Anxiety in Caregivers of Patients with Stroke: A Randomized Clinical Trial. Iran. J. Nurs. Midwifery Res. 2018, 23, 248–252.
[PubMed]
55. LeLaurin, J.H.; Freytes, I.M.; Findley ke Schmitzberger, M.K.; Eliazar-Macke, N.D.; Orozco, T.; Uphold, C.R. Feasibility and
acceptability of a telephone and web-bases stroke caregiver intervention: A pilot randomized controlled trial of the RESCUE
intervention. Clin. Rehabil. 2021, 35, 253–265. [CrossRef] [PubMed]
56. Elsheikh, M.A.; Moriyama, M.; Rahman, M.M.; Kako, M.; El-Monshed, A.H.; Zoromba, M.; Zehry, H.; Khalil, M.H.; El-Gilany,
A.H.; Amr, M. Effect of a tailored multidimensional intervention on the care burden among family caregivers of stroke survivors:
A randomised controlled trial. BMJ Open 2022, 12, e049741. [CrossRef] [PubMed]
57. Mou, H.; Lam, S.K.K.; Chien, W.T. Effects of a family-focused dyadic psychoeducational intervention for stroke survivors and
their family caregivers: A pilot study. BMC Nurs. 2022, 21, 364. [CrossRef]
58. Bitek, D.E.; Erol, O. The effect of discharge training and telephone counseling service on patients’ functional status and caregiver
burden after stroke: A randomized controlled trial. Neurol. Asia 2023, 28, 583–592. [CrossRef]
59. Demir Avci, Y.; Gözüm, S. Effects of Transitional Care Model-Based Interventions for Stroke Patients and Caregivers on Caregivers’
Competence and Patient Outcomes: Randomized Controlled Trial. Comput. Inform. Nurs. 2023, 41, 805–814. [CrossRef]
60. Hussin, R.; Aziz, A.F.A.; Ali, M.F.; Monoto, E.M.M.; Arvinder-Singh, H.S.; Alabed, A.A.A.; Zaidi, W.A.W.; Ibrahim, N.M.; FRCPE.
Stroke Riskometer Application (SRA™) influence on lifestyle changes of home bound familial Malaysian stroke caregivers: A
randomised controlled trial in a primary care based longer term stroke care facility. BMC Prim. Care 2023, 24, 181. [CrossRef]
61. Mohammadi, F.; Ardalan, H.B.; Dehghankar, L.; Motalebi, S.A. Effect of Telenursing on the Quality of Life of Caregivers of Older
Patients with Stroke. Rev. Recent Clin. Trials 2023, 18, 275–281. [CrossRef]
62. Perry, L.; Middleton, S. An investigation of family carers’ needs following stroke survivors’ discharge from acute hospital care in
Australia. Disabil. Rehabil. 2011, 33, 1890–1900. [CrossRef]
63. Piran, P.; Thomas, J.; Kunnakkat, S.; Pandey, A.; Gilles, N.; Weingast, S.; Burton, D.; Balucani, C.; Levine, S.R. Mobile Applications
for Stroke (MAPPS) Investigators. Medical Mobile Applications for Stroke Survivors and Caregivers. J. Stroke Cerebrovasc. Dis.
2019, 28, 104318. [CrossRef]
64. Dunne, S.; Close, H.; Richards, N.; Ellison, A.; Lane, A.R. Maximizing Telerehabilitation for Patients with Visual Loss after Stroke:
Interview and Focus Group Study with Stroke Survivors, Carers, and Occupational Therapists. J. Med. Internet Res. 2020, 22,
e19604. [CrossRef]
J. Clin. Med. 2024, 13, 1810 20 of 20

65. Brouns, B.; Meesters, J.J.L.; Wentink, M.M.; de Kloet, A.J.; Arwert, H.J.; Vliet Vlieland, T.P.M.; Boyce, L.W.; van Bodegom-Vos, L.
Why the uptake of eRehabilitation programs in stroke care is so difficult-a focus group study in the Netherlands. Implement. Sci.
2018, 13, 133. [CrossRef]
66. Busetto, L.; Sert, M.; Herzog, F.; Hoffmann, J.; Stang, C.; Amiri, H.; Seker, F.; Purrucker, J.; Mundiyanapurath, S.; Ringleb, P.A.;
et al. “But it’s a nice compromise”—Qualitative multi-centre study of barriers and facilitators to acute telestroke cooperation in a
regional stroke network. Eur. J. Neurol. 2022, 29, 208–216. [CrossRef]
67. Lutz, B.J.; Chumbler, N.R.; Lyles, T.; Hoffman, N.; Kobb, R. Testing a home-telehealth programme for US veterans recovering
from stroke and their family caregivers. Disabil. Rehabil. 2009, 31, 402–409. [CrossRef] [PubMed]
68. Taylor, D.M.; Stone, S.D.; Huijbregts, M.P. Remote participants’ experiences with a group-based stroke self-management program
using videoconference technology. Rural Remote Health 2012, 12, 1947. [CrossRef] [PubMed]
69. Al-Khathaami, A.M.; Alshahrani, S.M.; Kojan, S.M.; Al-Jumah, M.A.; Alamry, A.A.; El-Metwally, A.A. Cultural acceptance of
robotic telestroke medicine among patients and healthcare providers in Saudi Arabia. Results of a pilot study. Neurosciences 2015,
20, 27–30. [PubMed]
70. Gong, E.; Gu, W.; Luo, E.; Tan, L.; Donovan, J.; Sun, C.; Yang, Y.; Zang, L.; Bao, P.; Yan, L.L. Development and Local Contextual-
ization of Mobile Health Messages for Enhancing Disease Management Among Community-Dwelling Stroke Patients in Rural
China: Multimethod Study. JMIR Mhealth Uhealth 2019, 7, e15758. [CrossRef]
71. Bakas, T.; Farran, C.J.; Austin, J.K.; Given, B.A.; Johnson, E.A.; Williams, L.S. Content validity and satisfaction with a stroke
caregiver intervention program. J. Nurs. Sch. 2009, 41, 368–375. [CrossRef] [PubMed]
72. Nichols, M.; Singh, A.; Sarfo, F.S.; Treiber, F.; Tagge, R.; Jenkins, C.; Ovbiagele, B. Post-intervention qualitative assessment of
mobile health technology to manage hypertension among Ghanaian stroke survivors. J. Neurol. Sci. 2019, 406, 116462. [CrossRef]
73. Gibson, J.; Lightbody, E.; McLoughlin, A.; McAdam, J.; Gibson, A.; Day, E.; Fitzgerald, J.; May, C.; Price, C.; Emsley, H.; et al. ‘It
was like he was in the room with us’: Patients’ and carers’ perspectives of telemedicine in acute stroke. Health Expect. 2016, 19,
98–111. [CrossRef]
74. Wentink, M.; van Bodegom-Vos, L.; Brouns, B.; Arwert, H.; Houdijk, S.; Kewalbansing, P.; Boyce, L.; Vliet Vlieland, T.; de Kloet, A.;
Meesters, J. How to improve eRehabilitation programs in stroke care? A focus group study to identify requirements of end-users.
BMC Med. Inform. Decis. Mak. 2019, 19, 145. [CrossRef]
75. Arnrich, B.; Mayora, O.; Bardram, J.; Tröster, G. Pervasive healthcare: Paving the way for a pervasive, user-centered and
preventive healthcare model. Methods Inf. Med. 2010, 49, 67–73. [PubMed]
76. Bakas, T.; McCarthy, M.J.; Israel, J.; Brehm, B.J.; Dunning, K.; Rota, M.; Turner, M.; Miller, E.L. Adapting the telephone assessment
and skill-building kit to the telehealth technology preferences of stroke family caregivers. Res. Nurs. Health 2021, 44, 81–91.
[CrossRef]
77. Bernocchi, P.; Vanoglio, F.; Baratti, D.; Morini, R.; Rocchi, S.; Luisa, A.; Scalvini, S. Home-based telesurveillance and rehabilitation
after stroke: A real-life study. Top. Stroke Rehabil. 2016, 23, 106–115. [CrossRef] [PubMed]
78. Bakas, T.; Jessup, N.M.; McLennon, S.M.; Habermann, B.; Weaver, M.T.; Morrison, G. Tracking patterns of needs during a
telephone follow-up programme for family caregivers of persons with stroke. Disabil. Rehabil. 2016, 38, 1780–1790. [CrossRef]
[PubMed]
79. Lee, J.Y.; Lee, S.W.H. Telemedicine Cost-Effectiveness for Diabetes Management: A Systematic Review. Diabetes Technol. Ther.
2018, 20, 492–500. [CrossRef] [PubMed]
80. Yi, J.S.; Pittman, C.A.; Price, C.L.; Nieman, C.L.; Oh, E.S. Telemedicine and Dementia Care: A Systematic Review of Barriers and
Facilitators. J. Am. Med. Dir. Assoc. 2021, 22, 1396–1402. [CrossRef] [PubMed]
81. Ariza-Vega, P.; Prieto-Moreno, R.; Mora-Traverso, M.; Molina-García, P.; Ashe, M.C.; Martín-Matillas, M. Co-creation of mHealth
intervention for older adults with hip fracture and family caregivers: A qualitative study. Disabil. Rehabil. Assist. Technol. 2022,
1–10. [CrossRef]

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