Review question/objective The review objective is to synthesize the best available evidence on the efficacy of interventions using the telephone to improve the wellbeing of family caregivers of people with chronic diseases. The review question is: What are the effects of interventions using the telephone versus other technologies, strategies, or usual care to improve the wellbeing of family caregivers of people with chronic diseases, in the physical, psychological, or spiritual domains? Background According to the World Health Organization (WHO), chronic diseases are permanent, leave residual disability, are caused by nonreversible pathological alteration, require special training of the patient for the rehabilitation, or may be expected to require a long period of supervision, observation or care1. Chronic diseases include hypertension, diabetes, cardiovascular diseases, cancer, stroke, and Alzheimer's disease, among others. Due to the characteristics and consequences of these diseases, those affected constantly need someone to support them and provide basic care, this person is often known as a caregiver. The family caregiver refers to an adult, with kinship or affinity, who assumes the responsibilities of caring for a loved one living with a chronic and disabling disease, and participates in decision making. The family caregiver performs or supervises the activities of daily life to compensate for the malfunctions or limitations of the person in need of care2. The experience of being a caregiver for a person with a chronic disease is variable according to each situation. Often, it causes self-negligence, increased duties and responsibilities, health issues, anxiety, depression, and changes in lifestyle of the caregiver3. This means that caring becomes a stress factor that impacts negatively on the caregivers and may overloads them. In this sense, providing informal care has been conceptualized as a stressful life event4. In recent years, Information and Communication Technologies such as the telephone, television, and internet have the potential to improve the quality of care and access to health services to different populations, including family caregivers of people with chronic diseases5 Since its invention, the telephone has been used as a fundamental tool in medical communication6, especially in industrialized countries7. Its use has been important to offer health care, including education, psychosocial therapy8, and emotional support9 for people with chronic illness and their family caregivers. According to Skipwith10, telephone use eliminates some of the major limitations of out-of-home interventions, such as traveling, making arrangements for an alternative caregiver, searching for an alternate caregiver, and worrying due to absence from the person being cared for. It also provides a means of reaching isolated or rural caregivers who have few or no available services. Telephone care can be a cost-effective, time efficient, and culturally acceptable intervention, and has a potential value with caregivers comparable to the outcomes derived from pioneer mental health services, such as crisis intervention, suicide hot lines, and information and referral services Studies conducted in the United States11-12 and United Kingdom13-14, researching the possibility of using the phone in health has shown that people would like to have access to health care professionals by phone. The assessment of satisfaction with this medium was high in groups where this strategy was used15. Chang and Nitta16 developed a controlled clinical trial to determine the perceived helpfulness of telephone calls to 83 caregivers of family members with dementia. Major reasons for perceived helpfulness were that participants were assisted in sharing thoughts and feelings, expressing feelings of being overwhelmed, discussing physical and psychosocial problems, forgetting the situation, seeking reassurance, and asking for information. The results from this study suggest that family caregivers can be helped through a variety of social support mechanisms, including the use of the phone even though several participants perceived the telephone calls to be lacking in helpfulness16. Additionally, there are studies that demonstrate the efficacy of interventions executed by telephone, addressed to family caregivers, in decreasing the prevalence of anxiety, depression and reduced caregiver burden. However, most of these studies17-19 were conducted with family caregivers of people with Alzheimer's. One notable study was when Tremont and colleagues17 conducted a randomized controlled clinical trial. They examined the preliminary efficacy of the Family Intervention: Telephone Tracking Dementia (FITT-D), a multi-component intervention that is delivered in 23 telephone contacts over 12 months. Thirty-three caregivers of patients with dementia were assigned to receive either FITT-D (n = 16) or standard care (n = 17). Each contact followed a standardized treatment manual, involving assessment and individualized application of interventions to address mood, family functioning, social support, and health. As a result of the study, caregivers receiving FITT-D exhibited significantly lower burden scores and less severe reactions to memory and behavior problems than caregivers in the standard care condition. In another case, Gallagher-Thompson and Heather18 conducted a study in China to explore the impact of a direct intervention in the home compared with telephone support for depression symptoms and perceived stress of Alzheimer patients' caregivers. The caregivers were randomly assigned to a telephone support condition (TSC) or to an in-home behavioral management program (IHBMP) that consisted of six modules aimed at learning skills to help caregivers cope with the stress derived from their work. Each module included one or more 90-minute session, focusing on information about caregiver stress, inappropriate thoughts, communication strategies, decisions at the end of life, and enjoyable activities. The comparison group consisted of telephone support for the caregivers through six calls in intervals of two weeks over 12 weeks. It was found that the first program, with a duration of four months, resulted in less stress on the caregiver and decreased levels of depression associated with caring, whereas the comparison group showed no variation. Caregivers with higher self-efficacy benefited from both treatments. Similarly, Winter and Gitlin19 conducted a controlled clinical trial to evaluate the feasibility and effectiveness of support groups led by professionals, using the telephone, for female family caregivers of community-dwelling dementia patients. Recruited through various community sources, 103 female caregivers were randomized to the telesupport treatment group or a control condition. Effects on caregiver burden, depression, and personal gains were evaluated at 6 months, the main end point. Older caregivers (65 years old or older) in the telesupport group reported lower depression than control group caregivers. A preliminary search of Cochrane Database of Systematic Reviews, Joanna Briggs Institute Library of Systematic Reviews, Medline, CINAHL and PROSPERO found three systematic reviews 20-22 about this topic: A review20 of eight papers conducted in 2007 of the effects of interventions for adult family caregivers of people who have had a stroke assessed the effects of caregiver training interventions. Examples of such interventions include education and counseling, social problem solving partnerships, psycho-educational telephone support groups, a nurse-led education and support program, as well as a support program delivered in hospital or at home. The review found that all interventions tested in the RCTs provided some benefit, although trials were generally of low quality, preventing firm conclusions being drawn. Legg and colleagues21 reviewed, in 2010, eight studies and categorized interventions into three groups: support and information, teaching procedural knowledge/vocational training, and psycho-educational type interventions. The review included one trial assessing a telephone intervention with family caregivers of stroke survivors. For caregivers' stress or strain, they found no significant results within categories of intervention, with the exception of one single-center study examining the effects of a 'vocational training' type intervention. This study found a mean difference between the intervention and comparator group at the end of scheduled follow-up of -8.67 (95% confidence interval -11.30 to -6.04, P < 0.001) in favor of the 'teaching procedural knowledge' intervention group. They did not pool the results of all the studies because of substantial methodological, statistical and clinical heterogeneity. In 2010, a systematic review22 of interventions for non-professional caregivers of individuals with dementia was published. The purpose of this report was to systematically review the evidence on the effects of caregiver interventions on burden, mood (including depression and anxiety), and ability to manage problematic behavior, as well as the effects on care. The authors had limitations on generalizing findings from the review of technology-based interventions, which included the telephone, because the findings were largely descriptive and did not appraise the quality of the included studies. However, the studies reviewed provide a comprehensive overview of Information and Communication Technologies services available for individuals with dementia and their caregivers. The three systematic reviews20-22 reported that the heterogeneity of the interventions included in the studies made it impossible to establish which intervention was most effective. This indicates that no studies exist that independently assessed the effectiveness of telephone intervention in caregivers of persons with chronic diseases, like the review proposed here. Given the impact chronic diseases have on the quality of life of people and their families, it is important to establish interventions that are more efficient and less expensive that standard or routine care to promote the wellbeing of family caregivers. Despite studies that demonstrate the usefulness of the phone to make health interventions, there is no summary of evidence of the effectiveness of its use. Therefore, filling this gap is important for health professionals, so they may base decisions on the use of telephone interventions to improve the wellbeing of family caregivers of people with chronic diseases.