Health literacy and care burden in family caregivers of patients undergoing hemodialysis: a cross-sectional study in southeast Iran

Health literacy and care burden in family caregivers of patients undergoing hemodialysis: a cross-sectional study in southeast Iran | 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 Health literacy and care burden in family caregivers of patients undergoing hemodialysis: a cross-sectional study in southeast Iran Parniya Abolghaseminejad, Reza Sadeghi, Abedin Iranpour, Parvin Mangolian Shahrbabaki, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7873982/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Family caregivers of patients undergoing hemodialysis face significant challenges that may lead to increased caregiving burden. Health literacy has been suggested as a key factor influencing caregivers’ ability to manage responsibilities effectively. However, limited evidence exists on the relationship between health literacy and caregiving burden in this population. This study aimed to examine the relationship between health literacy and caregiving burden among family caregivers of patients receiving hemodialysis in Kerman, Iran. Methods A descriptive-analytical cross-sectional study was conducted in 2024 with 217 family caregivers recruited from Shafa Hospital and Javad-al-Aemeh Dialysis Clinic. Data were collected using a demographic questionnaire, the Health Literacy for Iranian Adults (HELIA) instrument, and the Caregiver Burden Inventory (CBI). Descriptive and inferential statistics, including t-test, ANOVA, correlation analysis, and multiple regression, were applied using SPSS version 22. Results The mean caregiver age was 38.7 ± 8.7 years, and 60.6% were female. The mean health literacy score was 82.56 ± 14.28 (adequate), and the mean caregiving burden score was 52.22 ± 13.23 (moderate). Care burden was significantly higher among female caregivers, those caring for older patients, caregivers of patients with diabetes, and caregivers of patients undergoing more frequent dialysis sessions (p < 0.05). Regression analysis indicated that dialysis frequency, caregiver gender, and patient age predicted 46% of the variance in caregiver burden. No significant overall correlation was found between health literacy and caregiving burden, though a weak association emerged between the “understanding” dimension of health literacy and time-related caregiving stress. Conclusions While caregivers demonstrated adequate health literacy, it did not independently reduce caregiving burden. Instead, systemic factors such as dialysis frequency, gender roles, and patient age were stronger determinants of burden. Interventions to alleviate caregiver strain should therefore extend beyond health literacy enhancement and address psychosocial support, gender-sensitive strategies, and tailored assistance for families managing high-intensity dialysis schedules. Health literacy Care Burden Caregivers Hemodialysis Iran Introduction Chronic Renal Failure (CRF), currently referred to as Chronic Kidney Disease (CKD), is a slow, irreversible, and progressive condition that develops over the course of several years [ 1 ]. During the progression of this disease, the kidneys lose their ability to excrete metabolic waste products and to maintain fluid and electrolyte balance, which leads to an accumulation of urea and other toxins in the blood. At this stage, patients require hemodialysis or kidney transplantation [ 2 ]. Hemodialysis is one of the most common treatment methods, primarily aimed at improving patients’ quality of life [ 3 ]. Evidence indicates that currently, more than 3 million individuals worldwide with kidney failure are undergoing hemodialysis, with this number increasing by approximately 7% annually. Projections suggest that by 2030, this figure will double [ 4 ]. In Iran as well, nearly half of patients with kidney disease are treated using this method [ 5 ]. Although hemodialysis prolongs survival, it significantly reduces patients’ energy levels. Moreover, due to the frequent need for dialysis sessions, it adversely affects their ability to work and perform daily activities, thereby disrupting the ordinary lives of both patients and their caregivers [ 6 ]. Caregivers—typically family members or close friends— provide the greatest share of care during the illness. They help patients adapt to and manage their disease, yet they receive no compensation for their efforts [ 7 ]. Several factors, including the chronic nature of kidney disease, complications of hemodialysis, and significant lifestyle changes, impose a heavy caregiving burden on family members [ 8 ]. Caregiving burden is a term that refers to the distress and strain caregivers experience because of caring for patients [ 9 ]. In some sources, it is defined as the imbalance between patients’ needs and caregivers’ available resources. This imbalance is influenced by caregivers’ multiple roles, physical and mental health, financial resources, and the quality of healthcare services. The type of illness also determines the degree of caregiving burden [ 10 ]. For instance, various studies have shown that caregivers of hemodialysis patients are under considerable physical, psychological, and financial stress [ 11 , 12 ]. In addition to these challenges, caregivers who lack adequate knowledge and awareness, or do not have access to reliable informational resources, often feel helpless and defeated in performing their responsibilities [ 10 ]. Such negative experiences not only endanger caregivers’ own health but also negatively affect patients’ quality of life. Caring for patients thus requires special conditions to ensure timely and effective support. Caregivers, who consider themselves responsible for patients’ well-being, often spare no effort in supporting treatment. Nevertheless, caregiving is a demanding responsibility that requires patience, perseverance, and a broad set of essential knowledge and skills [ 13 ]. These skills go beyond mere access to health-related information, encompassing the ability to evaluate, understand, and apply health information, to communicate effectively with healthcare providers, and to participate in decision-making. Collectively, these abilities are referred to as health literacy. Caregivers must possess sufficient health literacy [ 14 ] since they are often responsible for understanding medical information, coordinating supportive services, communicating with healthcare providers, and engaging in problem-solving and decision-making related to patients’ care. In such contexts, caregivers’ health literacy plays a particularly important role [ 15 ] and can significantly enhance their quality of life while also benefiting patients with chronic conditions [ 16 ]. In this regard, researchers in one study emphasized that caregivers must possess adequate health literacy to properly comprehend essential health information and adopt appropriate self-care behaviors, enabling them to maintain their own health and improve their patients’ outcomes [ 17 ]. Similarly, Pedro and colleagues found that higher levels of health literacy were associated with better quality of life and reduced caregiving burden. These findings highlight the importance of prioritizing health literacy and identifying its related factors to promote the health and quality of life of both patients and caregivers [ 18 ]. Taken together, existing studies demonstrate that low health literacy among caregivers can substantially increase their caregiving burden. On the one hand, caregivers are often required to manage patients’ medication regimens, dietary restrictions, and medical appointments. On the other hand, limited health literacy makes it difficult for them to understand and adhere to these requirements, which in turn increases stress and psychological strain. Hemodialysis patients are no exception, and failure to address caregivers’ burden in this group can have serious consequences for both patients and their caregivers. Understanding the impact of health literacy on caregiving burden may therefore help identify the specific challenges faced by hemodialysis patients and their families, while also guiding the development of targeted interventions and support programs aimed at reducing burden and improving overall well-being. Furthermore, a review of the existing literature suggests that the relationship between health literacy and caregiving burden among caregivers of hemodialysis patients has received relatively little attention. Additionally, since no studies on this topic were identified in Kerman through database searches, the present study was conducted with the aim of examining the relationship between health literacy and caregiving burden among family caregivers of patients undergoing hemodialysis in Kerman in 2024. Methods This study is a descriptive-analytical cross-sectional survey conducted to determine the health literacy and care burden in family caregivers of patients undergoing hemodialysis in Kerman, Iran, in 2024. Sample The study population consisted of family caregivers of patients undergoing hemodialysis at Shafa Hospital and Javad-al-Aemeh Dialysis Clinic in Kerman, and sampling was performed during patient dialysis sessions among those who met the eligibility criteria. Inclusion criteria required that both the patient and caregiver provide informed consent, the caregiver be a first-degree relative of the patient (parent, spouse, child, or sibling), have provided care for at least six months, have no history of chronic psychiatric illness, and not be using psychiatric medications. Exclusion criteria included incomplete questionnaire responses and withdrawal from the study at any stage. The sample size was calculated using the following formula for estimating the mean health literacy, resulting in 138 participants. Considering a 10% non-response rate, the minimum required sample size for this study was determined to be 152 participants. In this formula, a significance level of 5%, a standard deviation of 36 based on a similar study [ 19 ], and a precision (d) of 6 were assumed. It should be noted that the samples will be selected through stratified sampling with proportional allocation from two hemodialysis centers: Shafa Hospital and Javad Al-Aemeh Clinic. Data Collection Following ethical approval from the Research Ethics Committee of Sirjan University of Medical Sciences, the researchers obtained the necessary permissions from hospital authorities. Eligible caregivers were identified as the primary caregiver through patient report. After providing a full explanation of the study objectives, participants who met the inclusion criteria were asked to complete the questionnaires. Written informed consent was obtained before participation. Caregivers accompanying patients during hemodialysis sessions were asked to complete the questionnaires during the treatment period (approximately three hours). In cases where the main caregiver was not present, data collection was arranged through telephone coordination and scheduled meetings. Questionnaires were completed anonymously, and participants were reassured of the confidentiality of their information. Data were collected using a four-part questionnaire. 1) Demographic Questionnaire for Patients: Included age, sex, education, marital status, occupation, cause of renal failure, and number of dialysis sessions per week. 2) Demographic Questionnaire for Caregivers: Included age, sex, education, marital status, occupation, economic self-assessment, relationship with patient, daily caregiving hours, and main sources of health-related information. 3) Health Literacy Instrument for Adults (HELIA): This questionnaire was developed by Montazeri et al. (2014). For Iranian adults, its validity was confirmed using both face validity and construct validity. Cronbach’s alpha coefficients for the relevant subscales were found to be acceptable, thereby confirming the reliability of the scale. The 33-item instrument consists of five subscales: a) Access skills (6 items, α = 0.86), b) Reading skills (4 items, α = 0.72), c) Comprehension (7 items, α = 0.86), d) Evaluation (4 items, α = 0.77), and e) Decision-making and use of health information (12 items, α = 0.89). The Reading Skills subscale is rated on a 5-point Likert scale ranging from 1 (“completely difficult”) to 5 (“completely easy”). The other subscales are rated on a 5-point Likert scale ranging from 1 (“never”) to 5 (“always”). The total score ranges from 33 to 165. To facilitate interpretation, scores are converted to a standardized scale from 0 to 100 and categorized as follows: Inadequate health literacy (0–50), Not very adequate health literacy (50.1–66), Adequate health literacy (66.1–84), and Excellent health literacy (84.1–100) [ 20 ]. Zareban et. al (2016) further assessed the validity and reliability of this questionnaire. They reported that the Health Literacy for Iranian Adults (HELIA) scale demonstrated strong internal consistency for measuring health literacy. Confirmatory factor analysis supported the construct validity of the instrument, indicating that the HELIA reliably measures health literacy across its five subscales: access, reading, comprehension, evaluation, and decision-making. Their findings confirmed the overall validity and reliability of HELIA in the target population [ 21 ]. 4) Caregiver Burden Inventory (CBI): The 24-item Caregiver Burden Inventory (CBI) was developed by Novak and Guest in 1989. This questionnaire comprises five subscales: a) Time-dependence burden (items 1–5), b) Developmental burden (items 6–10), c) Physical burden (items 11–14), d) Social burden (items 15–19), and e) Emotional burden (items 20–24). Responses are measured on a 5-point Likert scale ranging from strongly disagree (score = 1) to strongly agree (score = 5). Total scores range from 24 to 120, with higher scores indicating a greater negative impact of caregiving on different aspects of the caregiver’s life. Based on cut-off points, scores of 24–47 indicate mild burden, 48–71 moderate burden, 72–95 severe burden, and 96–120 very severe burden [ 22 ]. The CBI has demonstrated good reliability, with Cronbach’s alpha coefficients for the subscales ranging from 0.69 to 0.87, and an overall reliability coefficient of 0.80 [ 23 ]. In addition, Aghili et al. reported satisfactory validity and reliability of the Persian version, with a Cronbach’s alpha of 0.85 for the total scale [ 24 ]. Data Analysis Data will be analyzed using SPSS version 22. Descriptive statistics (frequency, percentage, mean, standard deviation) will be used to summarize demographic data, health literacy scores, and caregiver burden levels. Normality of quantitative variables will be assessed using the Kolmogorov–Smirnov test. For inferential analysis, parametric tests (independent t-test, ANOVA, Pearson correlation) will be applied if assumptions are met; otherwise, non-parametric equivalents (Mann–Whitney U, Kruskal–Wallis, Spearman correlation) will be used. A significance level of p < 0.05 will be considered statistically significant. Ethical approval was obtained from the Research Ethics Committee of Sirjan University of Medical Sciences. Additional permissions were secured from the authorities of the participating hospitals. Written informed consent was obtained from all participants. Questionnaires were anonymous, and participants were assured that their information would remain confidential and be used solely for research purposes. Participants’ dignity and social status were respected throughout the study. Upon completion, study results will be shared with patients and their caregivers. Results The mean age of the patients was 51.19 ± 11.75 years (Min = 25 and Max = 72). Most of the patients were male (n = 139; 64.1%), married (n = 153; 70.8%), and freelancers (n = 76; 35.2%). The mean age of the caregivers was 38.70 ± 8.72 years (Min = 17 and Max = 60). Most of the caregivers were female (n = 129; 60.6%), had a Bachelor's degree (n = 63; 29.0%), and were the patients' spouses (n = 91; 41.9%). Hypertension disease was the most common cause of CKD in patients (n = 105; 48.4%), and most patients underwent hemodialysis once a week (n = 96; 44.2%) (Table 1 ). No significant difference in health literacy was observed among age groups (F = 0.81, p = 0.48). No significant difference in health literacy was found between males and females (p > 0.05). A significant difference in health literacy was found between caregiver age (p = 0.02). The care burden was significantly higher in older age groups (particularly 51–60 years and > 60 years) (F = 4.51, p = 0.004). In examining CKD causes, patients with diabetes exhibited the highest care burden (mean = 59.28), with a highly significant difference between groups (F = 13.02, p < 0.001). Increased dialysis sessions were associated with a higher care burden. The group undergoing dialysis three times per week reported the highest care burden (mean = 62.66) (F = 92.09, p < 0.001). Female caregivers demonstrated a higher care burden (mean = 54.36) compared to males (mean = 49.39, p = 0.01) (Table 1 ). Table 1 Demographic characteristics of the participants and their associations with health literacy and care burden (n = 217). Variable Frequency (%) Health literacy Care burden Mean (SD) Statistical test (P value) Mean (SD) Statistical test (P value) Patient's age (yr.) ≤ 40 41 (18.9) 83.24 (15.77) F = 0.81 (0.48) 48.55 (11.76) F = 4.51 (0.004) 41–50 63 (29.0) 80.04 (12.41) 49.00 (12.36) 51–60 53 (24.4) 81.56 (12.02) 54.08 (13.25) > 60 60 (27.6) 83.56 (14.83) 56.54 (13.79) Gender Male 139 (64.1) 81.27 (13.47) t = -1.03 (0.30) 52.63 (13.25) t = 0.56 (0.57) Female 78 (35.9) 83.76 (14.05) 51.52 (13.25) Marital status Married 153 (70.8) 82.55 (13.94) t = 1.10 (0.27) 51.97 (13.08) t = -0.56 (0.57) Divorced/widow(er) 63 (29.2) 80.30 (12.84) 53.15 (13.54) Education level Illiterate 16 (7.4) 85.93 (15.05) F = 1.27 (0.27) 53.35 (11.17) F = 0.93 (0.45) Primary 55 (25.3) 81.01 (13.37) 53.43 (13.36) Diploma 54 (24.9) 81.18 (14.32) 53.06 (13.90) Associate degree 44 (20.3) 81.63 (13.49) 53.33 (14.33) Bachelor's degree 36 (16.6) 85.38(12.87) 47.88 (12.78) Master's degree 12 (5.5) 76.00 (12.50) 51.27 (7.37) Job Employee 40 (18.5) 81.17 (14.07) F = 1.05 (0.36) 52.08 (14.59) F = 0.64 (0.58) Self-employed 76 (35.2) 81.17 (13.47) 53.93 (12.67) Retired 60 (27.8) 81.06 (12.06) 50.80 (13.62) other 40 (18.4) 85.40 (15.78) 51.22 (12.36) Cause of CKD Hypertension 105 (48.4) 80.11 (11.91) F = 2.34 (0.09) 52.58 (11.33) F = 13.02 (p < 0.001) Diabetes 43 (19.8) 85.20 (15.23) 59.28 (13.43) other 69 (31.8) 82.85 (14.89) 46.32 (13.63) Dialysis sessions per week Once a week 96 (44.2) 80.87 (13.00) F = 2.33 (0.09) 41.78 (8.35) F = 92.09 (p < 0.001) Twice a week 67 (30.9) 80.80 (12.70) 57.88 (9.54) Three a week 54 (24.9) 85.46 (15.59) 62.66 (11.13) Caregiver gender Male 84 (39.4) 83.22 (14.53) t = 1.24 (0.21) 49.39 (12.06) t = -2.56 (0.01) Female 129 (60.6) 80.83 (13.03) 54.36 (13.64) Caregiver age (yr.) ≤ 40 117 (53.9) 83.84 (14.96) t = 2.21 (0.02) 52.77 (14.29) Z = -0.23 (0.81) > 40 100 (46.1) 79.83 (11.72) 51..60 (11.93) Caregiver education level Primary 36 (16.6) 79.58 (11.27) F = 1.72 (0.14) 53.34 (12.50) H = 6.07 (0.19) Diploma 41 (18.9) 81.12 (13.08) 50.55 (10.91) Associate degree 53 (24.4) 79.69 (15.78) 56.06 (14.33) Bachelor's degree 63 (29.0) 85.34 (13.94) 51.43 (14.35) Master's degree 24 (11.1) 83.37 (11.18) 48.04 (11.15) Caregiver marital status married 153 (71.5) 81.71 (13.54) t = -0.45 (0.65) 51.57 (12.53) Z = -0.80 (0.42) Single/ Divorced/ Widowed 61 (28.5) 82.65 (14.41) 53.86 (14.98) Caregiver occupation Employee 46 (21.2) 83.82 (13.93) F = 1.13 (0.33) 49.17 (12.91) H = 6.80 (0.07) Self-employed 76 (35.0) 82.43 (14.24) 51.26 (12.17) Housewife 63 (29.0) 79.44 (11.99) 52.20 (11.65) other 32 (14.7) 83.34 (14.97) 58.92 (17.23) Economic status Poor 17 (7.9) 77.29 (11.99) F = 1.15 (0.31) 52.35 (10.92) F = 1.66 (0.19) Average 156 (72.2) 82.59 (13.76) 51.21 (13.54) Good 43 (19.9) 81.76 (14.06) 55.56 (12.55) Caregiver-patient relationship Spouse 91 (41.9) 81.96 (13.19) H = 0.54 (0.76) 51.43 (12.29) H = 2.85 (0.24) Father/Mother 68 (31.3) 82.91 (14.38) 54.83 (15.29) Sister/Brother/Child 58 (26.7) 80.96 (13.76) 50.30 (11.63) How to obtain information Internet 43 (19.8) 84.88 (11.91) F = 1.28 (0.27) 51.44 (13.56) F = 0.96 (0.38) Getting information from medical and healthcare workers 134 (61.8) 81.52 (13.96) 53.19 (12.76) other 40 (18.4) 80.47 (14.40) 49.89 (14.36) SD = Standard Deviation, t = Independent t test, Z = Mann-Whitney U; F = Analysis of variance, H = Kruskal-Wallis H; The mean care burden was 52.22 ± 13.23. The proximity of the median (52.00) to the mean suggests an approximately symmetric distribution of the data. Among the various dimensions of care burden, time-related caregiving stress had the highest mean value (15.84 ± 3.09), while the social caregiving stress dimension had the lowest mean (7.64 ± 2.29). For health literacy, the mean score was 82.56 ± 14.28, with a median of 79.00. Among the health literacy components, the decision making and applying health information had the highest mean score (30.35 ± 4.72), whereas the evaluation dimension had the lowest mean (9.90 ± 1.89) (Table 2 ). Table 2 Distribution of the health literacy and care burden in patients undergoing hemodialysis (n = 217). Variable Median Mean SD Min Max Care burden 52.00 52.22 13.23 32 90 Time-related caregiving stress 15.00 15.84 3.09 9 23 Developmental caregiving stress 8.00 9.03 3.58 5 20 Physical caregiving stress 8.00 8.76 3.15 4 17 Social caregiving stress 7.00 7.64 2.92 5 17 Emotional caregiving stress 12.00 11.04 3.73 5 22 health literacy 79.00 82.56 14.28 54 121 Access 14.00 15.06 4.49 6 30 Reading skills 8.00 10.21 5.24 4 20 Understanding 17.00 16.72 2.96 9 27 Evaluation 10.00 9.90 1.89 4 15 Decision-making and applying health information 30.00 30.35 4.72 15 44 There was no significant correlation between health literacy and caregiving burden (p = 0.01). All dimensions of health literacy were not associated with health literacy dimensions, except for the domain of understanding. The understanding component of health literacy was associated with time-related caregiving stress (p = 0.01). This may indicate that greater awareness of health status exacerbates the stress of caregiving responsibilities (Table 3 ). Table 3 Correlation between the health literacy and care burden in patients undergoing hemodialysis (n = 217). Variable Time-related caregiving stress Developmental caregiving stress Physical caregiving stress Social caregiving stress Emotional caregiving stress Care burden Access 0.10 (0.11) 0.02 (0.71) 0.03 (0.57) 0.08 (0.20) 0.03 (0.61) 0.06 (0.34) Reading skills 0.09 (0.18) -0.03 (0.59) -0.004 (0.95) 0.49 (0.48) 0.03 (0.65) 0.02 (0.77) Understanding 0.16 (0.01) -0.03 (0.63) 0.03 (0.65) 0.04 (0.52) 0.04 (0.50) 0.06 (0.33) Evaluation 0.10 (0.12) 0.04 (0.54) 0.06 (0.37) 0.11 (0.10) 0.09 (0.16) 0.09 (0.17) Decision-making and applying health information -0.06 (0.37) -0.004 (0.94) -0.10 (0.11) -0.10 (0.12) -0.09 (0.16) -0.10 (0.15) health literacy 0.09 (0.16) -0.009 (0.90) -0.007 (0.92) 0.03 (0.61) 0.01 (0.85) 0.02 (0.75) Data were presented as Pearson's correlation coefficient. We used multiple regression with the backward method for further analysis and included all variables in the multivariate regression model. The result showed the R 2 for care burden was 0.46, which indicated that variables, i.e., dialysis sessions per week, caregiver gender, patients’ age, and health literacy, can predict nearly 46% of changes of care burden in hemodialysis patients. As shown in Table 4 , dialysis sessions per week ( B = 10.48; 95% confidence intervals (CI: 8.76–12.21), caregiver gender ( B = 3.84; CI: 0.99–6.69) and patients’ age ( B = 0.12; CI: 0.007–0.24) predicted 46% of the variance of care burden in the patient’s undergoing hemodialysis. Table 4 The multiple regression analysis summary for the care burden in patients undergoing hemodialysis (n = 217). Variable B SE‡ Βeta T P 95% Confidence interval for B Adjusted R 2 Care burden (Constant) 26.75 5.42 - 4.93 < 0.001 16.05 _ 37.45 46% Dialysis sessions per week 10.48 0.87 0.64 11.98 < 0.001 8.76_ 12.21 Caregiver gender 3.84 1.44 0.14 2.66 0.008 0.99_ 6.69 Patients age 0.12 0.06 0.11 2.09 0.038 0.007_ 0.24 Health literacy -0.03 0.05 -0.03 -0.60 0.54 -0.13_ 0.07 ‡: Standard error; Discussion The present study examined the relationship between health literacy and caregiving burden among family caregivers of patients undergoing hemodialysis in Kerman. The findings revealed that the overall level of health literacy in caregivers was relatively high, with the mean score indicating an adequate level. Research on health literacy (HL) has traditionally concentrated on patient populations, but more recently, attention has also turned to family caregivers. Studies in this area suggest that higher HL can enhance caregivers’ awareness of available health services and the importance of staying informed [ 25 ], improve communication with healthcare professionals [ 26 ], and increase access to caregiver support resources [ 27 , 28 ]. However, despite this growing body of work, relatively little attention has been directed toward the HL of caregivers of dialysis patients, even though this group faces substantial and unique caregiving demands. In contrast, the average caregiving burden was moderate, with time-related caregiving stress identified as the most prominent dimension. These findings are consistent with those of Jafari et al. [ 29 ] and Hamshaikh et al. [ 11 ], who also reported moderate to high levels of burden among caregivers of dialysis patients. Such consistency underscores that the chronic and intensive nature of hemodialysis imposes sustained physical and psychological demands on caregivers. However, our results differ from those of Pio et al. [ 30 ] and Rioux et al. [ 31 ], who observed comparatively lower levels of caregiver burden. This discrepancy may be explained by contextual differences in patient care settings. For example, both Pio and Rioux highlighted that patients undergoing overnight dialysis demonstrated greater independence and self-care ability, which in turn reduced reliance on family caregivers. In contrast, in our study setting, patients largely depended on their families for daily activities and logistical support during regular hemodialysis sessions, leading to a higher and more persistent caregiver burden. Importantly, no significant overall correlation was observed between health literacy and caregiving burden, except for a weak association between the “understanding” component of health literacy and time-related caregiving stress. These results are noteworthy, as they diverge from several previous studies suggesting that higher health literacy is linked to reduced caregiver burden and improved quality of life. For instance, Abed et. al reported that family caregivers with limited functional health literacy (FHL) experienced significantly higher burden—on average 4.6 points more—than those with adequate FHL [ 32 ]. Among family caregivers of patients with type two diabetes, Gibson also found a significant independent relationship of caregivers' health literacy to caregiving burden [ 33 ]. In bivariate analyses, Barutcu demonstrated weak to moderate, negative relationships of caregiving burden to health literacy in terms of information access, understanding, appraisal, and application [ 34 ]. In other bivariate analyses, Ishida et. al also found that health literacy of heart failure patients and their family caregivers was significantly associated with caregiving burden [ 35 ]. The lack of such association in our study may be due to contextual differences, cultural factors, or the characteristics of the studied population. For example, caregivers in this study had frequent exposure to healthcare settings during dialysis sessions, which may have provided them with structured support, reducing the independent impact of health literacy on caregiving outcomes. These contextual differences highlight how disease type and care setting can moderate the relationship between health literacy and caregiver burden. Our regression analysis indicated that the most powerful predictors of caregiving burden were the number of dialysis sessions per week, caregiver gender, and patient age, together explaining 46% of the variance. Caregivers of patients undergoing more frequent dialysis experienced significantly higher levels of burden, consistent with previous reports that intensive treatment schedules exacerbate physical, emotional, and financial stress. Female caregivers also reported greater burden compared with males, echoing earlier findings [ 36 , 37 ]. Several explanations may account for this finding. Gender-related differences in caregiving burden are often linked to traditional gender roles, in which women are typically expected to assume the primary responsibility for providing care in both family and informal settings [ 38 ]. As a result, women may be more inclined to take on caregiving duties compared to men. Another possible explanation is that women are generally more open in sharing their caregiving experiences, consistent with gender norms that encourage women to be more expressive and vocal about their emotions [ 39 ]. Consequently, women are more likely than men to communicate negative feelings such as stress or fatigue [ 40 ]. In contrast, cultural expectations in many Middle Eastern societies discourage men from voicing complaints or admitting vulnerability, as they are socially expected to appear strong and resilient under pressure [ 41 ]. Additionally, older patient age predicted higher caregiver burden, which may reflect the greater dependency of elderly patients and the prolonged caregiving role required of family members. Alshammari et al. found that older age and comorbidities were positively correlated with higher caregiver burden [ 42 ]. But in contrast to the findings of the present study, Cagan et al. reported no significant association between caregiver burden and caregiver age group [ 43 ]. Interestingly, caregivers’ education level, marital status, and economic self-assessment did not significantly influence burden. These results were consistent with Cagan's study [ 43 ]. But this is inconsistent with some studies that identified socioeconomic status and educational background as important correlates of caregiving stress [ 44 , 45 ]. One possible explanation is that in the context of hemodialysis, the structured and predictable nature of treatment creates a uniform caregiving demand across demographic groups, making these factors less influential. Another point of interest is the weak positive association between the “understanding” dimension of health literacy and time-related stress. It is plausible that caregivers with higher awareness and comprehension of patients’ health conditions become more conscious of the severity and complexity of care requirements, thereby experiencing greater stress. This paradox highlights the need for supportive interventions that not only improve caregivers’ knowledge but also provide coping strategies to manage the emotional consequences of increased awareness. Limitations This study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design precludes establishing causal relationships between health literacy and caregiving burden. Longitudinal or interventional studies are needed to confirm the direction and strength of these associations. Second, data collected through self-reported questionnaires may have been subject to recall bias or social desirability bias, potentially influencing the accuracy of responses. Third, the study was conducted in two hemodialysis centers in Kerman, which may limit the generalizability of the results to caregivers in other cultural or healthcare settings. Fourth, although health literacy and caregiving burden were assessed with validated instruments, unmeasured psychosocial variables—such as coping strategies, social support, or cultural norms—may have influenced the outcomes but were not included in the analysis. Finally, nearly 10% of participants did not complete the questionnaires, which may have introduced non-response bias despite efforts to ensure representativeness. Conclusions The findings of this study indicate that while family caregivers of hemodialysis patients in Kerman generally demonstrated adequate levels of health literacy, this factor alone did not significantly reduce their caregiving burden. Instead, systemic and demographic variables—particularly the frequency of dialysis sessions, caregiver gender, and patient age—emerged as stronger predictors of burden. Caregivers most affected were women, those supporting older patients, and families managing more frequent dialysis schedules. These results underscore that reducing caregiver burden requires multifaceted interventions that extend beyond enhancing health literacy. Policies and programs should integrate psychosocial support, gender-sensitive approaches, and targeted resources for families managing intensive dialysis regimens to promote both caregiver well-being and patient outcomes. Declarations Acknowledgments We want to thank the Vice Presidency for Research and Technology of the Sirjan School of Medical Sciences for providing the financial resources and all the participants who generously gave their valuable time to participate in this study. Authors’ contributions P.A & M.M collected the study data. P.A wrote the article. M.Z performed statistical analyses. R.S & A.I & P.MSH read the article and made the necessary checks for its correction. Then all of them approved the article. Funding No funding. Availability of Data and Materials All data generated or analysed during this study are included in this published article. Ethics approval and consent to participate After receiving the ethics code (IR.SIRUMS.REC.1403.020) from the ethics committee of Sirjan School of Medical Sciences and an official letter of introduction from Sirjan School of Medical Sciences, the researchers visited the research settings, explained the study objectives to the participants, emphasized the confidentiality of the information, and obtained their informed and written consent if they wished to participate in the study. All procedures were performed in accordance with the relevant guidelines and regulations contained in the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Author details 1 Sirjan School of Medical Sciences, Sirjan, Iran. 2 Ph. D. Student in Health Education and Promotion, Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. 3 Associate Professor of Health Education and Promotion, Department of Public Health, Sirjan School of Medical Sciences, Sirjan, Iran. 4 Associate Professor of Health Education and Promotion, HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. 5 Associate Professor of Nursing, Nursing Research Centre, Kerman University of Medical Sciences, Kerman, Iran. 6 Clinical Research Development Unit, Ali-Ibn Abi-Talib Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Iran. 7 Student Research Committee, Sirjan School of Medical Sciences, Sirjan, Iran. References K. Kheirollahi, R. Hemayati, and S. R. 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O’Halloran, "Caregiver burden in informal caregivers of patients in Saudi Arabia receiving hemodialysis: A mixed-methods study. ," Healthcare (Basel). vol. 11, no. 3, p. 366, 2023. O. Cagan, A. Unsal, N. Celik, A. Yilmaz, I. Culha, and H. Eren, "Care Burden of Caregivers of Hemodialysis Patients and Related Factors.," International Journal of Caring Sciences. , vol. 11, no. 1, p. 279, 2018. H. Mahmoud Mohammad Abdulaziz , Y. Mohamed Omar, A. Mohamed Naguib Attiya, and e. al., "Exploring the burden of informal caregiving for patients undergoing long-term hemodialysis: A multicenter study. ," Turk J Nephrol. , vol. 34, no. 3, pp. 188–194., 2025. M. Darwish, S. Hassan, S. Taha, H. Abd El-Megeed, and T. Ismail, "Family impact and economic burden among caregivers of children with chronic kidney disease in Assiut, Egypt. ," J Egypt Public Health Assoc. , vol. 95, no. 1, p. 27, 2020. Additional Declarations No competing interests reported. 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Renal Failure (CRF), currently referred to as Chronic Kidney Disease (CKD), is a slow, irreversible, and progressive condition that develops over the course of several years [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. During the progression of this disease, the kidneys lose their ability to excrete metabolic waste products and to maintain fluid and electrolyte balance, which leads to an accumulation of urea and other toxins in the blood. At this stage, patients require hemodialysis or kidney transplantation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Hemodialysis is one of the most common treatment methods, primarily aimed at improving patients\u0026rsquo; quality of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Evidence indicates that currently, more than 3\u0026nbsp;million individuals worldwide with kidney failure are undergoing hemodialysis, with this number increasing by approximately 7% annually. Projections suggest that by 2030, this figure will double [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Iran as well, nearly half of patients with kidney disease are treated using this method [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough hemodialysis prolongs survival, it significantly reduces patients\u0026rsquo; energy levels. Moreover, due to the frequent need for dialysis sessions, it adversely affects their ability to work and perform daily activities, thereby disrupting the ordinary lives of both patients and their caregivers [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Caregivers\u0026mdash;typically family members or close friends\u0026mdash; provide the greatest share of care during the illness. They help patients adapt to and manage their disease, yet they receive no compensation for their efforts [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral factors, including the chronic nature of kidney disease, complications of hemodialysis, and significant lifestyle changes, impose a heavy caregiving burden on family members [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Caregiving burden is a term that refers to the distress and strain caregivers experience because of caring for patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In some sources, it is defined as the imbalance between patients\u0026rsquo; needs and caregivers\u0026rsquo; available resources. This imbalance is influenced by caregivers\u0026rsquo; multiple roles, physical and mental health, financial resources, and the quality of healthcare services. The type of illness also determines the degree of caregiving burden [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. For instance, various studies have shown that caregivers of hemodialysis patients are under considerable physical, psychological, and financial stress [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In addition to these challenges, caregivers who lack adequate knowledge and awareness, or do not have access to reliable informational resources, often feel helpless and defeated in performing their responsibilities [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Such negative experiences not only endanger caregivers\u0026rsquo; own health but also negatively affect patients\u0026rsquo; quality of life.\u003c/p\u003e\u003cp\u003eCaring for patients thus requires special conditions to ensure timely and effective support. Caregivers, who consider themselves responsible for patients\u0026rsquo; well-being, often spare no effort in supporting treatment. Nevertheless, caregiving is a demanding responsibility that requires patience, perseverance, and a broad set of essential knowledge and skills [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These skills go beyond mere access to health-related information, encompassing the ability to evaluate, understand, and apply health information, to communicate effectively with healthcare providers, and to participate in decision-making. Collectively, these abilities are referred to as health literacy. Caregivers must possess sufficient health literacy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] since they are often responsible for understanding medical information, coordinating supportive services, communicating with healthcare providers, and engaging in problem-solving and decision-making related to patients\u0026rsquo; care. In such contexts, caregivers\u0026rsquo; health literacy plays a particularly important role [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and can significantly enhance their quality of life while also benefiting patients with chronic conditions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this regard, researchers in one study emphasized that caregivers must possess adequate health literacy to properly comprehend essential health information and adopt appropriate self-care behaviors, enabling them to maintain their own health and improve their patients\u0026rsquo; outcomes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, Pedro and colleagues found that higher levels of health literacy were associated with better quality of life and reduced caregiving burden. These findings highlight the importance of prioritizing health literacy and identifying its related factors to promote the health and quality of life of both patients and caregivers [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTaken together, existing studies demonstrate that low health literacy among caregivers can substantially increase their caregiving burden. On the one hand, caregivers are often required to manage patients\u0026rsquo; medication regimens, dietary restrictions, and medical appointments. On the other hand, limited health literacy makes it difficult for them to understand and adhere to these requirements, which in turn increases stress and psychological strain. Hemodialysis patients are no exception, and failure to address caregivers\u0026rsquo; burden in this group can have serious consequences for both patients and their caregivers. Understanding the impact of health literacy on caregiving burden may therefore help identify the specific challenges faced by hemodialysis patients and their families, while also guiding the development of targeted interventions and support programs aimed at reducing burden and improving overall well-being.\u003c/p\u003e\u003cp\u003eFurthermore, a review of the existing literature suggests that the relationship between health literacy and caregiving burden among caregivers of hemodialysis patients has received relatively little attention. Additionally, since no studies on this topic were identified in Kerman through database searches, the present study was conducted with the aim of examining the relationship between health literacy and caregiving burden among family caregivers of patients undergoing hemodialysis in Kerman in 2024.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is a descriptive-analytical cross-sectional survey conducted to determine the health literacy and care burden in family caregivers of patients undergoing hemodialysis in Kerman, Iran, in 2024.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSample\u003c/h2\u003e\u003cp\u003eThe study population consisted of family caregivers of patients undergoing hemodialysis at Shafa Hospital and Javad-al-Aemeh Dialysis Clinic in Kerman, and sampling was performed during patient dialysis sessions among those who met the eligibility criteria. Inclusion criteria required that both the patient and caregiver provide informed consent, the caregiver be a first-degree relative of the patient (parent, spouse, child, or sibling), have provided care for at least six months, have no history of chronic psychiatric illness, and not be using psychiatric medications. Exclusion criteria included incomplete questionnaire responses and withdrawal from the study at any stage.\u003c/p\u003e\u003cp\u003eThe sample size was calculated using the following formula for estimating the mean health literacy, resulting in 138 participants. Considering a 10% non-response rate, the minimum required sample size for this study was determined to be 152 participants.\u003c/p\u003e\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\" width=\"430\" height=\"106\"\u003e\u003c/p\u003e\u003cp\u003eIn this formula, a significance level of 5%, a standard deviation of 36 based on a similar study [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and a precision (d) of 6 were assumed. It should be noted that the samples will be selected through stratified sampling with proportional allocation from two hemodialysis centers: Shafa Hospital and Javad Al-Aemeh Clinic.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eFollowing ethical approval from the Research Ethics Committee of Sirjan University of Medical Sciences, the researchers obtained the necessary permissions from hospital authorities. Eligible caregivers were identified as the primary caregiver through patient report. After providing a full explanation of the study objectives, participants who met the inclusion criteria were asked to complete the questionnaires. Written informed consent was obtained before participation.\u003c/p\u003e\u003cp\u003eCaregivers accompanying patients during hemodialysis sessions were asked to complete the questionnaires during the treatment period (approximately three hours). In cases where the main caregiver was not present, data collection was arranged through telephone coordination and scheduled meetings. Questionnaires were completed anonymously, and participants were reassured of the confidentiality of their information. Data were collected using a four-part questionnaire.\u003c/p\u003e\u003cp\u003e1) Demographic Questionnaire for Patients: Included age, sex, education, marital status, occupation, cause of renal failure, and number of dialysis sessions per week.\u003c/p\u003e\u003cp\u003e2) Demographic Questionnaire for Caregivers: Included age, sex, education, marital status, occupation, economic self-assessment, relationship with patient, daily caregiving hours, and main sources of health-related information.\u003c/p\u003e\u003cp\u003e3) Health Literacy Instrument for Adults (HELIA): This questionnaire was developed by Montazeri et al. (2014). For Iranian adults, its validity was confirmed using both face validity and construct validity. Cronbach\u0026rsquo;s alpha coefficients for the relevant subscales were found to be acceptable, thereby confirming the reliability of the scale. The 33-item instrument consists of five subscales: a) Access skills (6 items, α\u0026thinsp;=\u0026thinsp;0.86), b) Reading skills (4 items, α\u0026thinsp;=\u0026thinsp;0.72), c) Comprehension (7 items, α\u0026thinsp;=\u0026thinsp;0.86), d) Evaluation (4 items, α\u0026thinsp;=\u0026thinsp;0.77), and e) Decision-making and use of health information (12 items, α\u0026thinsp;=\u0026thinsp;0.89). The Reading Skills subscale is rated on a 5-point Likert scale ranging from 1 (\u0026ldquo;completely difficult\u0026rdquo;) to 5 (\u0026ldquo;completely easy\u0026rdquo;). The other subscales are rated on a 5-point Likert scale ranging from 1 (\u0026ldquo;never\u0026rdquo;) to 5 (\u0026ldquo;always\u0026rdquo;). The total score ranges from 33 to 165. To facilitate interpretation, scores are converted to a standardized scale from 0 to 100 and categorized as follows: Inadequate health literacy (0\u0026ndash;50), Not very adequate health literacy (50.1\u0026ndash;66), Adequate health literacy (66.1\u0026ndash;84), and Excellent health literacy (84.1\u0026ndash;100) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Zareban et. al (2016) further assessed the validity and reliability of this questionnaire. They reported that the Health Literacy for Iranian Adults (HELIA) scale demonstrated strong internal consistency for measuring health literacy. Confirmatory factor analysis supported the construct validity of the instrument, indicating that the HELIA reliably measures health literacy across its five subscales: access, reading, comprehension, evaluation, and decision-making. Their findings confirmed the overall validity and reliability of HELIA in the target population [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e4) Caregiver Burden Inventory (CBI): The 24-item Caregiver Burden Inventory (CBI) was developed by Novak and Guest in 1989. This questionnaire comprises five subscales: a) Time-dependence burden (items 1\u0026ndash;5), b) Developmental burden (items 6\u0026ndash;10), c) Physical burden (items 11\u0026ndash;14), d) Social burden (items 15\u0026ndash;19), and e) Emotional burden (items 20\u0026ndash;24).\u003c/p\u003e\u003cp\u003eResponses are measured on a 5-point Likert scale ranging from strongly disagree (score\u0026thinsp;=\u0026thinsp;1) to strongly agree (score\u0026thinsp;=\u0026thinsp;5). Total scores range from 24 to 120, with higher scores indicating a greater negative impact of caregiving on different aspects of the caregiver\u0026rsquo;s life. Based on cut-off points, scores of 24\u0026ndash;47 indicate mild burden, 48\u0026ndash;71 moderate burden, 72\u0026ndash;95 severe burden, and 96\u0026ndash;120 very severe burden [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The CBI has demonstrated good reliability, with Cronbach\u0026rsquo;s alpha coefficients for the subscales ranging from 0.69 to 0.87, and an overall reliability coefficient of 0.80 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In addition, Aghili et al. reported satisfactory validity and reliability of the Persian version, with a Cronbach\u0026rsquo;s alpha of 0.85 for the total scale [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData will be analyzed using SPSS version 22. Descriptive statistics (frequency, percentage, mean, standard deviation) will be used to summarize demographic data, health literacy scores, and caregiver burden levels. Normality of quantitative variables will be assessed using the Kolmogorov\u0026ndash;Smirnov test. For inferential analysis, parametric tests (independent t-test, ANOVA, Pearson correlation) will be applied if assumptions are met; otherwise, non-parametric equivalents (Mann\u0026ndash;Whitney U, Kruskal\u0026ndash;Wallis, Spearman correlation) will be used. A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 will be considered statistically significant.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003e was obtained from the Research Ethics Committee of Sirjan University of Medical Sciences. Additional permissions were secured from the authorities of the participating hospitals. Written informed consent was obtained from all participants. Questionnaires were anonymous, and participants were assured that their information would remain confidential and be used solely for research purposes. Participants\u0026rsquo; dignity and social status were respected throughout the study. Upon completion, study results will be shared with patients and their caregivers.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age of the patients was 51.19\u0026thinsp;\u0026plusmn;\u0026thinsp;11.75 years (Min\u0026thinsp;=\u0026thinsp;25 and Max\u0026thinsp;=\u0026thinsp;72). Most of the patients were male (n\u0026thinsp;=\u0026thinsp;139; 64.1%), married (n\u0026thinsp;=\u0026thinsp;153; 70.8%), and freelancers (n\u0026thinsp;=\u0026thinsp;76; 35.2%). The mean age of the caregivers was 38.70\u0026thinsp;\u0026plusmn;\u0026thinsp;8.72 years (Min\u0026thinsp;=\u0026thinsp;17 and Max\u0026thinsp;=\u0026thinsp;60). Most of the caregivers were female (n\u0026thinsp;=\u0026thinsp;129; 60.6%), had a Bachelor's degree (n\u0026thinsp;=\u0026thinsp;63; 29.0%), and were the patients' spouses (n\u0026thinsp;=\u0026thinsp;91; 41.9%). Hypertension disease was the most common cause of CKD in patients (n\u0026thinsp;=\u0026thinsp;105; 48.4%), and most patients underwent hemodialysis once a week (n\u0026thinsp;=\u0026thinsp;96; 44.2%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNo significant difference in health literacy was observed among age groups (F\u0026thinsp;=\u0026thinsp;0.81, p\u0026thinsp;=\u0026thinsp;0.48). No significant difference in health literacy was found between males and females (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). A significant difference in health literacy was found between caregiver age (p\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e\u003cp\u003eThe care burden was significantly higher in older age groups (particularly 51\u0026ndash;60 years and \u0026gt;\u0026thinsp;60 years) (F\u0026thinsp;=\u0026thinsp;4.51, p\u0026thinsp;=\u0026thinsp;0.004). In examining CKD causes, patients with diabetes exhibited the highest care burden (mean\u0026thinsp;=\u0026thinsp;59.28), with a highly significant difference between groups (F\u0026thinsp;=\u0026thinsp;13.02, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Increased dialysis sessions were associated with a higher care burden. The group undergoing dialysis three times per week reported the highest care burden (mean\u0026thinsp;=\u0026thinsp;62.66) (F\u0026thinsp;=\u0026thinsp;92.09, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Female caregivers demonstrated a higher care burden (mean\u0026thinsp;=\u0026thinsp;54.36) compared to males (mean\u0026thinsp;=\u0026thinsp;49.39, p\u0026thinsp;=\u0026thinsp;0.01) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\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\u003eDemographic characteristics of the participants and their associations with health literacy and care burden (n\u0026thinsp;=\u0026thinsp;217).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFrequency (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eHealth literacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eCare burden\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eStatistical test (P value)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eStatistical test (P value)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003ePatient's age (yr.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (18.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.24 (15.77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;0.81 (0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e48.55 (11.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;4.51 (0.004)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63 (29.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.04 (12.41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49.00 (12.36)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (24.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.56 (12.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e54.08 (13.25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60 (27.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.56 (14.83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e56.54 (13.79)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e139 (64.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.27 (13.47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003et = -1.03 (0.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e52.63 (13.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;0.56 (0.57)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78 (35.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.76 (14.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51.52 (13.25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e153 (70.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82.55 (13.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;1.10 (0.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51.97 (13.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003et = -0.56 (0.57)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced/widow(er)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63 (29.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.30 (12.84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53.15 (13.54)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (7.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.93 (15.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;1.27 (0.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53.35 (11.17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;0.93 (0.45)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 (25.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.01 (13.37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53.43 (13.36)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiploma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54 (24.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.18 (14.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53.06 (13.90)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssociate degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44 (20.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.63 (13.49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53.33 (14.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (16.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.38(12.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e47.88 (12.78)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster's degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76.00 (12.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51.27 (7.37)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eJob\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (18.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.17 (14.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;1.05 (0.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e52.08 (14.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;0.64 (0.58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-employed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (35.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.17 (13.47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53.93 (12.67)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetired\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60 (27.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.06 (12.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e50.80 (13.62)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (18.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.40 (15.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51.22 (12.36)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eCause of CKD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105 (48.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.11 (11.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;2.34 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e52.58 (11.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;13.02 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (19.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.20 (15.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e59.28 (13.43)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69 (31.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82.85 (14.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e46.32 (13.63)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDialysis sessions per week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOnce a week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96 (44.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.87 (13.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;2.33 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e41.78 (8.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;92.09 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTwice a week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67 (30.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.80 (12.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e57.88 (9.54)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThree a week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54 (24.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.46 (15.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e62.66 (11.13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCaregiver gender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84 (39.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.22 (14.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;1.24 (0.21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49.39 (12.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003et = -2.56 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e129 (60.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.83 (13.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e54.36 (13.64)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCaregiver age (yr.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e117 (53.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.84 (14.96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;2.21 (0.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e52.77 (14.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eZ = -0.23 (0.81)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100 (46.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e79.83 (11.72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51..60 (11.93)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eCaregiver education level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (16.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e79.58 (11.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;1.72 (0.14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53.34 (12.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eH\u0026thinsp;=\u0026thinsp;6.07 (0.19)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiploma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (18.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.12 (13.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e50.55 (10.91)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssociate degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (24.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e79.69 (15.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e56.06 (14.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63 (29.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.34 (13.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51.43 (14.35)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster's degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (11.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.37 (11.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e48.04 (11.15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCaregiver marital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e153 (71.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.71 (13.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003et = -0.45 (0.65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51.57 (12.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eZ = -0.80 (0.42)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle/ Divorced/ Widowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61 (28.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82.65 (14.41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53.86 (14.98)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eCaregiver occupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (21.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.82 (13.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;1.13 (0.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49.17 (12.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eH\u0026thinsp;=\u0026thinsp;6.80 (0.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-employed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (35.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82.43 (14.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51.26 (12.17)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHousewife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63 (29.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e79.44 (11.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e52.20 (11.65)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (14.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.34 (14.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e58.92 (17.23)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eEconomic status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (7.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77.29 (11.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;1.15 (0.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e52.35 (10.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;1.66 (0.19)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAverage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e156 (72.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82.59 (13.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51.21 (13.54)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (19.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.76 (14.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e55.56 (12.55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eCaregiver-patient relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSpouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91 (41.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.96 (13.19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eH\u0026thinsp;=\u0026thinsp;0.54 (0.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51.43 (12.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eH\u0026thinsp;=\u0026thinsp;2.85 (0.24)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFather/Mother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68 (31.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82.91 (14.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e54.83 (15.29)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSister/Brother/Child\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.96 (13.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e50.30 (11.63)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eHow to obtain information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInternet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (19.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e84.88 (11.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;1.28 (0.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51.44 (13.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;0.96 (0.38)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGetting information from medical and healthcare workers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e134 (61.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.52 (13.96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53.19 (12.76)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (18.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.47 (14.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49.89 (14.36)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eSD\u0026thinsp;=\u0026thinsp;Standard Deviation, t\u0026thinsp;=\u0026thinsp;Independent t test, Z\u0026thinsp;=\u0026thinsp;Mann-Whitney U; F\u0026thinsp;=\u0026thinsp;Analysis of variance, H\u0026thinsp;=\u0026thinsp;Kruskal-Wallis H;\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe mean care burden was 52.22\u0026thinsp;\u0026plusmn;\u0026thinsp;13.23. The proximity of the median (52.00) to the mean suggests an approximately symmetric distribution of the data. Among the various dimensions of care burden, time-related caregiving stress had the highest mean value (15.84\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09), while the social caregiving stress dimension had the lowest mean (7.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.29). For health literacy, the mean score was 82.56\u0026thinsp;\u0026plusmn;\u0026thinsp;14.28, with a median of 79.00. Among the health literacy components, the decision making and applying health information had the highest mean score (30.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.72), whereas the evaluation dimension had the lowest mean (9.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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 the health literacy and care burden in patients undergoing hemodialysis (n\u0026thinsp;=\u0026thinsp;217).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMin\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMax\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCare burden\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e52.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime-related caregiving stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDevelopmental caregiving stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical caregiving stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial caregiving stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional caregiving stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehealth literacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e82.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAccess\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReading skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnderstanding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEvaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDecision-making and applying health information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere was no significant correlation between health literacy and caregiving burden (p\u0026thinsp;=\u0026thinsp;0.01). All dimensions of health literacy were not associated with health literacy dimensions, except for the domain of understanding. The understanding component of health literacy was associated with time-related caregiving stress (p\u0026thinsp;=\u0026thinsp;0.01). This may indicate that greater awareness of health status exacerbates the stress of caregiving responsibilities (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\u003cp\u003eCorrelation between the health literacy and care burden in patients undergoing hemodialysis (n\u0026thinsp;=\u0026thinsp;217).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTime-related caregiving stress\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDevelopmental caregiving stress\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhysical caregiving stress\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSocial caregiving stress\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEmotional caregiving stress\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCare burden\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAccess\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.10 (0.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.02 (0.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.03 (0.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.08 (0.20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.03 (0.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.06 (0.34)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReading skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.09 (0.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.03 (0.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.004 (0.95)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.49 (0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.03 (0.65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.02 (0.77)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnderstanding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.16 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.03 (0.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.03 (0.65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.04 (0.52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.04 (0.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.06 (0.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEvaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.10 (0.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.04 (0.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.06 (0.37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.11 (0.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.09 (0.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.09 (0.17)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDecision-making and applying health information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.06 (0.37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.004 (0.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.10 (0.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.10 (0.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.09 (0.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-0.10 (0.15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehealth literacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.09 (0.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.009 (0.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.007 (0.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.03 (0.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.01 (0.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.02 (0.75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData were presented as Pearson's correlation coefficient.\u003c/p\u003e\u003cp\u003eWe used multiple regression with the backward method for further analysis and included all variables in the multivariate regression model. The result showed the R\u003csup\u003e2\u003c/sup\u003e for care burden was 0.46, which indicated that variables, i.e., dialysis sessions per week, caregiver gender, patients\u0026rsquo; age, and health literacy, can predict nearly 46% of changes of care burden in hemodialysis patients. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, dialysis sessions per week (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10.48; 95% confidence intervals (CI: 8.76\u0026ndash;12.21), caregiver gender (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.84; CI: 0.99\u0026ndash;6.69) and patients\u0026rsquo; age (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.12; CI: 0.007\u0026ndash;0.24) predicted 46% of the variance of care burden in the patient\u0026rsquo;s undergoing hemodialysis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe multiple regression analysis summary for the care burden in patients undergoing hemodialysis (n\u0026thinsp;=\u0026thinsp;217).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSE\u0026Dagger;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eΒeta\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e95% Confidence interval for B\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eAdjusted R\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eCare burden\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(Constant)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e16.05 _ 37.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e46%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDialysis sessions per week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e11.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e8.76_ 12.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaregiver gender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.99_ 6.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatients age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.038\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.007_ 0.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth literacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e-0.13_ 0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u0026Dagger;: Standard error;\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e The present study examined the relationship between health literacy and caregiving burden among family caregivers of patients undergoing hemodialysis in Kerman. The findings revealed that the overall level of health literacy in caregivers was relatively high, with the mean score indicating an adequate level. Research on health literacy (HL) has traditionally concentrated on patient populations, but more recently, attention has also turned to family caregivers. Studies in this area suggest that higher HL can enhance caregivers\u0026rsquo; awareness of available health services and the importance of staying informed [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], improve communication with healthcare professionals [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], and increase access to caregiver support resources [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, despite this growing body of work, relatively little attention has been directed toward the HL of caregivers of dialysis patients, even though this group faces substantial and unique caregiving demands.\u003c/p\u003e\u003cp\u003eIn contrast, the average caregiving burden was moderate, with time-related caregiving stress identified as the most prominent dimension. These findings are consistent with those of Jafari et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and Hamshaikh et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], who also reported moderate to high levels of burden among caregivers of dialysis patients. Such consistency underscores that the chronic and intensive nature of hemodialysis imposes sustained physical and psychological demands on caregivers. However, our results differ from those of Pio et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and Rioux et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], who observed comparatively lower levels of caregiver burden. This discrepancy may be explained by contextual differences in patient care settings. For example, both Pio and Rioux highlighted that patients undergoing overnight dialysis demonstrated greater independence and self-care ability, which in turn reduced reliance on family caregivers. In contrast, in our study setting, patients largely depended on their families for daily activities and logistical support during regular hemodialysis sessions, leading to a higher and more persistent caregiver burden.\u003c/p\u003e\u003cp\u003eImportantly, no significant overall correlation was observed between health literacy and caregiving burden, except for a weak association between the \u0026ldquo;understanding\u0026rdquo; component of health literacy and time-related caregiving stress. These results are noteworthy, as they diverge from several previous studies suggesting that higher health literacy is linked to reduced caregiver burden and improved quality of life. For instance, Abed et. al reported that family caregivers with limited functional health literacy (FHL) experienced significantly higher burden\u0026mdash;on average 4.6 points more\u0026mdash;than those with adequate FHL [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Among family caregivers of patients with type two diabetes, Gibson also found a significant independent relationship of caregivers' health literacy to caregiving burden [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In bivariate analyses, Barutcu demonstrated weak to moderate, negative relationships of caregiving burden to health literacy in terms of information access, understanding, appraisal, and application [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In other bivariate analyses, Ishida et. al also found that health literacy of heart failure patients and their family caregivers was significantly associated with caregiving burden [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The lack of such association in our study may be due to contextual differences, cultural factors, or the characteristics of the studied population. For example, caregivers in this study had frequent exposure to healthcare settings during dialysis sessions, which may have provided them with structured support, reducing the independent impact of health literacy on caregiving outcomes. These contextual differences highlight how disease type and care setting can moderate the relationship between health literacy and caregiver burden.\u003c/p\u003e\u003cp\u003e Our regression analysis indicated that the most powerful predictors of caregiving burden were the number of dialysis sessions per week, caregiver gender, and patient age, together explaining 46% of the variance. Caregivers of patients undergoing more frequent dialysis experienced significantly higher levels of burden, consistent with previous reports that intensive treatment schedules exacerbate physical, emotional, and financial stress. Female caregivers also reported greater burden compared with males, echoing earlier findings [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Several explanations may account for this finding. Gender-related differences in caregiving burden are often linked to traditional gender roles, in which women are typically expected to assume the primary responsibility for providing care in both family and informal settings [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. As a result, women may be more inclined to take on caregiving duties compared to men. Another possible explanation is that women are generally more open in sharing their caregiving experiences, consistent with gender norms that encourage women to be more expressive and vocal about their emotions [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Consequently, women are more likely than men to communicate negative feelings such as stress or fatigue [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In contrast, cultural expectations in many Middle Eastern societies discourage men from voicing complaints or admitting vulnerability, as they are socially expected to appear strong and resilient under pressure [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdditionally, older patient age predicted higher caregiver burden, which may reflect the greater dependency of elderly patients and the prolonged caregiving role required of family members. Alshammari et al. found that older age and comorbidities were positively correlated with higher\u003c/p\u003e\u003cp\u003ecaregiver burden [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. But in contrast to the findings of the present study, Cagan et al. reported no significant association between caregiver burden and caregiver age group [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInterestingly, caregivers\u0026rsquo; education level, marital status, and economic self-assessment did not significantly influence burden. These results were consistent with Cagan's study [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. But this is inconsistent with some studies that identified socioeconomic status and educational background as important correlates of caregiving stress [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. One possible explanation is that in the context of hemodialysis, the structured and predictable nature of treatment creates a uniform caregiving demand across demographic groups, making these factors less influential.\u003c/p\u003e\u003cp\u003eAnother point of interest is the weak positive association between the \u0026ldquo;understanding\u0026rdquo; dimension of health literacy and time-related stress. It is plausible that caregivers with higher awareness and comprehension of patients\u0026rsquo; health conditions become more conscious of the severity and complexity of care requirements, thereby experiencing greater stress. This paradox highlights the need for supportive interventions that not only improve caregivers\u0026rsquo; knowledge but also provide coping strategies to manage the emotional consequences of increased awareness.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design precludes establishing causal relationships between health literacy and caregiving burden. Longitudinal or interventional studies are needed to confirm the direction and strength of these associations. Second, data collected through self-reported questionnaires may have been subject to recall bias or social desirability bias, potentially influencing the accuracy of responses. Third, the study was conducted in two hemodialysis centers in Kerman, which may limit the generalizability of the results to caregivers in other cultural or healthcare settings. Fourth, although health literacy and caregiving burden were assessed with validated instruments, unmeasured psychosocial variables\u0026mdash;such as coping strategies, social support, or cultural norms\u0026mdash;may have influenced the outcomes but were not included in the analysis. Finally, nearly 10% of participants did not complete the questionnaires, which may have introduced non-response bias despite efforts to ensure representativeness.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe findings of this study indicate that while family caregivers of hemodialysis patients in Kerman generally demonstrated adequate levels of health literacy, this factor alone did not significantly reduce their caregiving burden. Instead, systemic and demographic variables\u0026mdash;particularly the frequency of dialysis sessions, caregiver gender, and patient age\u0026mdash;emerged as stronger predictors of burden. Caregivers most affected were women, those supporting older patients, and families managing more frequent dialysis schedules. These results underscore that reducing caregiver burden requires multifaceted interventions that extend beyond enhancing health literacy. Policies and programs should integrate psychosocial support, gender-sensitive approaches, and targeted resources for families managing intensive dialysis regimens to promote both caregiver well-being and patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to thank the Vice Presidency for Research and Technology of the Sirjan School of Medical Sciences for providing the financial resources and all the participants who generously gave their valuable time to participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eP.A \u0026amp; M.M collected the study data. P.A wrote the article. M.Z performed statistical analyses. R.S \u0026amp; A.I \u0026amp; P.MSH read the article and made the necessary checks for its correction. Then all of them approved the article.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter receiving the ethics code (IR.SIRUMS.REC.1403.020) from the ethics committee of Sirjan School of Medical Sciences and an official letter of introduction from Sirjan School of Medical Sciences, the researchers visited the research settings, explained the study objectives to the participants, emphasized the confidentiality of the information, and obtained their informed and written consent if they wished to participate in the study. All procedures were performed in accordance with the relevant guidelines and regulations contained in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eSirjan School of Medical Sciences, Sirjan, Iran.\u003csup\u003e2\u003c/sup\u003e Ph. D. Student in Health Education and Promotion, Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. \u003csup\u003e3\u003c/sup\u003eAssociate Professor of Health Education and Promotion, Department of Public Health, Sirjan School of Medical Sciences, Sirjan, Iran. \u003csup\u003e4\u003c/sup\u003eAssociate Professor of Health Education and Promotion, HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. \u003csup\u003e5\u003c/sup\u003eAssociate Professor of Nursing, Nursing Research Centre, Kerman University of Medical Sciences, Kerman, Iran. \u003csup\u003e6\u003c/sup\u003eClinical Research Development Unit, Ali-Ibn Abi-Talib Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.\u003csup\u003e7\u003c/sup\u003eStudent Research Committee, Sirjan School of Medical Sciences, Sirjan, Iran.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eK. Kheirollahi, R. Hemayati, and S. R. Nabavinejad, \u0026quot;Frequency Distribution of Oral Manifestations in Diabetic and Non-Diabetic Patients Undergoing Hemodialysis,\u0026quot; \u003cem\u003eJournal of Shahid Sadoughi University of Medical Sciences, \u003c/em\u003e2022.\u003c/li\u003e\n\u003cli\u003eM. Pourfarahani, H. Shareh, and F. Haji Arbabi, \u0026quot;Effect of Group Acceptance and Commitment Therapy on Body Image and Self-compassion of Women Undergoing Dialysis: A Randomized Clinical Trial,\u0026quot; (in eng), \u003cem\u003eIranian Journal of Psychiatry and Clinical Psychology, \u003c/em\u003eOriginal Research vol. 29, no. 1, pp. 2\u0026ndash;17, 2023, doi: 10.32598/ijpcp.29.1.225.13.\u003c/li\u003e\n\u003cli\u003eF. Kiani, F. Salmani, and M. 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Ismail, \u0026quot;Family impact and economic burden among caregivers of children with chronic kidney disease in Assiut, Egypt. ,\u0026quot; \u003cem\u003eJ Egypt Public Health Assoc. , \u003c/em\u003evol. 95, no. 1, p. 27, 2020.\u003c/li\u003e\n\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":"Health literacy, Care Burden, Caregivers, Hemodialysis, Iran","lastPublishedDoi":"10.21203/rs.3.rs-7873982/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7873982/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eFamily caregivers of patients undergoing hemodialysis face significant challenges that may lead to increased caregiving burden. Health literacy has been suggested as a key factor influencing caregivers\u0026rsquo; ability to manage responsibilities effectively. However, limited evidence exists on the relationship between health literacy and caregiving burden in this population. This study aimed to examine the relationship between health literacy and caregiving burden among family caregivers of patients receiving hemodialysis in Kerman, Iran.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e A descriptive-analytical cross-sectional study was conducted in 2024 with 217 family caregivers recruited from Shafa Hospital and Javad-al-Aemeh Dialysis Clinic. Data were collected using a demographic questionnaire, the Health Literacy for Iranian Adults (HELIA) instrument, and the Caregiver Burden Inventory (CBI). Descriptive and inferential statistics, including t-test, ANOVA, correlation analysis, and multiple regression, were applied using SPSS version 22.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean caregiver age was 38.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7 years, and 60.6% were female. The mean health literacy score was 82.56\u0026thinsp;\u0026plusmn;\u0026thinsp;14.28 (adequate), and the mean caregiving burden score was 52.22\u0026thinsp;\u0026plusmn;\u0026thinsp;13.23 (moderate). Care burden was significantly higher among female caregivers, those caring for older patients, caregivers of patients with diabetes, and caregivers of patients undergoing more frequent dialysis sessions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Regression analysis indicated that dialysis frequency, caregiver gender, and patient age predicted 46% of the variance in caregiver burden. No significant overall correlation was found between health literacy and caregiving burden, though a weak association emerged between the \u0026ldquo;understanding\u0026rdquo; dimension of health literacy and time-related caregiving stress.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eWhile caregivers demonstrated adequate health literacy, it did not independently reduce caregiving burden. Instead, systemic factors such as dialysis frequency, gender roles, and patient age were stronger determinants of burden. Interventions to alleviate caregiver strain should therefore extend beyond health literacy enhancement and address psychosocial support, gender-sensitive strategies, and tailored assistance for families managing high-intensity dialysis schedules.\u003c/p\u003e","manuscriptTitle":"Health literacy and care burden in family caregivers of patients undergoing hemodialysis: a cross-sectional study in southeast Iran","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-06 07:08:34","doi":"10.21203/rs.3.rs-7873982/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-16T14:05:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152314700729599079250137811549354485675","date":"2026-01-19T14:04:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-28T20:15:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-10T09:35:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176444076787217522699165232390520866906","date":"2025-11-25T13:10:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219652067708545499854139163448134192101","date":"2025-11-19T20:40:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305210588611845382524777449986912084920","date":"2025-10-31T17:48:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-27T12:10:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-27T12:09:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-22T09:37:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-21T23:04:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-10-19T05:32:09+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":"ea58da8e-1295-4201-b2d3-850f72b1c990","owner":[],"postedDate":"November 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-06T07:08:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-06 07:08:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7873982","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7873982","identity":"rs-7873982","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}