Involvement, individual resilience and mental wellbeing of informal caregivers in elderly care: a correlational cross-sectional study from six European countries

Involvement, individual resilience and mental wellbeing of informal caregivers in elderly care: a correlational cross-sectional study from six European countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Involvement, individual resilience and mental wellbeing of informal caregivers in elderly care: a correlational cross-sectional study from six European countries Maha Kamran, Inger Johanne Bergerød, Veslemøy Guise, Kristin Akerjordet, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8172228/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: By 2060 the demand for caregiving is expected to exceed the number of informal carers available to care for the elderly in Europe. Informal caregivers already make a significant contribution across health sectors, both by alleviating the pressure on formal care services and by providing valuable information about patients. A projected shortfall in informal carers may challenge the caregiving capacity of elderly care services and the provision of high-quality care for elderly. Moreover, informal caregivers report poor communication and uncertainty around the division of care responsibilities with professional careers. Such external influences of these services can contribute to poor health outcomes and reduced motivation in the informal caregiving role. Evidence on how care services involvement of informal caregivers in care tasks and decisions impact their mental wellbeing is currently lacking. This quantitative study examines the factors influence mental wellbeing for informal caregivers in elderly care across six European countries: in Norway, Finland, the Netherlands, Italy, Romania and Spain. Methods: In this correlational cross-sectional study, N = 1487 informal caregivers were recruited across the six countries through purposeful selection. All participants provided unpaid care to elderly individuals aged 65 or older. The study featured self-reported measures and sociodemographic variables and self-assessed health. We measured involvement separately as involvement desire and opportunity, as well as mental wellbeing and resilience. These constructs were measured using the Family Involvement in Care Questionnaire, the Short Warwick Mental Well-being Scale and the Connor-Davidson Resilience Scale respectively. Results: Individual resilience was positively associated with mental wellbeing in informal caregivers in all six countries. Other country-specific associations with mental wellbeing were identified for self-assessed health, age, gender, education, caregiving time and experience. Neither involvement opportunity or desire was associated with mental wellbeing, with the exception of Romania where there was a positive association for involvement opportunity. Conclusions: Subjective influences on mental wellbeing among informal caregivers of the elderly varies greatly across European contexts. However, the individual capacity to deal with adversity is central to informal caregivers’ mental wellbeing across countries. These findings highlight the complex interplay between subjective and contextual predictors in shaping informal caregivers’ mental wellbeing. Informal caregivers elderly care wellbeing resilience involvement caregiving cross-country European Background Informal caregivers, family caregivers, unpaid carers or next of kin—there are many terms for family, friends and neighbors who provide long-term care. In 60% of the cases, this informal care is the only care received by elderly people across OECD countries ( 1 ). According to accounts from informal caregivers, providing care for an elderly spouse, parent or neighbor can be a meaningful experience ( 2 ). However, the future estimations pointing to a lack of informal caregivers available in Europe ( 3 , 4 ), can intensify the caregiving strain experienced by individual caregivers, explaining the recent escalation in research on caregiver burden ( 5 ). Studies on informal caregivers in general report poorer physical health and psychological wellbeing than the non-caregiver population, and pinpoint that the duration of caregiving time is essential for informal caregiver wellbeing ( 6 , 7 ). Caregivers’ capacities to deal with challenges that occur in the caregiving role is subject to external pressures, as studies highlight that wellbeing for informal caregivers is negatively affected by financial cutbacks in the healthcare sector ( 2 ), and that informal caregivers’ wellbeing decreases as their stressors increase ( 8 ). As such, more research is needed on the external associations of healthcare services on informal caregivers’ wellbeing. In European countries, informal caregivers’ role is context dependent, and the intensity of their caregiving role is thought to be associated with the quality of the care services ( 9 ). In Central and Eastern European countries, for instance, services are mixed between private services that rely on out-of-pocket payments and publicly funded services. Other countries such as Finland or Norway have mainly public services centered around primary care. A systematic review investigating European informal caregivers' needs across a variety of clinical contexts found that caregivers generally experienced poor collaboration with healthcare service providers, as well as a high caregiving burden ( 10 ). In addition, informal caregivers of frail elderly report that lack of communication with the elderly care services is key to understand their role, as well as having the potential to exacerbate crises in the elderly care sector ( 11 ). These findings suggest that improving caregivers’ experience of mental wellbeing generally is dependent on external factors, which may be related to how the healthcare services are organized. The influence of being a caregiver on financial, social, mental and/or physical wellbeing can vary greatly between caregivers’ individual capacities and the elderly care services they communicate with ( 7 , 9 ). Evidence suggests that informal caregivers are at a higher risk of emotional exhaustion and burnout than professional caregivers ( 12 ), and that maintaining mental wellbeing in such a context can prompt the use sick leave as a caretaking strategy ( 13 ). Some studies suggest that an increase in professional help for informal caregivers can be beneficial in supporting their wellbeing ( 2 , 10 , 14 ). Others point to strengthening individual coping skills such as individual resilience, where informal caregivers’ capability in employing coping strategies can buffer against mental health issues such as anxiety and depression ( 15 ). Furthermore, informal caregivers’ mental wellbeing can be influenced by their ability to successfully adapt to adversity and challenges across different elderly care contexts, namely their individual resilience ( 6 ). Individual resilience is a multidimensional construct, where a resilient coping style involves using characteristics of resilience such as problem-solving, reframing, acceptance, optimism, and social support to handle contextual stressors ( 15 , 17 ). For informal caregivers of elderly people, caregiving stressors might become more salient if they are expected to compensate for the expected lack of professional healthcare workers available in this sector ( 10 ). Several studies have investigated the link between caregivers' individual resilience and mental health, where one cross-sectional study found that individual resilience could be protective against depression symptoms, particularly for female caregivers ( 18 ). The informal caregiver sample in the study also reported higher mean depression scores compared to the global average, and the authors noted that the caregivers endorsed resilience items related to personal perception (e.g., “being able to adapt to change”) as particularly important for them. Other studies touch on different factors that affect caregiver resilience, where one study found a significant relationship between social support and caregiver resilience ( 19 ). This indicates that external influences could strengthen informal caregivers’ ability to cope and their overall wellbeing. More research is needed to understand whether involvement in care decisions and tasks by elderly care services can be experienced as social support for informal caregivers. Previous qualitative research with informal caregivers of elderly in a primary healthcare unit (PHU) in Sweden revealed that striving for partnership was central to their understanding of support ( 20 ). This was related to the informal caregivers’ desire to be actively involved in decisions about the care of their relative at the PHU. Collaboration, information sharing, participation, emotional burden, respect and dignity were all found to explain how informal caregivers’ burden and wellbeing could be interconnected with their involvement and having their efforts recognized. This idea of being acknowledged by healthcare services in order to perceive support through partnership and involvement is further supported by a Canadian study – where informal caregivers of elderly people felt they had to be assertive to access help, where as those who were less assertive felt less entitled of help from the healthcare system ( 21 ). Taken together, these findings suggest that caregivers’ personal capacities, such as caregiving time, assertiveness or individual resilience, may be determinants of their interpretation of support that they receive. This could help explain why some informal caregivers have different perspectives on the quality and ease of collaboration with elderly care services even though they receive similar services. As elderly people are not a homogenous group, the experience of caregiving informally might also depend on the elderly person’s disease and comorbidities and caring for someone with a higher activity dependency level, as well as the number of caregiving tasks, geographical distance to the elderly person, restrictions on informal caregivers’ time ( 7 ). Thus it remains unclear how informal caregivers' individual characteristics and their external interaction with the elderly care services influence their mental wellbeing. Understanding caregivers’ mental wellbeing is multifaceted. Research has for instance found that wellbeing can be linked to the individual caregivers’ perception of strain in their role, and individual resilience ( 15 , 22 ). Furthermore, a recent Italian study explored perspectives on burden by investigating the interconnectedness of emotional strategies, coping mechanisms and resilience in informal caregivers during COVID, and found that psychological resources (positive attitude, emotional regulation, reappraisal, problem orientation and trait resilience) could buffer against anxiety and depression ( 15 ). Overall, current literature points to both internal and external factors factors contributing to informal caregivers’ mental wellbeing, such as their communication with services, involvement characteristics, and individual psychological traits. However, there is a knowledge gap and a need for research examining cross-national variations in external and internal factors associated with informal caregivers’ wellbeing. Methods Aim This study aims to examine which factors influence mental wellbeing for informal caregivers in elderly care across six European countries: in Norway (NO), Finland (FI), the Netherlands (NL), Italy (IT), Romania (RO) and Spain (ES). The following research question guided the study: What is the association between caregiver involvement, individual resilience and personal characteristics on mental wellbeing of informal caregivers in a European elderly care context? Based on the research findings on how factors that may influence informal caregiver wellbeing, as well as their ability to cope with their caregiving tasks, the following hypotheses will be tested: Involvement opportunity in elderly care services is positively associated with mental wellbeing. (H1) Involvement desire is negatively associated with mental wellbeing. (H2) Individual resilience is positively associated with mental wellbeing. (H3) Time spent caregiving per week and years of experience of caregiving are negatively associated with mental wellbeing. (H4) Informal caregivers’ demographics (age, gender, education) are associated with mental wellbeing. (H5) Self-assessed physical health is positively associated with mental wellbeing. (H6) Study design and context This study has a correlational cross-sectional design, and it aims to expand the understanding of contextual similarities and differences in factors influencing informal caregivers’ mental wellbeing across Europe. These insights offer perspectives that can inform and advance our knowledge and understanding of how to support informal caregivers in elderly care services. The data collection for this study was done as part of the Support4Resilience (S4R) project. The S4R project’s aim is to strengthen resilience and mental wellbeing through the development of a toolbox for leaders in elderly care ( 23 ). The project is financed by the European Commission and coordinated by the University of Stavanger. Recruitment and participants Participants who were eligible for the study were recruited through a variety of different methods in each country described in Table 1 , as they responded to questions in a questionnaire. In total 1487 informal caregiver participants providing unpaid care to elderly individuals over the age of 65 years were recruited across six countries (NO, FI, NL, IT, RO and ES) through purposive selection. This method of recruitment was considered appropriate for identifying participants with insights and experience relevant for the study ( 24 ). All participants gave consent for their participation through either the digital questionnaire or physical consent forms. Table 1 Methods of recruitment by country Country Recruitment Empirical partner FI Marketed digital survey via online platforms such as national informal caregivers Facebook page, and local informal caregivers Facebook page University of Eastern Finland ES Physical recruitment through publicly funded care centers. University of Jaume I IT Recruited family members of patients staying at an Italian non-profit organization that cares for approximately 500 people, relying on voluntary contributions from health professionals Fondazione Casa Cardinale Maffi NL Physical recruitment through participating organization networks, newsletters, informal caregiver networks and team leaders, as well as some social media activity. ERASMUS University NO Recruited via Facebook ads, as well as local recruitment through pamphlets distribution at elderly care-institutions Norwegian University of Science and Technology (NTNU) - Gjøvik RO Recruited caregivers that accompanied their elderly to a large public hospital for medical investigations and/or treatment. Ştefan cel Mare University of Suceava Instruments The questionnaire [see English language version in appendix] used in this study was assembled from novel questions developed for this study, as well as the existing scales as referred to below. The questionnaire measured mental wellbeing, individual resilience, involvement in care, self-assessed health as well as demographic information: age, gender, caregiving time, time spent with the person, education, consisting of 36 items and took about 10–15 minutes to complete. The questionnaire was translated into Norwegian, Finnish, Dutch, Italian, Romanian by the respective empirical partners in the S4R project. Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS) The SWEMWBS consisted of 7 items measuring mental wellbeing, and this short version was a better psychometric fit for capturing the psychological and eudemonic aspects of mental wellbeing ( 25 ), with less of a gender bias than the original 14-item scale ( 26 ). SWEMWBS comprises of questions, varying from: ‘I’ve been feeling optimistic about the future’, to for instance, ‘I’ve been able to make up my own mind about things’, alongside question on whether the statements accurately reflected participants feelings and thoughts over the last 2 weeks. For each question, participants could select one five responses ranging from: ‘none of the time’ to ‘all of the time’. Scores ranged from 7 to 35, with a higher score reflecting a higher level of mental wellbeing. Connor-Davidson Resilience Scale (CD-RISC) In this study the CD-RISC was a 10-item unidimensional scale, extracted from the original 25 item CD-RISC scale, that has become a standard within psychometric measurement of individual resilience, and the ability to bounce back after facing adversity ( 27 ). CD-RISC comprises of statements varying from: ‘Able to adapt to change’ to ‘Tries to see humorous side of problems’, alongside with a question stem on a five-point Likert scale on whether the statements accurately reflected participants remembered or imagined experience from the last month. For each question, caregivers could choose six response categories, from: ‘Not true at all,’ to ‘True nearly all of the time’. Scores could range from 0–40, with a higher score reflecting a stronger individual resilience. Family Involvement in Care Questionnaire (FICQ) The FICQ was considered a generic questionnaire on family involvement in inpatient care, developed to suit a context where family involvement and support were investigated when the patient was still able to make decisions about their own treatment ( 28 ). In the S4R project we used a 13- item FICQ questionnaire which deviated somewhat from the original 16-item questionnaire, omitting item number 8, 15 and 16, as those where not relevant for the context of elderly care. In this study, the following four FICQ items were analyzed together as measures of involvement opportunity: ‘I have the opportunity to ask questions about my family member’s illness/condition’ (FICQ.1), ‘I can participate in discussions about which examinations/treatments that should be done’(FICQ.4), ‘It is easy to get in touch with the staff when I feel the need’ (FICQ.9), and ‘I’m well received by the staff’ (FICQ.10). In addition, the following involvement item was analyzed separately as a measure of involvement desire: ‘I would have liked to be more involved in planning my family member’s care’ (FICQ.6). The response categories were presented on a 5-point Likert scale from ‘fully agree’, ‘largely agree’, and ‘somewhat agree’, to ‘fully disagree’ and ‘not relevant’. The reason these items were chosen was because there was a conceptual fit with informal caregivers’ perception of opportunity and desire for involvement in elderly care, without requiring them to already been in contact with elderly care services, as that might be relevant to only some of the participants. Data analysis All analyses were conducted using RStudio (version 4.5.0). The final dataset included N = 1487 participants from Norway, Finland, Romania, the Netherlands, Italy, and Spain, after excluding entries without informed consent. Descriptive statistics were computed to summarize the sample’s demographic and caregiving characteristics, stratified by country. Continuous variables (e.g., age) were summarized using means and standard deviations; categorical variables (e.g., gender, education, caregiving time, and experience) were presented as frequency distributions and proportions within countries, as seen in Table 2 . A power calculation was performed based on nine predictors, a significance level of 0.05 and a power of 0.95. The effect size ranged from 0.05 to 0.13, depending on the sample size in each country. The number of participants for each country, means of the resilience, wellbeing, involvement opportunity, and involvement desire scores, as well as gender and mean age, education, caregiving time and caregiving experience, is sorted by country in Table 2 . To examine associations between key predictors and outcomes, a series of within-country multiple linear regression analyses were performed. As predictors we used family involvement (FICQ), individual resilience (CD-RISC), as well as caregiving time, caregiving experience, age, gender, and education. The primary outcome was mental wellbeing (SWEMWBS). Education was recoded so the countries could fit their school systems in a seven-staged hierarchy. The score for the family involvement items, measured by the FICQ instrument, ranged between 1 and 4 since the value 5 corresponded to “not relevant” and was therefore excluded from the computation of the score. The family involvement score was first investigated as a mean for all the chosen items (FICQ.1,FICQ.4, FICQ.6, FICQ.9, FICQ.10). Since the FICQ.6 was a negatively phrased item (I would have liked to be more involved in planning my family member’s care), it was reverse coded. A reliability analysis was then conducted for selected items from the FICQ scale as a measure of informal caregiver involvement opportunity. The reversed item FICQ.6 (‘I would have liked to be more involved in planning my family member’s care’) correlated negatively with the overall involvement construct, and Cronbach’s α improved consistently across countries when it was excluded (from .55–.79 with the item to .72–.82 without). These findings support the use of only the four items (excluding FICQ.6) as semantically consistent indicators of caregiver involvement opportunity, and FICQ.6 as a separate measure of involvement desire. Results are presented below with beta estimates and standard errors. This provides information about the magnitude and precision of the effects in the study. All missing values were handled using pairwise deletion, with no imputation conducted, in line with the analytic focus on observed associations within valid responses. Significance levels were set at p < 0.05. Results Descriptive data analysis Sample characteristics for this study can be seen in Table 2 , where the total distribution participants, including age, gender, education, caregiving time, and caregiving experience is presented by country. All the countries had more female (range 64.9%-84.6%) than male participants. Mean age varied by country, with Finland having the oldest, and Romania the youngest (range 50.1–65.3 years), with the overall mean age of the total sample being 58.8 years. A majority of around 60% of the participants from Finland and 55% from Italy did not have a higher education than secondary school. For the other country samples most participants had higher education, ranging from 51.6% for Romania to 77.1% for the sample from the Netherlands. Some other notable differences in the descriptive data can be related to the category of caregiving time (time spent together in a week), among others between Finland and Italy in terms of participants living with the person they are caregivers for, dropping from 60% to 7%, respectively, with a spread between 15–32% for the other countries. Most of the participants in this study have been caregiving for between less than a year and up to five years, across all countries, with Finland having the least participants caregiving for more than 21 years at 1.7%, compared to Spain with 9%. There was no notable difference between countries in mental wellbeing, individual resilience and involvement opportunity means. However, for involvement desire the Romanian sample mean was substantially lower (M = 1.65) than the highest mean in the Dutch sample (M = 2.4). Table 2 Distribution of participants Descriptives ES FI IT NL NO RO Total Participants 181 177 186 441 214 288 Female 82.9% 75% 64.9% 69.7% 84.6% 77.5% Male 17.1% 25% 35.1% 30.3% 15.4% 22.5% Missing values 0 1 0 2 0 4 Age 55.9 (11.4) 65.3 (12.2) 58 (8.1) 64.5 (10.6) 59.1 (10.8) 50.1 (12.7) Missing values 8 6 1 9 16 8 Education None 1.1% 3.4% - 0.2% - - Primary 12.3% 6.8% 15.8% 1.1% 3.7% 4.9% Secondary 19.6% 49.4% 38.6% 21.5% 22.9% 43.5% Less than 3 years 19.0% 9.1% 16.3% 27.2% 12.6% 13.7% Bachelor 30.2% 19.3% 12.5% 35.7% 36.0% 24.2% Master 16.2% 10.8% 16.3% 12.1% 18.7% 12.3% PhD 1.7% 1.1% 0.5% 2.1% 6.1% 1.4% Missing values 8 6 1 9 16 8 Caregiving time 1–5 hrs 23.7% 8.0% 58.2% 28.9% 31.8% 29.7% 6–10 hrs 20.9% 17.0% 22.0% 31.2% 30.8% 18.2% 11–20 hrs 16.4% 5.7% 7.1% 13.0% 13.1% 6.6% 21–30 hrs 6.8% 4.0% 1.6% 3.2% 2.3% 5.9% 30 + hrs 11.3% 4.5% 3.3% 7.7% 4.2% 7.0% Live together 20.9% 60.8% 7.7% 15.9% 17.8% 32.5% Missing values 4 1 4 2 0 2 Caregiving experience <1 year 7.3% 13.6% 19.6% 3.4% 3.3% 32.3% 1–5 yrs 41.0% 64.2% 45.1% 43.8% 53.7% 25.3% 6–10 yrs 25.3% 11.4% 20.7% 26.5% 26.6% 18.2% 11–15 yrs 12.4% 6.8% 5.4% 11.8% 8.9% 12.3% 16–20 yrs 5.1% 2.3% 2.2% 6.3% 3.7% 6.7% 21 + yrs 9.0% 1.7% 7.1% 8.2% 3.7% 5.3% Missing values 3 1 2 0 0 3 Mental Wellbeing 26 (4.5) 25.2 (4.5) 25.6 (4.4) 26.6 (3.9) 24.7 (4.4) 28.8 (3.9) Individual resilience 28.5 (6.64) 27.3 (6.09) 24.7 ( 7 ) 27.2 (6.16) 26.5 (6.3) 29 (6.8) Involvement opportunity 3.2 (.7) 3.1 (.8) 3.5 (.59) 3.3 (.8) 3.1 (.8) 3.4 (.6) Involvement desire 2.1 (.1) 2.3 (1.1) 2.3 (.1) 2.4 ( 1 ) 2.1 (1.1) 1.7 (.9) Multiple linear regression analysis Linear regression analyses were performed for each country to identify the effect of the following predictors on mental wellbeing. The models’ predictors were the involvement opportunity, involvement desire, age, gender, education, caregiving time, caregiving experience, self-assessed health and resilience. Model output and main effects are displayed in Table 3 . Table 3 Mental Wellbeing ES FI IT NL NO RO B(SE) P B(SE) P B(SE) P B(SE) P B(SE) P B(SE) P Age .02(.02) .38 .07(.02) < .01* .06(.03) .09 .007(.01) .66 .04(.02) .03* .01(.01) .32 Gender 1.07(.88) .22 .65(.66) .32 .71(.55) .19 .71(.35) .04* 1.59(.70) .02* .30(.40) .45 Caregiving time − .18(.18) .29 .03(.18) .85 − .40(.19) .03* − .29(.10) < .01* − .30(.15) .04* − .06(.08) .44 Caregiving experience .18(.26) .48 − .33(.30) .26 − .65(.21) < .01*. − .01(.12) .91 − .18(.25) .46 .07(.12) .55 Education − .67(.25) < .01* − .27(.21) .19 − .33(.21) .12 − .30(.16) .07 − .02(.19) .90 − .02(.14) .84 SAH 1.05(.44) .01* − .46(.30) .13 .89(.39) .02* .68(.18) < .01* .56(.28) .04* .27(.23) .23 Individual resilience .32(.05) < .01** .39(.05) < .01** .35(.04) < .01** .37(.02) < .01** .37(.04) < .01** .33(.02) < .01** Involv_Opp − .26(.49) .58 .39(.05) .38 − .66(.34) .09 − .12(.16) .45 .36(.37) .05 .84(.32) < .01* Involv_Des .24(.34) .47 .55(.29) .06 − .16(.28) .57 − .12(.16) .45 .27(.24) .27 .01(.22) .96 Adjusted R2 .33 .45 .42 .46 .45 .44 Involv_Opp = Involvement opportunity, Involv_Des = Involvement desire (FICQ.6 reversed), β = standardized beta coefficients, SE = Standard Error *p < .05 ** p < .001 Demographics and mental wellbeing The assumption of H5 was that demographics were associated with mental wellbeing. For age (β = .04, p = .03) and gender (β = 1.59, p = .02) in Norway the null hypothesis was rejected and H5 was supported, as older age and male gender was significantly associated with higher mental wellbeing scores. The null hypothesis was also rejected for Finland and Netherlands, as age was positively associated with mental wellbeing in Finland (β = .07, p = .007), and being male was also associated with higher wellbeing in Netherlands (β = .71, p = .04). Even though the direction of the association was similarly negative for all the other countries, higher education was only significantly associated with lower mental wellbeing in Spain (β = −.67, p = .008). The null hypothesis was supported for Romania and Italy, as no other significant association between mental wellbeing in terms of age, gender and/or education was found. Involvement and mental wellbeing The assumption of H1 and H2 was that both involvement opportunity and desire to be involved in care tasks and decisions were associated with mental wellbeing. Across countries the family involvement desire items were not significantly associated with wellbeing, and so the null hypothesis was supported. Involvement opportunity was positively associated with mental wellbeing in the Romanian sample (β = .84, p = .008). The null hypothesis was supported for Spain, Norway, Finland, Italy and Netherlands. Individual resilience and mental wellbeing Across all country samples, individual resilience showed a consistent positive association with mental wellbeing (β range 0.33–0.41, all p < .001), consistent with H3. As such H3 was supported and the null hypothesis was rejected. Caregiving-factors and mental wellbeing The assumption of H4 was that high caregiving time (time spent per week) and experience (caregiving life years) would be negatively associated with mental wellbeing. Caregiving experience was largely unrelated to mental wellbeing, with Italy being the exception as higher number of caregiving years was associated with lower mental wellbeing (β = − .65, p = .004). In addition, longer weekly caregiving time was associated with lower mental wellbeing in Italy (β = −.40, p = .03), Norway (β = −.30, p = .04), and the Netherlands (β = −.29, p = .007), rejecting the null hypothesis for these countries. In contrast, for Romania, Spain and Finland H4 was not supported. Self-assessed health and mental wellbeing Higher self-assessed health was positively associated with mental wellbeing in Italy (β = .89, p = .02), the Netherlands (β = .63, p = .003), and Norway (β = .56, p = .04), and so the null hypothesis for these countries was rejected. The assumption of H6 was that physical activity would be positively associated with mental wellbeing. For Romania, Spain and Finland this hypothesis was not supported. Discussion The aim of this study was to examine factors influencing mental wellbeing of informal caregivers’ mental wellbeing, consisting of their opportunity to be involved in elderly care tasks and decisions, as well as their desire to be involved, individual resilience, self-assessed health, and other demographic characteristics. We found no consistent evidence of the influence of the two aspects involvement on informal caregivers’ overall mental wellbeing in the context of elderly care, except for the Romanian sample in terms of involvement opportunity. As the context of elderly care in Romania is centered around family care practices to a greater extent than other countries ( 29 ), the opportunity to have an elderly care service which would be more attentive and proactive in caregiver involvement could explain its positive association to mental wellbeing. Country-level variation in the health effects of informal care is well documented, so our Romania result should be interpreted in the light of differing care regimes ( 30 ). In terms of involvement in care practices and decisions of informal caregivers in other countries, however, a lack of association with involvement and mental wellbeing provides insight into how mental wellbeing of informal caregivers might have little to do with how involved informal caregivers are in these specific involvement forms. It is worth noting that Romania had the lowest mean involvement desire and the youngest mean age amongst countries, which could indicate that the impact of involvement opportunities is subject to change over time in the informal caregiver’s life, and that certain caregivers might be too involved. Our findings show that informal caregivers’ individual resilience is a robust predictor for mental wellbeing in an elderly care context. This finding supports the notion that coping mechanisms are an important feature of these caregivers’ quality of life ( 15 ), regardless of their demographic characteristics. Future studies should investigate the influence of subjective perception in determining whether the elderly care services influence individual resilience or not, and whether tools promoting individual resilience within this context can strengthen the caregiver’s mental wellbeing. As such, the influence of utilitarian support and emotional support from the elderly care services should probably be examined further. This could allow for a deeper understanding of whether involvement in healthcare services actually has a similar emotional impact as social support on individual resilience ( 19 ). Regarding other predictors associated with mental wellbeing, our results show a variety of country-specific associations, potentially pointing towards a heterogeneity of effects. For factors like gender and age, the Norwegian and Dutch samples demonstrate that male caregivers have higher wellbeing scores than females. This aligns with studies finding a gender bias associated with informal caregiving, as more females tend to carry out caregiving responsibilities ( 31 , 32 ). A study on elderly Finnish informal caregivers found that female caregivers tended to have higher odds of loneliness than men ( 33 ), and since the mean age of the Finnish sample was the highest amongst the countries, this can be taken into account as a possible explanation for how age might be associated with mental wellbeing. However, country specific studies are needed to investigate this assumption further. Even though negative associations were observed for most of the countries in terms of caregiving time and mental wellbeing, this association was only significant for half of the countries. In Norway, the Netherlands and Italy, the higher amount of time spent caregiving per week seemed to significantly impact the mental wellbeing of informal caregivers negatively. This makes sense, as more hours of caregiving work indicates a higher individual burden on the informal caregivers, which in turn can influence wellbeing ( 5 ). As some intervention programs in both the Netherlands and Norway focus on providing informal caregivers with digital self-efficacy and resilience tools ( 34 , 35 ), our finding argues for a more holistic intervention strategy for these caregivers in terms of alleviation and support. This could include measures improving communication between the services in addition to opportunities of alleviation and emotional support. This study reveals significant associations between informal caregivers self-assessed physical health and their mental wellbeing in Spain, Italy, the Netherlands, and Norway. Low self-assessed physical health amongst mentally distressed caregivers of dementia-related diseases has previously been associated ( 36 ), whilst in our study we demonstrate that this association also exists amongst informal caregivers of elderly in general. It seems that strong physical health is an indication that informal caregivers of the elderly generally have a better time in their caregiving role, supported by other studies indicating that physical health and caregiving wellbeing are associated ( 7 ). The reason why physical health is important in this setting, beyond its predictive value on mental wellbeing in general, is that caregivers’ physical strain is associated with their mental strain ( 37 ), and that informal caregivers’ capacity to deal with demands is thus linked. Our findings suggest mental wellbeing is contextually framed and that a standardized ‘one-size-fits-all’ involvement or emotional support protocol may be ineffective without local adaptation. As the only variables showing clear associations to mental wellbeing are individual resilience and, for most of the countries’ self-assessed health, this study argues for an increase in focus on individualised support amongst informal caregivers of elderly with low mental wellbeing. Strengths and limitations A notable strength of this study versus other studies that focus on burden and informal caregivers’ experiences of care services as inefficient ( 11 ), is that its findings emphasize that people’s personal capabilities may determine whether someone will thrive in the caregiver role. The large sample size and the varying care contexts underscore how this is an important phenomenon across countries. However, a limitation that could have influenced the findings regarding caregiver involvement in this study is that some participants might have assumed that the question “I would like to be more involved in planning my family’s care” entailed an assumption that their current efforts needed to increase, or that the question “It is easy to get in touch with the staff when I feel the need” was irrelevant if no such need has occurred. Clarifying and elaborating on the essence of involvement and support in this context is therefore a suitable topic for a future qualitative study. The items chosen to measure involvement could be limited in capturing the essence of involvement for the informal caregivers in this study. Since the effect directions of involvement opportunities and desires for each country were interchangeably negative and positive in terms of mental wellbeing, it would be beneficial to examine the contextual as well as conceptual meaning of involvement for informal caregivers across the various countries in terms of age groups. In addition, most of the participants in this study were women, and even though this reflects society’s gender biases in caregiving ( 32 ), possible biases should be considered when adopting these findings is for other studies or interventions. It is also worth considering that we have no pre-post-test on mental wellbeing or individual resilience before and after caregiving, and thus we cannot accurately predict whether mental wellbeing as measured here changes with individual resilience against the ups and downs of caregiving. As such we cannot assess whether individual resilience is as dynamic in the trajectory of caregiving as perhaps mental wellbeing. Finally, as the involvement items were chosen and separated based on semantic association, a more thorough inspection of the contextual meaning of involvement would have been needed to capture this experience accurately through a questionnaire. Implications Our findings carry several implications for the healthcare services potential to support informal caregivers. First, the lack of associations with involvement opportunity and desire suggests that role of policy and service design in informal caregivers’ wellbeing may be misplaced ( 38 ). This matters, because many interventions aimed at informal caregivers implicitly assume that enhancing their participation in the care process will reduce strain, which is not always the case ( 39 ). Current models often emphasise improving caregiver communication, information flow, or service accessibility as pathways to a good service. In this study, however, the subjective variability in informal caregiver wellbeing highlights how personhood, i.e., the way that you are in terms of individual resilience and physical health, seems to matter more than how and if you are involved in the elderly care services. Even if the elderly care services double up on self-help apps and individualized tools, informal caregivers with lower capacity to cope in this context, our study suggests that they need to be followed up interpersonally. This is because holding informal caregivers accountable for their own mental wellbeing, neglects the negative external influences care services might have on informal caregiving capacity. Thus, maintaining that informal caregivers are subjectively in good physical health and resilient before they venture on to take on caregiving tasks seems, seems like an essential starting point for health interventions. Conclusions This study found that involvement in elderly care was generally not associated with caregiver mental wellbeing. Instead, individual resilience consistently predicted higher wellbeing across all countries, highlighting its central role in supporting caregiver wellbeing. Other predictors showed country-specific associations, such as caregiving time in the Netherlands, Italy and Norway, caregiving experience in Italy, and self-assessed health in Spain, Italy, the Netherlands, and Norway. These findings suggest that while individual resilience appears to influence mental wellbeing in a European setting, how other variables influence caregiver wellbeing are highly context dependent. More in-depth research on informal caregivers’ subjective support experiences and the mechanisms influencing their wellbeing is needed. Abbreviations Abbreviations Definition CD-RISC Connor-Davidson Resilience Scale COVID coronavirus disease 2019 ES Spain EU European Union FI Finland FICQ Family Involvement in Care Questionnaire IT Italy Involv_Opp Involvement opportunity Involv_Des Involvement desire NL The Netherlands NO Norway OECD The Organization for Economic Co-operation and Development RO Romania S4R Support4resilience SAH Self-assessed health SWEMWBS Short Warwick-Edinburgh Mental Wellbeing Scale Declarations Ethics approval The S4R project places a strong emphasis on ethics at all levels, ensuring that its research activities align with national, EU, and international ethical standards. This study follows the ALLEA Guidelines, the General Data Protection Regulation (GDPR) 2016/679, and the Declaration of Helsinki. Ethical approval is obtained from country-specific ethics committees before the commencement of studies. This study was approved by the following relevant agencies in the six countries. In Norway, by the Norwegian Agency for Shared Services in Education and Research (number 881988). In Romania by the Stefan cel Mare University of Suceava (number 220/25.07.2024) and the Sfantul Ioan cel Nou Clinical Emergency Hospital of Suceava (number 36/30.07.2024). In the Netherlands by the Erasmus School of Health Policy and Management Research Ethics Review Committee (number ETH2324-0548). In Spain by the Ethics Committee for Research with Human Beings of the Universitat Jaume I of Castellon de la Plana (number CEISH/72/2004). In Italy by the Joint Ethical Committee for Research (number 32/2024). In Finland by the Research Ethics Committee of Turku University of Applied Sciences (number 14/2024). Consent to participate All participants were given an information sheet before participation and provided digital informed consent that their data could be used and published. Consent to publish declaration: Not applicable. Availability of data and materials All data used for supporting the conclusions of this article is kept by the S4R empirical partners. Upon reasonable request to author Daniel Adrian Lungu at [email protected] , the data can be made available. Competing interests Not applicable Funding This research was funded by EU Horizon project number 101136291. Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or European Health and Digital Executive Agency (HADEA). Neither the European Union nor the granting authority can be held responsible for them. Authors' contributions MK and DAL contributed to the data analysis process. Otherwise, all authors participated in the design, coordination, and recruitment in this research, as well as drafting and revising the manuscript. Acknowledgements The authors are grateful for the assistance of organizations in terms of recruitment, as well as all informal caregivers who participated in this study. References Rocard E, Llena-Nozal A. Supporting informal carers of older people: Policies to leave no carer behind [Internett]. Paris: OECD; 2022. https://www.oecd-ilibrary.org/social-issues-migration-health/supporting-informal-carers-of-older-people_0f0c0d52-en . mai [sitert 24november 2024]. Tilgjengelig på. Verbakel E, Metzelthin SF, Kempen GIJM. Caregiving to Older Adults: Determinants of Informal Caregivers’ Subjective Well-being and Formal and Informal Support as Alleviating Conditions. J Gerontol B Psychol Sci Soc Sci. 29. april 2016;gbw047. Pickard L, King D. Modelling the future supply of informal care for older people in Europe. 2012. Ribeiro O, Araújo L, Figueiredo D, Paúl C, Teixeira L. The Caregiver Support Ratio in Europe: Estimating the Future of Potentially (Un)Available Caregivers. Healthc Basel Switz 22 desember. 2021;10(1):11. Chien SC, Chang YH, Yen CM, Onthoni DD, Wu IC, Hsu CC. mfl. Exploring concepts and trends in informal caregiver burden: systematic review using citation network and content analysis. Aging Clin Exp Res desember. 2023;35(12):2873–85. Berglund E, Lytsy P, Westerling R. Health and wellbeing in informal caregivers and non-caregivers: a comparative cross-sectional study of the Swedish general population. Health Qual Life Outcomes desember. 2015;13(1):1–11. Lindt N, Berkel J, Mulder B. Determinants of overburdening among informal carers: a systematic review. BMC Geriatr. august 2020;26:20. Pinquart M, Sörensen S. Associations of caregiver stressors and uplifts with subjective well-being and depressive mood: a meta-analytic comparison. Aging Ment Health 1 september. 2004;8(5):438–49. Verbakel E, Tamlagsrønning S, Winstone L, Fjær EL, Eikemo TA. Informal care in Europe: findings from the European Social Survey (2014) special module on the social determinants of health. Eur J Public Health 1 februar. 2017;27(suppl1):90–5. Ambugo EA, de Bruin SR, Masana L, MacInnes J, Mateu NC, Hagen TP. mfl. A Cross-European Study of Informal Carers’ Needs in the Context of Caring for Older People, and their Experiences with Professionals Working in Integrated Care Settings. Int J Integr Care 8 juli. 2021;21(3):2. Myhre J, Bergh S, Kirkevold Ø, Lichtwarck B. An organisation working mainly reactively instead of proactively: a qualitative study of how frail users of home care services and their next of kin experience crises. BMC Health Serv Res 19 september. 2024;24(1):1102. Gérain P, Zech E. Do informal caregivers experience more burnout? A meta-analytic study. Psychol Health Med. februar 2021;26(2):145–61. 7. Gautun H, Bratt C. Caring for older parents in Norway – How does it affect labor market participation and absence from work? Soc Sci Med. april 2024;346:116722. 1. Akgun-Citak E, Attepe-Ozden S, Vaskelyte A, van Bruchem-Visser RL, Pompili S, Kav S. mfl. Challenges and needs of informal caregivers in elderly care: Qualitative research in four European countries, the TRACE project. Arch Gerontol Geriatr. 1. mars 2020;87:103971. Panzeri A, Bottesi G, Ghisi M, Scalavicci C, Spoto A, Vidotto G. Emotional Regulation, Coping, and Resilience in Informal Caregivers: A Network Analysis Approach. Behav Sci Basel Switz. august 2024;13(8):709. Wiig S, Aase K, Billett S, Canfield C, Røise O. Njå O, mfl. Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program. BMC Health Serv Res 19 april. 2020;20(1):330. Bonanno GA. Uses and abuses of the resilience construct: Loss, trauma, and health-related adversities. Soc Sci Med mars. 2012;74(5):753–6. Vázquez FL, Blanco V, Andrade E, Otero P, Bueno AM, Simón MA. mfl. Resilience as a protective factor against depression in informal caregivers. Front Psychol. 10. juli 2024;15. Ruisoto P, Contador I, Fernández-Calvo B, Serra L, Jenaro C, Flores N. mfl. Mediating effect of social support on the relationship between resilience and burden in caregivers of people with dementia. Arch Gerontol Geriatr 1 januar. 2020;86:103952. Westerling U, Hellgren M, Hermansson L, Strid EN. Informal caregivers’ experiences of support from a tailored primary healthcare unit for older adults - A focus group study. Scand J Caring Sci september. 2024;38(3):730–44. Wiles J. Informal caregivers’ experiences of formal support in a changing context. Health Soc Care Community. 2003;11(3):189–207. Gérain P, Zech E. Informal Caregiver Burnout? Development of a Theoretical Framework to Understand the Impact of Caregiving. Front Psychol 31 juli. 2019;10:1748. Support4Resilence - Empowering healthcare leaders [Internett]. 2021 [sitert 27. november 2024]. Tilgjengelig på: https://support4resilience.eu/ Patton MQ. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. SAGE; 2014. 833 s. Melendez-Torres GJ, Hewitt G, Hallingberg B, Anthony R, Collishaw S, Hall J. mfl. Measurement invariance properties and external construct validity of the short Warwick-Edinburgh mental wellbeing scale in a large national sample of secondary school students in Wales. Health Qual Life Outcomes 14 august. 2019;17(1):139. Stewart-Brown S, Tennant A, Tennant R, Platt S, Parkinson J, Weich S. Internal construct validity of the Warwick-Edinburgh Mental Well-being Scale (WEMWBS): a Rasch analysis using data from the Scottish Health Education Population Survey. Health Qual Life Outcomes 19 februar. 2009;7(1):15. Campbell-Sills L, Stein MB. Psychometric analysis and refinement of the connor–davidson resilience scale (CD-RISC): Validation of a 10-item measure of resilience. J Trauma Stress. 2007;20(6):1019–28. Drakenberg A, Sluys KP, Ericsson E, Sundqvist AS. The Family Involvement in Care Questionnaire—An instrument measuring family involvement in inpatient care. PLoS ONE. august 2023;15(8):e0285562. Thelen T. Care of the Elderly, Migration, Community: Explorations From Rural Romania. I: Alber E, Drotbohm H, redaktører. Anthropological Perspectives on Care: Work, Kinship, and the Life-Course [Internett]. New York: Palgrave Macmillan US; 2015 [sitert 1. september 2025]. s. 137–55. Tilgjengelig på: https://doi.org/10.1057/9781137513441_7 Kaschowitz J, Brandt M. Health effects of informal caregiving across Europe: A longitudinal approach. Soc Sci Med 1982 januar. 2017;173:72–80. Bowlby S, McKie L. Care and caring: An ecological framework. Area 30 september. 2019;51(3):532–9. Zarzycki M, Morrison V, Bei E, Seddon D. Cultural and societal motivations for being informal caregivers: a qualitative systematic review and meta-synthesis. Health Psychol Rev 3 april. 2023;17(2):247–76. Åkerman S, Nyqvist F, Nygård M, Snellman F, Olofsson B. Risk factors for loneliness among older informal caregivers in regions of Finland and Sweden: a longitudinal study. Scand J Public Health. 8. januar 2025;14034948241308029. Christie HL, Boots LMM, Peetoom K, Tange HJ, Verhey FRJ, de Vugt ME. Developing a Plan for the Sustainable Implementation of an Electronic Health Intervention (Partner in Balance) to Support Caregivers of People With Dementia: Case Study. JMIR Aging 25 juni. 2020;3(1):e18624. Digitale verktøy gir nye muligheter for å involvere pårørende | Sykepleien [Internett]. 2025 [sitert 29. august 2025]. Tilgjengelig på: https://sykepleien.no/fag/2025/06/digitale-verktoy-gir-nye-muligheter-involvere-parorende Pinquart M, Sörensen S. Correlates of Physical Health of Informal Caregivers: A Meta-Analysis. J Gerontol Ser B 1 mars. 2007;62(2):P126–37. Oh E, Moon S, Chung D, Choi R, Hong GRS. The moderating effect of care time on care-related characteristics and caregiver burden: differences between formal and informal caregivers of dependent older adults. Front Public Health. april 2024;4:12:1354263. McGuigan K, Laurente G, Christie A, Carswell C, Moran C, Yaqoob MM. mfl. Effectiveness of interventions for informal caregivers of people with end-stage chronic illness: a systematic review. Syst Rev 28 september. 2024;13(1):245. Janse B, Huijsman R, de Kuyper RDM, Fabbricotti IN. The effects of an integrated care intervention for the frail elderly on informal caregivers: a quasi-experimental study. BMC Geriatr 1 mai. 2014;14(1):58. Additional Declarations No competing interests reported. Supplementary Files Appendix.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 Jan, 2026 Reviewers agreed at journal 10 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviewers invited by journal 07 Jan, 2026 Editor assigned by journal 05 Jan, 2026 Editor invited by journal 11 Dec, 2025 Submission checks completed at journal 11 Dec, 2025 First submitted to journal 28 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8172228","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":570976205,"identity":"fde650ed-8514-434c-aa08-3557949ad493","order_by":0,"name":"Maha Kamran","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYFACHiA+AGYxPmAwIFELswHJWtgkiNKg23724AeGM3bR5u1nj1XzFNQxmLM34NdidiYvWYLhRnLunDN5abd5DA4zWPYcIKDlQI6BBMMH5twZDDlmQC0HGAxuJBDQcv6N8Q+GD/W5M/jfmBXzGNQRoeVGjhnQYYdzZ0jkmDHzGDATo+WNmUXCmeNALW+MJecYHOYxOEPIL+dzjG98OFYNdFiO4Yc3f+rkDI434NcCBsgu4SFC/SgYBaNgFIwCQgAACt5DoWk1xuUAAAAASUVORK5CYII=","orcid":"","institution":"University of Stavanger","correspondingAuthor":true,"prefix":"","firstName":"Maha","middleName":"","lastName":"Kamran","suffix":""},{"id":570976206,"identity":"876bdf26-6f09-445d-8a78-978a56749db0","order_by":1,"name":"Inger Johanne Bergerød","email":"","orcid":"","institution":"University of Stavanger","correspondingAuthor":false,"prefix":"","firstName":"Inger","middleName":"Johanne","lastName":"Bergerød","suffix":""},{"id":570976216,"identity":"0dc80a98-3099-4138-acfe-8bf35a531a13","order_by":2,"name":"Veslemøy Guise","email":"","orcid":"","institution":"University of Stavanger","correspondingAuthor":false,"prefix":"","firstName":"Veslemøy","middleName":"","lastName":"Guise","suffix":""},{"id":570976219,"identity":"1f074620-ea49-4ff5-a0dd-bf2e51330e53","order_by":3,"name":"Kristin Akerjordet","email":"","orcid":"","institution":"University of Stavanger","correspondingAuthor":false,"prefix":"","firstName":"Kristin","middleName":"","lastName":"Akerjordet","suffix":""},{"id":570976221,"identity":"3eabe90b-f87f-49fc-8370-163d146f6ea3","order_by":4,"name":"Florin Tibu","email":"","orcid":"","institution":"Ştefan cel Mare University of Suceava","correspondingAuthor":false,"prefix":"","firstName":"Florin","middleName":"","lastName":"Tibu","suffix":""},{"id":570976222,"identity":"ecf8fae1-250a-461f-9e8b-efc57ef5ee24","order_by":5,"name":"Mari Lahti","email":"","orcid":"","institution":"Turku University of Appled Science","correspondingAuthor":false,"prefix":"","firstName":"Mari","middleName":"","lastName":"Lahti","suffix":""},{"id":570976223,"identity":"49e48fca-3b88-47e0-a139-3545ed32440e","order_by":6,"name":"Syb Kuijper","email":"","orcid":"","institution":"Erasmus University Rotterdam","correspondingAuthor":false,"prefix":"","firstName":"Syb","middleName":"","lastName":"Kuijper","suffix":""},{"id":570976224,"identity":"cafee4a7-604d-47f6-a684-2f47c28ee5f2","order_by":7,"name":"Luca Scopis","email":"","orcid":"","institution":"Sant'Anna School of Advanced Studies","correspondingAuthor":false,"prefix":"","firstName":"Luca","middleName":"","lastName":"Scopis","suffix":""},{"id":570976229,"identity":"31816062-7f63-4ef9-a9aa-701da23cb4aa","order_by":8,"name":"Juana Maria Delgado-Saborit","email":"","orcid":"","institution":"University Jaume I De Castellon","correspondingAuthor":false,"prefix":"","firstName":"Juana","middleName":"Maria","lastName":"Delgado-Saborit","suffix":""},{"id":570976238,"identity":"44bb7a54-a0ac-4d86-8458-9ee7989111cf","order_by":9,"name":"Siri Wiig","email":"","orcid":"","institution":"University of Stavanger","correspondingAuthor":false,"prefix":"","firstName":"Siri","middleName":"","lastName":"Wiig","suffix":""},{"id":570976242,"identity":"580a310e-1462-44db-9194-9f11832b4839","order_by":10,"name":"Daniel Adrian Lungu","email":"","orcid":"","institution":"University of Stavanger","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"Adrian","lastName":"Lungu","suffix":""}],"badges":[],"createdAt":"2025-11-21 10:06:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8172228/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8172228/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":99883100,"identity":"14a19e31-455f-4dc7-9019-e5a3050bc174","added_by":"auto","created_at":"2026-01-09 11:52:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":146973,"visible":true,"origin":"","legend":"","description":"","filename":"InformalCaregiversS4Rstudysubmissionedition.docx","url":"https://assets-eu.researchsquare.com/files/rs-8172228/v1/ff0c923decbebb69b01edc97.docx"},{"id":100357753,"identity":"4b68e84a-16f7-471c-b409-d09b5f18d4aa","added_by":"auto","created_at":"2026-01-16 07:20:17","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":12379,"visible":true,"origin":"","legend":"","description":"","filename":"8f59a290a0ff46b7b5f5152351f403e5.json","url":"https://assets-eu.researchsquare.com/files/rs-8172228/v1/2f89b72fc48a6dbf5255630e.json"},{"id":99883104,"identity":"a7fed14d-1f50-4825-951a-67c6ad626422","added_by":"auto","created_at":"2026-01-09 11:52:47","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":512240,"visible":true,"origin":"","legend":"","description":"","filename":"Appendixd1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8172228/v1/1bb2045dcaba481ed7871d8a.pdf"},{"id":100358938,"identity":"a5485be6-3eaf-47c5-bda4-2ae0e8a657d8","added_by":"auto","created_at":"2026-01-16 07:21:35","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":146114,"visible":true,"origin":"","legend":"","description":"","filename":"8f59a290a0ff46b7b5f5152351f403e51enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8172228/v1/758853f2ae77ed8eb4ea1563.xml"},{"id":99883101,"identity":"78a255c8-36ca-44c1-8955-b7f6b31820eb","added_by":"auto","created_at":"2026-01-09 11:52:47","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":143331,"visible":true,"origin":"","legend":"","description":"","filename":"8f59a290a0ff46b7b5f5152351f403e51structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8172228/v1/600b914c9a84442d49d2e092.xml"},{"id":100358870,"identity":"deef07b0-17b1-470f-967a-58cbee6c401b","added_by":"auto","created_at":"2026-01-16 07:21:31","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":158247,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8172228/v1/fa335148b2dea9dabfc2d1e5.html"},{"id":100377043,"identity":"f429b65e-d8c8-4303-9a27-8277e03cbc9b","added_by":"auto","created_at":"2026-01-16 08:46:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1089182,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8172228/v1/3c0dca07-618a-4fbd-8097-cc27148c8e01.pdf"},{"id":99883099,"identity":"11de4a0e-3cf2-4f51-8d8a-b792a8824289","added_by":"auto","created_at":"2026-01-09 11:52:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":512240,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8172228/v1/b62b92ea493e30449788584c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Involvement, individual resilience and mental wellbeing of informal caregivers in elderly care: a correlational cross-sectional study from six European countries","fulltext":[{"header":"Background","content":"\u003cp\u003eInformal caregivers, family caregivers, unpaid carers or next of kin\u0026mdash;there are many terms for family, friends and neighbors who provide long-term care. In 60% of the cases, this informal care is the only care received by elderly people across OECD countries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). According to accounts from informal caregivers, providing care for an elderly spouse, parent or neighbor can be a meaningful experience (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, the future estimations pointing to a lack of informal caregivers available in Europe (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), can intensify the caregiving strain experienced by individual caregivers, explaining the recent escalation in research on caregiver burden (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Studies on informal caregivers in general report poorer physical health and psychological wellbeing than the non-caregiver population, and pinpoint that the duration of caregiving time is essential for informal caregiver wellbeing (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Caregivers\u0026rsquo; capacities to deal with challenges that occur in the caregiving role is subject to external pressures, as studies highlight that wellbeing for informal caregivers is negatively affected by financial cutbacks in the healthcare sector (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), and that informal caregivers\u0026rsquo; wellbeing decreases as their stressors increase (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). As such, more research is needed on the external associations of healthcare services on informal caregivers\u0026rsquo; wellbeing.\u003c/p\u003e \u003cp\u003eIn European countries, informal caregivers\u0026rsquo; role is context dependent, and the intensity of their caregiving role is thought to be associated with the quality of the care services (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In Central and Eastern European countries, for instance, services are mixed between private services that rely on out-of-pocket payments and publicly funded services. Other countries such as Finland or Norway have mainly public services centered around primary care. A systematic review investigating European informal caregivers' needs across a variety of clinical contexts found that caregivers generally experienced poor collaboration with healthcare service providers, as well as a high caregiving burden (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In addition, informal caregivers of frail elderly report that lack of communication with the elderly care services is key to understand their role, as well as having the potential to exacerbate crises in the elderly care sector (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These findings suggest that improving caregivers\u0026rsquo; experience of mental wellbeing generally is dependent on external factors, which may be related to how the healthcare services are organized.\u003c/p\u003e \u003cp\u003eThe influence of being a caregiver on financial, social, mental and/or physical wellbeing can vary greatly between caregivers\u0026rsquo; individual capacities and the elderly care services they communicate with (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Evidence suggests that informal caregivers are at a higher risk of emotional exhaustion and burnout than professional caregivers (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), and that maintaining mental wellbeing in such a context can prompt the use sick leave as a caretaking strategy (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Some studies suggest that an increase in professional help for informal caregivers can be beneficial in supporting their wellbeing (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Others point to strengthening individual coping skills such as individual resilience, where informal caregivers\u0026rsquo; capability in employing coping strategies can buffer against mental health issues such as anxiety and depression (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Furthermore, informal caregivers\u0026rsquo; mental wellbeing can be influenced by their ability to successfully adapt to adversity and challenges across different elderly care contexts, namely their individual \u003cem\u003eresilience\u003c/em\u003e (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIndividual resilience is a multidimensional construct, where a resilient coping style involves using characteristics of resilience such as problem-solving, reframing, acceptance, optimism, and social support to handle contextual stressors (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). For informal caregivers of elderly people, caregiving stressors might become more salient if they are expected to compensate for the expected lack of professional healthcare workers available in this sector (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Several studies have investigated the link between caregivers' individual resilience and mental health, where one cross-sectional study found that individual resilience could be protective against depression symptoms, particularly for female caregivers (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The informal caregiver sample in the study also reported higher mean depression scores compared to the global average, and the authors noted that the caregivers endorsed resilience items related to personal perception (e.g., \u0026ldquo;being able to adapt to change\u0026rdquo;) as particularly important for them. Other studies touch on different factors that affect caregiver resilience, where one study found a significant relationship between social support and caregiver resilience (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This indicates that external influences could strengthen informal caregivers\u0026rsquo; ability to cope and their overall wellbeing. More research is needed to understand whether involvement in care decisions and tasks by elderly care services can be experienced as social support for informal caregivers.\u003c/p\u003e \u003cp\u003ePrevious qualitative research with informal caregivers of elderly in a primary healthcare unit (PHU) in Sweden revealed that \u003cem\u003estriving for partnership\u003c/em\u003e was central to their understanding of support (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This was related to the informal caregivers\u0026rsquo; desire to be actively involved in decisions about the care of their relative at the PHU. Collaboration, information sharing, participation, emotional burden, respect and dignity were all found to explain how informal caregivers\u0026rsquo; burden and wellbeing could be interconnected with their involvement and having their efforts recognized. This idea of being acknowledged by healthcare services in order to perceive support through partnership and involvement is further supported by a Canadian study \u0026ndash; where informal caregivers of elderly people felt they had to be assertive to access help, where as those who were less assertive felt less entitled of help from the healthcare system (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTaken together, these findings suggest that caregivers\u0026rsquo; personal capacities, such as caregiving time, assertiveness or individual resilience, may be determinants of their interpretation of support that they receive. This could help explain why some informal caregivers have different perspectives on the quality and ease of collaboration with elderly care services even though they receive similar services. As elderly people are not a homogenous group, the experience of caregiving informally might also depend on the elderly person\u0026rsquo;s disease and comorbidities and caring for someone with a higher activity dependency level, as well as the number of caregiving tasks, geographical distance to the elderly person, restrictions on informal caregivers\u0026rsquo; time (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Thus it remains unclear how informal caregivers' individual characteristics and their external interaction with the elderly care services influence their mental wellbeing.\u003c/p\u003e \u003cp\u003eUnderstanding caregivers\u0026rsquo; mental wellbeing is multifaceted. Research has for instance found that wellbeing can be linked to the individual caregivers\u0026rsquo; perception of strain in their role, and individual resilience (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Furthermore, a recent Italian study explored perspectives on burden by investigating the interconnectedness of emotional strategies, coping mechanisms and resilience in informal caregivers during COVID, and found that psychological resources (positive attitude, emotional regulation, reappraisal, problem orientation and trait resilience) could buffer against anxiety and depression (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Overall, current literature points to both internal and external factors factors contributing to informal caregivers\u0026rsquo; mental wellbeing, such as their communication with services, involvement characteristics, and individual psychological traits. However, there is a knowledge gap and a need for research examining cross-national variations in external and internal factors associated with informal caregivers\u0026rsquo; wellbeing.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis study aims to examine which factors influence mental wellbeing for informal caregivers in elderly care across six European countries: in Norway (NO), Finland (FI), the Netherlands (NL), Italy (IT), Romania (RO) and Spain (ES).\u003c/p\u003e \u003cp\u003eThe following research question guided the study:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWhat is the association between caregiver involvement, individual resilience and personal characteristics on mental wellbeing of informal caregivers in a European elderly care context?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eBased on the research findings on how factors that may influence informal caregiver wellbeing, as well as their ability to cope with their caregiving tasks, the following hypotheses will be tested:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInvolvement opportunity in elderly care services is positively associated with mental wellbeing. (H1)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInvolvement desire is negatively associated with mental wellbeing. (H2)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIndividual resilience is positively associated with mental wellbeing. (H3)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTime spent caregiving per week and years of experience of caregiving are negatively associated with mental wellbeing. (H4)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInformal caregivers\u0026rsquo; demographics (age, gender, education) are associated with mental wellbeing. (H5)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSelf-assessed physical health is positively associated with mental wellbeing. (H6)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design and context\u003c/h3\u003e\n\u003cp\u003e This study has a correlational cross-sectional design, and it aims to expand the understanding of contextual similarities and differences in factors influencing informal caregivers\u0026rsquo; mental wellbeing across Europe. These insights offer perspectives that can inform and advance our knowledge and understanding of how to support informal caregivers in elderly care services.\u003c/p\u003e \u003cp\u003eThe data collection for this study was done as part of the Support4Resilience (S4R) project. The S4R project\u0026rsquo;s aim is to strengthen resilience and mental wellbeing through the development of a toolbox for leaders in elderly care (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The project is financed by the European Commission and coordinated by the University of Stavanger.\u003c/p\u003e\n\u003ch3\u003eRecruitment and participants\u003c/h3\u003e\n\u003cp\u003eParticipants who were eligible for the study were recruited through a variety of different methods in each country described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, as they responded to questions in a questionnaire. In total 1487 informal caregiver participants providing unpaid care to elderly individuals over the age of 65 years were recruited across six countries (NO, FI, NL, IT, RO and ES) through purposive selection. This method of recruitment was considered appropriate for identifying participants with insights and experience relevant for the study (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). All participants gave consent for their participation through either the digital questionnaire or physical consent forms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMethods of recruitment by country\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecruitment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmpirical partner\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarketed digital survey via online platforms such as national informal caregivers Facebook page, and local informal caregivers Facebook page\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUniversity of Eastern Finland\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical recruitment through publicly funded care centers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUniversity of Jaume I\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecruited family members of patients staying at an Italian non-profit organization that cares for approximately 500 people, relying on voluntary contributions from health professionals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFondazione Casa Cardinale Maffi\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical recruitment through participating organization networks, newsletters, informal caregiver networks and team leaders, as well as some social media activity.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eERASMUS University\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecruited via Facebook ads, as well as local recruitment through pamphlets distribution at elderly care-institutions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNorwegian University of Science and Technology (NTNU) - Gj\u0026oslash;vik\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecruited caregivers that accompanied their elderly to a large public hospital for medical investigations and/or treatment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eŞtefan cel Mare University of Suceava\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eInstruments\u003c/h3\u003e\n\u003cp\u003eThe questionnaire [see English language version in appendix] used in this study was assembled from novel questions developed for this study, as well as the existing scales as referred to below. The questionnaire measured mental wellbeing, individual resilience, involvement in care, self-assessed health as well as demographic information: age, gender, caregiving time, time spent with the person, education, consisting of 36 items and took about 10\u0026ndash;15 minutes to complete. The questionnaire was translated into Norwegian, Finnish, Dutch, Italian, Romanian by the respective empirical partners in the S4R project.\u003c/p\u003e \u003cp\u003e \u003cb\u003eShort Warwick-Edinburgh Mental Wellbeing Scale\u003c/b\u003e (SWEMWBS)\u003c/p\u003e \u003cp\u003eThe SWEMWBS consisted of 7 items measuring mental wellbeing, and this short version was a better psychometric fit for capturing the psychological and eudemonic aspects of mental wellbeing (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), with less of a gender bias than the original 14-item scale (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSWEMWBS comprises of questions, varying from: \u0026lsquo;I\u0026rsquo;ve been feeling optimistic about the future\u0026rsquo;, to for instance, \u0026lsquo;I\u0026rsquo;ve been able to make up my own mind about things\u0026rsquo;, alongside question on whether the statements accurately reflected participants feelings and thoughts over the last 2 weeks. For each question, participants could select one five responses ranging from: \u0026lsquo;none of the time\u0026rsquo; to \u0026lsquo;all of the time\u0026rsquo;. Scores ranged from 7 to 35, with a higher score reflecting a higher level of mental wellbeing.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConnor-Davidson Resilience Scale\u003c/b\u003e (CD-RISC)\u003c/p\u003e \u003cp\u003eIn this study the CD-RISC was a 10-item unidimensional scale, extracted from the original 25 item CD-RISC scale, that has become a standard within psychometric measurement of individual resilience, and the ability to bounce back after facing adversity (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCD-RISC comprises of statements varying from: \u0026lsquo;Able to adapt to change\u0026rsquo; to \u0026lsquo;Tries to see humorous side of problems\u0026rsquo;, alongside with a question stem on a five-point Likert scale on whether the statements accurately reflected participants remembered or imagined experience from the last month. For each question, caregivers could choose six response categories, from: \u0026lsquo;Not true at all,\u0026rsquo; to \u0026lsquo;True nearly all of the time\u0026rsquo;. Scores could range from 0\u0026ndash;40, with a higher score reflecting a stronger individual resilience.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFamily Involvement in Care Questionnaire\u003c/b\u003e (FICQ)\u003c/p\u003e \u003cp\u003eThe FICQ was considered a generic questionnaire on family involvement in inpatient care, developed to suit a context where family involvement and support were investigated when the patient was still able to make decisions about their own treatment (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In the S4R project we used a 13- item FICQ questionnaire which deviated somewhat from the original 16-item questionnaire, omitting item number 8, 15 and 16, as those where not relevant for the context of elderly care.\u003c/p\u003e \u003cp\u003eIn this study, the following four FICQ items were analyzed together as measures of involvement opportunity: \u0026lsquo;I have the opportunity to ask questions about my family member\u0026rsquo;s illness/condition\u0026rsquo; (FICQ.1), \u0026lsquo;I can participate in discussions about which examinations/treatments that should be done\u0026rsquo;(FICQ.4), \u0026lsquo;It is easy to get in touch with the staff when I feel the need\u0026rsquo; (FICQ.9), and \u0026lsquo;I\u0026rsquo;m well received by the staff\u0026rsquo; (FICQ.10). In addition, the following involvement item was analyzed separately as a measure of involvement desire: \u0026lsquo;I would have liked to be more involved in planning my family member\u0026rsquo;s care\u0026rsquo; (FICQ.6). The response categories were presented on a 5-point Likert scale from \u0026lsquo;fully agree\u0026rsquo;, \u0026lsquo;largely agree\u0026rsquo;, and \u0026lsquo;somewhat agree\u0026rsquo;, to \u0026lsquo;fully disagree\u0026rsquo; and \u0026lsquo;not relevant\u0026rsquo;. The reason these items were chosen was because there was a conceptual fit with informal caregivers\u0026rsquo; perception of opportunity and desire for involvement in elderly care, without requiring them to already been in contact with elderly care services, as that might be relevant to only some of the participants.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll analyses were conducted using RStudio (version 4.5.0). The final dataset included N\u0026thinsp;=\u0026thinsp;1487 participants from Norway, Finland, Romania, the Netherlands, Italy, and Spain, after excluding entries without informed consent. Descriptive statistics were computed to summarize the sample\u0026rsquo;s demographic and caregiving characteristics, stratified by country. Continuous variables (e.g., age) were summarized using means and standard deviations; categorical variables (e.g., gender, education, caregiving time, and experience) were presented as frequency distributions and proportions within countries, as seen in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eA power calculation was performed based on nine predictors, a significance level of 0.05 and a power of 0.95. The effect size ranged from 0.05 to 0.13, depending on the sample size in each country. The number of participants for each country, means of the resilience, wellbeing, involvement opportunity, and involvement desire scores, as well as gender and mean age, education, caregiving time and caregiving experience, is sorted by country in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. To examine associations between key predictors and outcomes, a series of within-country multiple linear regression analyses were performed. As predictors we used family involvement (FICQ), individual resilience (CD-RISC), as well as caregiving time, caregiving experience, age, gender, and education. The primary outcome was mental wellbeing (SWEMWBS). Education was recoded so the countries could fit their school systems in a seven-staged hierarchy.\u003c/p\u003e \u003cp\u003eThe score for the family involvement items, measured by the FICQ instrument, ranged between 1 and 4 since the value 5 corresponded to \u0026ldquo;not relevant\u0026rdquo; and was therefore excluded from the computation of the score. The family involvement score was first investigated as a mean for all the chosen items (FICQ.1,FICQ.4, FICQ.6, FICQ.9, FICQ.10). Since the FICQ.6 was a negatively phrased item (I would have liked to be more involved in planning my family member\u0026rsquo;s care), it was reverse coded. A reliability analysis was then conducted for selected items from the FICQ scale as a measure of informal caregiver involvement opportunity. The reversed item FICQ.6 (\u0026lsquo;I would have liked to be more involved in planning my family member\u0026rsquo;s care\u0026rsquo;) correlated negatively with the overall involvement construct, and Cronbach\u0026rsquo;s α improved consistently across countries when it was excluded (from .55\u0026ndash;.79 with the item to .72\u0026ndash;.82 without). These findings support the use of only the four items (excluding FICQ.6) as semantically consistent indicators of caregiver involvement opportunity, and FICQ.6 as a separate measure of involvement desire.\u003c/p\u003e \u003cp\u003eResults are presented below with beta estimates and standard errors. This provides information about the magnitude and precision of the effects in the study. All missing values were handled using pairwise deletion, with no imputation conducted, in line with the analytic focus on observed associations within valid responses. Significance levels were set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive data analysis\u003c/h2\u003e \u003cp\u003eSample characteristics for this study can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, where the total distribution participants, including age, gender, education, caregiving time, and caregiving experience is presented by country. All the countries had more female (range 64.9%-84.6%) than male participants. Mean age varied by country, with Finland having the oldest, and Romania the youngest (range 50.1\u0026ndash;65.3 years), with the overall mean age of the total sample being 58.8 years.\u003c/p\u003e \u003cp\u003eA majority of around 60% of the participants from Finland and 55% from Italy did not have a higher education than secondary school. For the other country samples most participants had higher education, ranging from 51.6% for Romania to 77.1% for the sample from the Netherlands. Some other notable differences in the descriptive data can be related to the category of caregiving time (time spent together in a week), among others between Finland and Italy in terms of participants living with the person they are caregivers for, dropping from 60% to 7%, respectively, with a spread between 15\u0026ndash;32% for the other countries. Most of the participants in this study have been caregiving for between less than a year and up to five years, across all countries, with Finland having the least participants caregiving for more than 21 years at 1.7%, compared to Spain with 9%.\u003c/p\u003e \u003cp\u003eThere was no notable difference between countries in mental wellbeing, individual resilience and involvement opportunity means. However, for involvement desire the Romanian sample mean was substantially lower (M\u0026thinsp;=\u0026thinsp;1.65) than the highest mean in the Dutch sample (M\u0026thinsp;=\u0026thinsp;2.4).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDescriptives\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eIT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003eRO\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e288\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e64.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e69.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e84.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e77.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e35.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e30.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e15.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e22.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing values\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.9 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e65.3 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e58 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e64.5 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e59.1 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e50.1 (12.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing values\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e0.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e15.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e1.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e3.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e4.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e49.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e38.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e21.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e22.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e43.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e9.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e16.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e27.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e12.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e13.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e19.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e35.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e36.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e24.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e10.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e16.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e12.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e18.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e12.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e2.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e6.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing values\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiving time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;5 hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e8.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e58.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e28.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e31.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e29.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e17.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e22.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e31.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e30.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e18.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;20 hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e7.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e13.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e6.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;30 hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e4.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e3.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e2.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e5.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026thinsp;+\u0026thinsp;hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e4.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e3.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e7.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e4.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e7.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLive together\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e60.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e7.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e15.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e17.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e32.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing values\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiving experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e13.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e19.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e3.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e3.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e32.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;5 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e64.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e45.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e43.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e53.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e25.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e11.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e20.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e26.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e26.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e18.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;15 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e5.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e11.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e8.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e12.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;20 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e6.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e3.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e6.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026thinsp;+\u0026thinsp;yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e7.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e8.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e3.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e5.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing values\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental Wellbeing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e25.2 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e25.6 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e26.6 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e24.7 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e28.8 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual resilience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.5 (6.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e27.3 (6.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e24.7 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e27.2 (6.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e26.5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e29 (6.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolvement\u003c/p\u003e \u003cp\u003eopportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2 (.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3.1 (.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e3.5 (.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e3.3 (.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e3.1 (.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e3.4 (.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolvement desire\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1 (.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.3 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2.3 (.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e2.4 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e2.1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1.7 (.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMultiple linear regression analysis\u003c/h3\u003e\n\u003cp\u003eLinear regression analyses were performed for each country to identify the effect of the following predictors on mental wellbeing. The models\u0026rsquo; predictors were the involvement opportunity, involvement desire, age, gender, education, caregiving time, caregiving experience, self-assessed health and resilience. Model output and main effects are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental Wellbeing\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eIT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eNL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003eRO\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB(SE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB(SE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eB(SE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eB(SE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eB(SE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eB(SE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.02(.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.07(.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.06(.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.007(.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.04(.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.03*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.01(.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.07(.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.65(.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.71(.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.71(.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.04*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.59(.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.02*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.30(.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiving time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.18(.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.03(.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.40(.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.03*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.29(.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.30(.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.04*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.06(.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiving experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.18(.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.33(.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.65(.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01*.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.01(.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.18(.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.07(.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.67(.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.27(.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.33(.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.30(.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.02(.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.02(.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSAH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.05(.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.01*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.46(.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.89(.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.02*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.68(.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.56(.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.04*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.27(.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual resilience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.32(.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.39(.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.35(.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.37(.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.37(.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.33(.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolv_Opp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.26(.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.39(.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.66(.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.12(.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.36(.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.84(.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolv_Des\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.24(.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.55(.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.16(.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.12(.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.27(.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.01(.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjusted R2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003eInvolv_Opp\u0026thinsp;=\u0026thinsp;Involvement opportunity, Involv_Des\u0026thinsp;=\u0026thinsp;Involvement desire (FICQ.6 reversed), β\u0026thinsp;=\u0026thinsp;standardized beta coefficients, SE\u0026thinsp;=\u0026thinsp;Standard Error *p\u0026thinsp;\u0026lt;\u0026thinsp;.05 ** p\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDemographics and mental wellbeing\u003c/h2\u003e \u003cp\u003eThe assumption of H5 was that demographics were associated with mental wellbeing. For age (β\u0026thinsp;=\u0026thinsp;.04, p\u0026thinsp;=\u0026thinsp;.03) and gender (β\u0026thinsp;=\u0026thinsp;1.59, p\u0026thinsp;=\u0026thinsp;.02) in Norway the null hypothesis was rejected and H5 was supported, as older age and male gender was significantly associated with higher mental wellbeing scores. The null hypothesis was also rejected for Finland and Netherlands, as age was positively associated with mental wellbeing in Finland (β\u0026thinsp;=\u0026thinsp;.07, p\u0026thinsp;=\u0026thinsp;.007), and being male was also associated with higher wellbeing in Netherlands (β\u0026thinsp;=\u0026thinsp;.71, p\u0026thinsp;=\u0026thinsp;.04). Even though the direction of the association was similarly negative for all the other countries, higher education was only significantly associated with lower mental wellbeing in Spain (β = \u0026minus;.67, p\u0026thinsp;=\u0026thinsp;.008). The null hypothesis was supported for Romania and Italy, as no other significant association between mental wellbeing in terms of age, gender and/or education was found.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInvolvement and mental wellbeing\u003c/h2\u003e \u003cp\u003eThe assumption of H1 and H2 was that both involvement opportunity and desire to be involved in care tasks and decisions were associated with mental wellbeing. Across countries the family involvement desire items were not significantly associated with wellbeing, and so the null hypothesis was supported. Involvement opportunity was positively associated with mental wellbeing in the Romanian sample (β\u0026thinsp;=\u0026thinsp;.84, p\u0026thinsp;=\u0026thinsp;.008). The null hypothesis was supported for Spain, Norway, Finland, Italy and Netherlands.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eIndividual resilience and mental wellbeing\u003c/h2\u003e \u003cp\u003eAcross all country samples, individual resilience showed a consistent positive association with mental wellbeing (β range 0.33\u0026ndash;0.41, all p\u0026thinsp;\u0026lt;\u0026thinsp;.001), consistent with H3. As such H3 was supported and the null hypothesis was rejected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCaregiving-factors and mental wellbeing\u003c/h2\u003e \u003cp\u003eThe assumption of H4 was that high caregiving time (time spent per week) and experience (caregiving life years) would be negatively associated with mental wellbeing. Caregiving experience was largely unrelated to mental wellbeing, with Italy being the exception as higher number of caregiving years was associated with lower mental wellbeing (β = \u0026minus;\u0026thinsp;.65, p\u0026thinsp;=\u0026thinsp;.004). In addition, longer weekly caregiving time was associated with lower mental wellbeing in Italy (β = \u0026minus;.40, p\u0026thinsp;=\u0026thinsp;.03), Norway (β = \u0026minus;.30, p\u0026thinsp;=\u0026thinsp;.04), and the Netherlands (β = \u0026minus;.29, p\u0026thinsp;=\u0026thinsp;.007), rejecting the null hypothesis for these countries. In contrast, for Romania, Spain and Finland H4 was not supported.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSelf-assessed health and mental wellbeing\u003c/h2\u003e \u003cp\u003eHigher self-assessed health was positively associated with mental wellbeing in Italy (β\u0026thinsp;=\u0026thinsp;.89, p\u0026thinsp;=\u0026thinsp;.02), the Netherlands (β\u0026thinsp;=\u0026thinsp;.63, p\u0026thinsp;=\u0026thinsp;.003), and Norway (β\u0026thinsp;=\u0026thinsp;.56, p\u0026thinsp;=\u0026thinsp;.04), and so the null hypothesis for these countries was rejected. The assumption of H6 was that physical activity would be positively associated with mental wellbeing. For Romania, Spain and Finland this hypothesis was not supported.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this study was to examine factors influencing mental wellbeing of informal caregivers\u0026rsquo; mental wellbeing, consisting of their opportunity to be involved in elderly care tasks and decisions, as well as their desire to be involved, individual resilience, self-assessed health, and other demographic characteristics.\u003c/p\u003e \u003cp\u003eWe found no consistent evidence of the influence of the two aspects involvement on informal caregivers\u0026rsquo; overall mental wellbeing in the context of elderly care, except for the Romanian sample in terms of involvement opportunity. As the context of elderly care in Romania is centered around family care practices to a greater extent than other countries (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), the opportunity to have an elderly care service which would be more attentive and proactive in caregiver involvement could explain its positive association to mental wellbeing. Country-level variation in the health effects of informal care is well documented, so our Romania result should be interpreted in the light of differing care regimes (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn terms of involvement in care practices and decisions of informal caregivers in other countries, however, a lack of association with involvement and mental wellbeing provides insight into how mental wellbeing of informal caregivers might have little to do with how involved informal caregivers are in these specific involvement forms. It is worth noting that Romania had the lowest mean involvement desire and the youngest mean age amongst countries, which could indicate that the impact of involvement opportunities is subject to change over time in the informal caregiver\u0026rsquo;s life, and that certain caregivers might be too involved.\u003c/p\u003e \u003cp\u003eOur findings show that informal caregivers\u0026rsquo; individual resilience is a robust predictor for mental wellbeing in an elderly care context. This finding supports the notion that coping mechanisms are an important feature of these caregivers\u0026rsquo; quality of life (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), regardless of their demographic characteristics. Future studies should investigate the influence of subjective perception in determining whether the elderly care services influence individual resilience or not, and whether tools promoting individual resilience within this context can strengthen the caregiver\u0026rsquo;s mental wellbeing. As such, the influence of utilitarian support and emotional support from the elderly care services should probably be examined further. This could allow for a deeper understanding of whether involvement in healthcare services actually has a similar emotional impact as social support on individual resilience (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding other predictors associated with mental wellbeing, our results show a variety of country-specific associations, potentially pointing towards a heterogeneity of effects. For factors like gender and age, the Norwegian and Dutch samples demonstrate that male caregivers have higher wellbeing scores than females. This aligns with studies finding a gender bias associated with informal caregiving, as more females tend to carry out caregiving responsibilities (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). A study on elderly Finnish informal caregivers found that female caregivers tended to have higher odds of loneliness than men (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and since the mean age of the Finnish sample was the highest amongst the countries, this can be taken into account as a possible explanation for how age might be associated with mental wellbeing. However, country specific studies are needed to investigate this assumption further.\u003c/p\u003e \u003cp\u003eEven though negative associations were observed for most of the countries in terms of caregiving time and mental wellbeing, this association was only significant for half of the countries. In Norway, the Netherlands and Italy, the higher amount of time spent caregiving per week seemed to significantly impact the mental wellbeing of informal caregivers negatively. This makes sense, as more hours of caregiving work indicates a higher individual burden on the informal caregivers, which in turn can influence wellbeing (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). As some intervention programs in both the Netherlands and Norway focus on providing informal caregivers with digital self-efficacy and resilience tools (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), our finding argues for a more holistic intervention strategy for these caregivers in terms of alleviation and support. This could include measures improving communication between the services in addition to opportunities of alleviation and emotional support.\u003c/p\u003e \u003cp\u003eThis study reveals significant associations between informal caregivers self-assessed physical health and their mental wellbeing in Spain, Italy, the Netherlands, and Norway. Low self-assessed physical health amongst mentally distressed caregivers of dementia-related diseases has previously been associated (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), whilst in our study we demonstrate that this association also exists amongst informal caregivers of elderly in general. It seems that strong physical health is an indication that informal caregivers of the elderly generally have a better time in their caregiving role, supported by other studies indicating that physical health and caregiving wellbeing are associated (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The reason why physical health is important in this setting, beyond its predictive value on mental wellbeing in general, is that caregivers\u0026rsquo; physical strain is associated with their mental strain (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), and that informal caregivers\u0026rsquo; capacity to deal with demands is thus linked.\u003c/p\u003e \u003cp\u003eOur findings suggest mental wellbeing is contextually framed and that a standardized \u0026lsquo;one-size-fits-all\u0026rsquo; involvement or emotional support protocol may be ineffective without local adaptation. As the only variables showing clear associations to mental wellbeing are individual resilience and, for most of the countries\u0026rsquo; self-assessed health, this study argues for an increase in focus on individualised support amongst informal caregivers of elderly with low mental wellbeing.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eA notable strength of this study versus other studies that focus on burden and informal caregivers\u0026rsquo; experiences of care services as inefficient (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), is that its findings emphasize that people\u0026rsquo;s personal capabilities may determine whether someone will thrive in the caregiver role. The large sample size and the varying care contexts underscore how this is an important phenomenon across countries. However, a limitation that could have influenced the findings regarding caregiver involvement in this study is that some participants might have assumed that the question \u0026ldquo;I would like to be more involved in planning my family\u0026rsquo;s care\u0026rdquo; entailed an assumption that their current efforts needed to increase, or that the question \u0026ldquo;It is easy to get in touch with the staff when I feel the need\u0026rdquo; was irrelevant if no such need has occurred. Clarifying and elaborating on the essence of involvement and support in this context is therefore a suitable topic for a future qualitative study.\u003c/p\u003e \u003cp\u003eThe items chosen to measure involvement could be limited in capturing the essence of involvement for the informal caregivers in this study. Since the effect directions of involvement opportunities and desires for each country were interchangeably negative and positive in terms of mental wellbeing, it would be beneficial to examine the contextual as well as conceptual meaning of involvement for informal caregivers across the various countries in terms of age groups. In addition, most of the participants in this study were women, and even though this reflects society\u0026rsquo;s gender biases in caregiving (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), possible biases should be considered when adopting these findings is for other studies or interventions.\u003c/p\u003e \u003cp\u003eIt is also worth considering that we have no pre-post-test on mental wellbeing or individual resilience before and after caregiving, and thus we cannot accurately predict whether mental wellbeing as measured here changes with individual resilience against the ups and downs of caregiving. As such we cannot assess whether individual resilience is as dynamic in the trajectory of caregiving as perhaps mental wellbeing. Finally, as the involvement items were chosen and separated based on semantic association, a more thorough inspection of the contextual meaning of involvement would have been needed to capture this experience accurately through a questionnaire.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eOur findings carry several implications for the healthcare services potential to support informal caregivers. First, the lack of associations with involvement opportunity and desire suggests that role of policy and service design in informal caregivers\u0026rsquo; wellbeing may be misplaced (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). This matters, because many interventions aimed at informal caregivers implicitly assume that enhancing their participation in the care process will reduce strain, which is not always the case (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Current models often emphasise improving caregiver communication, information flow, or service accessibility as pathways to a good service. In this study, however, the subjective variability in informal caregiver wellbeing highlights how personhood, i.e., the way that you are in terms of individual resilience and physical health, seems to matter more than how and if you are involved in the elderly care services.\u003c/p\u003e \u003cp\u003eEven if the elderly care services double up on self-help apps and individualized tools, informal caregivers with lower capacity to cope in this context, our study suggests that they need to be followed up interpersonally. This is because holding informal caregivers accountable for their own mental wellbeing, neglects the negative external influences care services might have on informal caregiving capacity. Thus, maintaining that informal caregivers are subjectively in good physical health and resilient before they venture on to take on caregiving tasks seems, seems like an essential starting point for health interventions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study found that involvement in elderly care was generally not associated with caregiver mental wellbeing. Instead, individual resilience consistently predicted higher wellbeing across all countries, highlighting its central role in supporting caregiver wellbeing. Other predictors showed country-specific associations, such as caregiving time in the Netherlands, Italy and Norway, caregiving experience in Italy, and self-assessed health in Spain, Italy, the Netherlands, and Norway. These findings suggest that while individual resilience appears to influence mental wellbeing in a European setting, how other variables influence caregiver wellbeing are highly context dependent. More in-depth research on informal caregivers\u0026rsquo; subjective support experiences and the mechanisms influencing their wellbeing is needed.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbbreviations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDefinition\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCD-RISC\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConnor-Davidson Resilience Scale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ecoronavirus disease 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eES\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSpain\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEU\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEuropean Union\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eFI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFinland\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eFICQ\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFamily Involvement in Care Questionnaire\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIT\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eItaly\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eInvolv_Opp\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInvolvement opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eInvolv_Des\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInvolvement desire\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNL\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe Netherlands\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNO\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorway\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOECD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe Organization for Economic Co-operation and Development\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eRO\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRomania\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eS4R\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSupport4resilience\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSAH\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSelf-assessed health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSWEMWBS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShort Warwick-Edinburgh Mental Wellbeing Scale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe S4R project places a strong emphasis on ethics at all levels, ensuring that its research activities align with national, EU, and international ethical standards. This study follows the ALLEA Guidelines, the General Data Protection Regulation (GDPR) 2016/679, and the Declaration of Helsinki. Ethical approval is obtained from country-specific ethics committees before the commencement of studies. This study was approved by the following relevant agencies in the six countries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Norway, by the Norwegian Agency for Shared Services in Education and Research\u0026nbsp;(number\u0026nbsp;881988).\u003c/p\u003e\n\u003cp\u003eIn Romania by the Stefan cel Mare University of Suceava (number 220/25.07.2024) and the Sfantul Ioan cel Nou Clinical Emergency Hospital of Suceava (number 36/30.07.2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the Netherlands by the Erasmus School of Health Policy and Management Research Ethics Review Committee (number ETH2324-0548).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Spain by the Ethics Committee for Research with Human Beings of the Universitat Jaume I of Castellon de la Plana (number CEISH/72/2004).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Italy by the Joint Ethical Committee for Research (number 32/2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Finland by the Research Ethics Committee of Turku University of Applied Sciences (number 14/2024). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants were given an information sheet before participation and provided digital informed consent that their data could be used and published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish declaration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll data used for supporting the conclusions of this article is kept by the S4R empirical partners. Upon reasonable request to author Daniel Adrian Lungu at [email protected], the data can be made available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research was funded by EU Horizon project number 101136291. Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or European Health and Digital Executive Agency (HADEA). Neither the European Union nor the granting authority can be held responsible for them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMK and DAL contributed to the data analysis process. Otherwise, all authors participated in the design, coordination, and recruitment in this research, as well as drafting and revising the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors are grateful for the assistance of organizations in terms of recruitment, as well as all informal caregivers who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRocard E, Llena-Nozal A. Supporting informal carers of older people: Policies to leave no carer behind [Internett]. Paris: OECD; 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.oecd-ilibrary.org/social-issues-migration-health/supporting-informal-carers-of-older-people_0f0c0d52-en\u003c/span\u003e\u003cspan address=\"https://www.oecd-ilibrary.org/social-issues-migration-health/supporting-informal-carers-of-older-people_0f0c0d52-en\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. mai [sitert 24november 2024]. Tilgjengelig p\u0026aring;.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerbakel E, Metzelthin SF, Kempen GIJM. Caregiving to Older Adults: Determinants of Informal Caregivers\u0026rsquo; Subjective Well-being and Formal and Informal Support as Alleviating Conditions. J Gerontol B Psychol Sci Soc Sci. 29. april 2016;gbw047.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePickard L, King D. Modelling the future supply of informal care for older people in Europe. 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRibeiro O, Ara\u0026uacute;jo L, Figueiredo D, Pa\u0026uacute;l C, Teixeira L. The Caregiver Support Ratio in Europe: Estimating the Future of Potentially (Un)Available Caregivers. Healthc Basel Switz 22 desember. 2021;10(1):11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChien SC, Chang YH, Yen CM, Onthoni DD, Wu IC, Hsu CC. mfl. Exploring concepts and trends in informal caregiver burden: systematic review using citation network and content analysis. Aging Clin Exp Res desember. 2023;35(12):2873\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerglund E, Lytsy P, Westerling R. Health and wellbeing in informal caregivers and non-caregivers: a comparative cross-sectional study of the Swedish general population. Health Qual Life Outcomes desember. 2015;13(1):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindt N, Berkel J, Mulder B. Determinants of overburdening among informal carers: a systematic review. BMC Geriatr. august 2020;26:20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinquart M, S\u0026ouml;rensen S. Associations of caregiver stressors and uplifts with subjective well-being and depressive mood: a meta-analytic comparison. Aging Ment Health 1 september. 2004;8(5):438\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerbakel E, Tamlagsr\u0026oslash;nning S, Winstone L, Fj\u0026aelig;r EL, Eikemo TA. Informal care in Europe: findings from the European Social Survey (2014) special module on the social determinants of health. Eur J Public Health 1 februar. 2017;27(suppl1):90\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmbugo EA, de Bruin SR, Masana L, MacInnes J, Mateu NC, Hagen TP. mfl. A Cross-European Study of Informal Carers\u0026rsquo; Needs in the Context of Caring for Older People, and their Experiences with Professionals Working in Integrated Care Settings. Int J Integr Care 8 juli. 2021;21(3):2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyhre J, Bergh S, Kirkevold \u0026Oslash;, Lichtwarck B. An organisation working mainly reactively instead of proactively: a qualitative study of how frail users of home care services and their next of kin experience crises. BMC Health Serv Res 19 september. 2024;24(1):1102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026eacute;rain P, Zech E. Do informal caregivers experience more burnout? A meta-analytic study. Psychol Health Med. februar 2021;26(2):145\u0026ndash;61. 7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGautun H, Bratt C. Caring for older parents in Norway \u0026ndash; How does it affect labor market participation and absence from work? Soc Sci Med. april 2024;346:116722. 1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkgun-Citak E, Attepe-Ozden S, Vaskelyte A, van Bruchem-Visser RL, Pompili S, Kav S. mfl. Challenges and needs of informal caregivers in elderly care: Qualitative research in four European countries, the TRACE project. Arch Gerontol Geriatr. 1. mars 2020;87:103971.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanzeri A, Bottesi G, Ghisi M, Scalavicci C, Spoto A, Vidotto G. Emotional Regulation, Coping, and Resilience in Informal Caregivers: A Network Analysis Approach. Behav Sci Basel Switz. august 2024;13(8):709.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiig S, Aase K, Billett S, Canfield C, R\u0026oslash;ise O. Nj\u0026aring; O, mfl. Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program. BMC Health Serv Res 19 april. 2020;20(1):330.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonanno GA. Uses and abuses of the resilience construct: Loss, trauma, and health-related adversities. Soc Sci Med mars. 2012;74(5):753\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eV\u0026aacute;zquez FL, Blanco V, Andrade E, Otero P, Bueno AM, Sim\u0026oacute;n MA. mfl. Resilience as a protective factor against depression in informal caregivers. Front Psychol. 10. juli 2024;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuisoto P, Contador I, Fern\u0026aacute;ndez-Calvo B, Serra L, Jenaro C, Flores N. mfl. Mediating effect of social support on the relationship between resilience and burden in caregivers of people with dementia. Arch Gerontol Geriatr 1 januar. 2020;86:103952.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWesterling U, Hellgren M, Hermansson L, Strid EN. Informal caregivers\u0026rsquo; experiences of support from a tailored primary healthcare unit for older adults - A focus group study. Scand J Caring Sci september. 2024;38(3):730\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiles J. Informal caregivers\u0026rsquo; experiences of formal support in a changing context. Health Soc Care Community. 2003;11(3):189\u0026ndash;207.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026eacute;rain P, Zech E. Informal Caregiver Burnout? Development of a Theoretical Framework to Understand the Impact of Caregiving. Front Psychol 31 juli. 2019;10:1748.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSupport4Resilence - Empowering healthcare leaders [Internett]. 2021 [sitert 27. november 2024]. Tilgjengelig p\u0026aring;: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://support4resilience.eu/\u003c/span\u003e\u003cspan address=\"https://support4resilience.eu/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatton MQ. Qualitative Research \u0026amp; Evaluation Methods: Integrating Theory and Practice. SAGE; 2014. 833 s.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelendez-Torres GJ, Hewitt G, Hallingberg B, Anthony R, Collishaw S, Hall J. mfl. Measurement invariance properties and external construct validity of the short Warwick-Edinburgh mental wellbeing scale in a large national sample of secondary school students in Wales. Health Qual Life Outcomes 14 august. 2019;17(1):139.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStewart-Brown S, Tennant A, Tennant R, Platt S, Parkinson J, Weich S. Internal construct validity of the Warwick-Edinburgh Mental Well-being Scale (WEMWBS): a Rasch analysis using data from the Scottish Health Education Population Survey. Health Qual Life Outcomes 19 februar. 2009;7(1):15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell-Sills L, Stein MB. Psychometric analysis and refinement of the connor\u0026ndash;davidson resilience scale (CD-RISC): Validation of a 10-item measure of resilience. J Trauma Stress. 2007;20(6):1019\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrakenberg A, Sluys KP, Ericsson E, Sundqvist AS. The Family Involvement in Care Questionnaire\u0026mdash;An instrument measuring family involvement in inpatient care. PLoS ONE. august 2023;15(8):e0285562.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThelen T. Care of the Elderly, Migration, Community: Explorations From Rural Romania. I: Alber E, Drotbohm H, redakt\u0026oslash;rer. Anthropological Perspectives on Care: Work, Kinship, and the Life-Course [Internett]. New York: Palgrave Macmillan US; 2015 [sitert 1. september 2025]. s. 137\u0026ndash;55. Tilgjengelig p\u0026aring;: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1057/9781137513441_7\u003c/span\u003e\u003cspan address=\"10.1057/9781137513441_7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaschowitz J, Brandt M. Health effects of informal caregiving across Europe: A longitudinal approach. Soc Sci Med 1982 januar. 2017;173:72\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowlby S, McKie L. Care and caring: An ecological framework. Area 30 september. 2019;51(3):532\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZarzycki M, Morrison V, Bei E, Seddon D. Cultural and societal motivations for being informal caregivers: a qualitative systematic review and meta-synthesis. Health Psychol Rev 3 april. 2023;17(2):247\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Aring;kerman S, Nyqvist F, Nyg\u0026aring;rd M, Snellman F, Olofsson B. Risk factors for loneliness among older informal caregivers in regions of Finland and Sweden: a longitudinal study. Scand J Public Health. 8. januar 2025;14034948241308029.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristie HL, Boots LMM, Peetoom K, Tange HJ, Verhey FRJ, de Vugt ME. Developing a Plan for the Sustainable Implementation of an Electronic Health Intervention (Partner in Balance) to Support Caregivers of People With Dementia: Case Study. JMIR Aging 25 juni. 2020;3(1):e18624.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDigitale verkt\u0026oslash;y gir nye muligheter for \u0026aring; involvere p\u0026aring;r\u0026oslash;rende | Sykepleien [Internett]. 2025 [sitert 29. august 2025]. Tilgjengelig p\u0026aring;: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sykepleien.no/fag/2025/06/digitale-verktoy-gir-nye-muligheter-involvere-parorende\u003c/span\u003e\u003cspan address=\"https://sykepleien.no/fag/2025/06/digitale-verktoy-gir-nye-muligheter-involvere-parorende\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinquart M, S\u0026ouml;rensen S. Correlates of Physical Health of Informal Caregivers: A Meta-Analysis. J Gerontol Ser B 1 mars. 2007;62(2):P126\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOh E, Moon S, Chung D, Choi R, Hong GRS. The moderating effect of care time on care-related characteristics and caregiver burden: differences between formal and informal caregivers of dependent older adults. Front Public Health. april 2024;4:12:1354263.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGuigan K, Laurente G, Christie A, Carswell C, Moran C, Yaqoob MM. mfl. Effectiveness of interventions for informal caregivers of people with end-stage chronic illness: a systematic review. Syst Rev 28 september. 2024;13(1):245.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJanse B, Huijsman R, de Kuyper RDM, Fabbricotti IN. The effects of an integrated care intervention for the frail elderly on informal caregivers: a quasi-experimental study. BMC Geriatr 1 mai. 2014;14(1):58.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Informal caregivers, elderly care, wellbeing, resilience, involvement, caregiving, cross-country, European","lastPublishedDoi":"10.21203/rs.3.rs-8172228/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8172228/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBy 2060 the demand for caregiving is expected to exceed the number of informal carers available to care for the elderly in Europe. Informal caregivers already make a significant contribution across health sectors, both by alleviating the pressure on formal care services and by providing valuable information about patients. A projected shortfall in informal carers may challenge the caregiving capacity of elderly care services and the provision of high-quality care for elderly. Moreover, informal caregivers report poor communication and uncertainty around the division of care responsibilities with professional careers. Such external influences of these services can contribute to poor health outcomes and reduced motivation in the informal caregiving role. Evidence on how care services involvement of informal caregivers in care tasks and decisions impact their mental wellbeing is currently lacking. This quantitative study examines the factors influence mental wellbeing for informal caregivers in elderly care across six European countries: in Norway, Finland, the Netherlands, Italy, Romania and Spain.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn this correlational cross-sectional study, N\u0026thinsp;=\u0026thinsp;1487 informal caregivers were recruited across the six countries through purposeful selection. All participants provided unpaid care to elderly individuals aged 65 or older. The study featured self-reported measures and sociodemographic variables and self-assessed health. We measured involvement separately as involvement desire and opportunity, as well as mental wellbeing and resilience. These constructs were measured using the Family Involvement in Care Questionnaire, the Short Warwick Mental Well-being Scale and the Connor-Davidson Resilience Scale respectively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIndividual resilience was positively associated with mental wellbeing in informal caregivers in all six countries. Other country-specific associations with mental wellbeing were identified for self-assessed health, age, gender, education, caregiving time and experience. Neither involvement opportunity or desire was associated with mental wellbeing, with the exception of Romania where there was a positive association for involvement opportunity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSubjective influences on mental wellbeing among informal caregivers of the elderly varies greatly across European contexts. However, the individual capacity to deal with adversity is central to informal caregivers\u0026rsquo; mental wellbeing across countries. These findings highlight the complex interplay between subjective and contextual predictors in shaping informal caregivers\u0026rsquo; mental wellbeing.\u003c/p\u003e","manuscriptTitle":"Involvement, individual resilience and mental wellbeing of informal caregivers in elderly care: a correlational cross-sectional study from six European countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-09 11:52:39","doi":"10.21203/rs.3.rs-8172228/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-16T12:45:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155218966541027545333211653803158700002","date":"2026-01-10T17:58:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78228485931425901511541992052795011179","date":"2026-01-07T16:02:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T11:01:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T11:53:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-11T12:57:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-11T12:08:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-28T11:38:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"554e5e91-26c0-4eb2-8588-f03dfaa9b8f1","owner":[],"postedDate":"January 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-09T11:52:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-09 11:52:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8172228","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8172228","identity":"rs-8172228","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}