Resilience among Caregivers of Patients with Palliative Care Needs and Its Associated Factors: Using the CD-RISC Tool

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Understanding caregiver resilience and its determinants is crucial for developing targeted interventions to strengthen care for both patients and their caregivers. Objective To assess resilience levels among caregivers of palliative care patients and identify associated factors via the Connor–Davidson Resilience Scale (CD-RISC). Methods A cross-sectional study was conducted across five palliative care centers in Nepal from 2023–2024. The participants included 422 family caregivers of palliative care patients identified via the Supportive and Palliative Care Indicator Tool for Low-Income Settings (SPICT-LIS). Data were collected via demographic questionnaires and the Nepalese version of the CD-RISC. Statistical analysis was performed via nonparametric tests, with significance set at p < 0.05. Results The caregivers had a mean age of 38.03 years (SD ± 12.3), with 51.2% being male. The resilience scores ranged from 13–100 (median 70.5). Caregiver resilience was significantly associated with perceived health status (p < 0.001) and patient diagnosis (p = 0.002). Caregivers with "very good" or "good" perceived health demonstrated higher resilience scores (median 74 and 73, respectively). Those caring for patients with cardiopulmonary conditions presented the highest resilience (median 75), whereas chronic kidney disease caregivers presented the greatest variability in resilience scores. Conclusions Caregivers’ self-perceived health status and patient diagnosis were found to be key determinants of resilience. These findings highlight the importance of addressing caregiver health as an integral component of patient care and developing diagnosis-specific support interventions for caregivers for the holistic care of patients. Caregivers CD-RISC LMIC Nepal Palliative Care Resilience Introduction The global burden of chronic noncommunicable diseases and aging populations has led to an unprecedented increase in palliative care needs. Approximately 56.8 million people worldwide require palliative care, including 31.1 million people before the end of life and 25.7 million people near death. These patients present complex needs requiring prolonged care, creating substantial physical, financial, and psychosocial/emotional burdens on their caregivers. 1 – 4 Caregivers, who may or may not be family members, lay individuals in close supportive roles who share the illness experience and undertake vital care work and emotional management. 2–7 For sustainable long-term care, caregivers require resilience—an internal psychological resource that helps reduce emotional distress and maintain or restore mental health. 8 Resilience varies across cultures, societies, and geographical contexts, with different impacts on individuals. 9–12 Caregiver resilience enables care recipients to remain within their social environments, reducing formal resource utilization and delaying or preventing institutional admissions. 11 , 12 Despite its importance, the World Health Organization classifies Nepal as having isolated palliative care services (Level 3a), facing unique challenges due to cultural diversity, limited healthcare infrastructure, and socioeconomic disparities. 11 – 13 Recent systematic reviews underscore the necessity of investigating factors contributing to caregiver burden within local community settings, thereby supporting the appropriateness of culturally specific research methodologies. 13 Research on caregiver resilience in Nepal remains limited. This study explores caregiver resilience and its associated factors to inform evidence-based strategies for supporting caregivers and enhancing holistic patient care. Methods Study Design and Setting A cross-sectional study was conducted from 2023–2024 across five palliative care centers in Nepal: the Patan Academy of Health Sciences (Lalitpur), the Green Pasture Hospital (Pokhara), Hospice Nepal, the Makawanpur Community-based Palliative Care program area, and Bhaktapur Cancer Hospital. These sites provide formal palliative care services, with Makawanpur representing a rural geographic setting. Ethical considerations Ethical approval was obtained from the Institutional Review Committee, Patan Academy of Health Sciences (Reference No. FLW2309051795). Written and verbal informed consent was obtained from all participants. Participants and Sampling Family caregivers of patients needing palliative care composed the study population. The inclusion criteria were age ≥ 18 years, providing care for > 1 month, and the ability to read and write in Nepali. Caregivers with mental health disorders or a history of psychiatric conditions were excluded. The sample size was calculated assuming 0.5 prevalence, a 5% margin of error, and a 95% confidence interval, yielding 384 participants. To account for potential nonresponse, the sample was increased to 422 (10% buffer). Eligible participants were conveniently sampled upon expressing interest and providing consent. Data collection Patient identification Palliative care patients were identified via the Supportive and Palliative Care Indicator Tool for Low-Income Settings (SPICT-LIS). 14 , 15 Patient performance status was assessed via the Eastern Cooperative Oncology Group (ECOG) scale. 16 Caregiver assessment The Nepalese version of the Connor-Davidson Resilience Scale (CD-RISC) was administered to assess caregiver resilience. 17 The CD-RISC is a 25-item instrument grounded in stress, coping, and adaptation research. 7 The CD-RISC has demonstrated strong psychometric properties across diverse populations and cultural contexts. The items are scored on a 5-point scale (0–4), with higher scores indicating greater resilience. 18,19 Demographic Data Comprehensive demographic information, including age, sex, education, marital status, health status, and duration of caregiving, was collected for both patients and caregivers. Statistical analysis The data were analyzed via SPSS version 20. Descriptive statistics of the study variables. Given the nonnormal distribution of resilience scores, nonparametric tests were used to examine associations between resilience and demographic characteristics. Statistical significance was set at p < 0.05 with 95% confidence intervals. Results Caregiver characteristics The study included 422 caregivers with a mean age of 38.03 years (SD ± 12.3). Males comprised 51.2% of the participants. The duration of care ranged from 1 month to 27 years. Most caregivers were Hindu (82.7%), married (76.5%), and had secondary education (44.5%). The majority lived in joint families (55.9%) and had no chronic diseases (89.3%). Blood relatives (parents, children, grandparents) constituted 64% of the caregivers. Patient characteristics The patients had a mean age of 58 years (SD ± 20), with 53.1% being older than 60 years. The age range was 5–98 years, with 54.5% being female. The most common conditions requiring palliative care were cancer (44.8%), followed by neurological diseases (17.3%) and chronic obstructive pulmonary disease. Most patients (97.4%) had single conditions, and 65.4% had better performance status (ECOG 0–2). Resilience scores The CD-RISC scores ranged from 13–100, with a median of 70.5, indicating substantial heterogeneity in resilience capacity among caregivers. Factors associated with caregiver resilience Caregiver Factors The perceived health status of the caregiver was strongly associated with resilience (p < 0.001). Caregivers who rated their health as "very good" or "good" demonstrated significantly higher resilience scores (median 74 and 73, respectively) than those who reported "average" (67), "poor" (65), or "very poor" (45) health, indicating a graded relationship. No other caregiver demographic characteristics (age, sex, education, marital status, religion, family type, caregiving history, or relationship with the patient) were significantly associated with resilience scores. Table 1 . Table 1 Characteristics of Caregivers and Association with Resilience (n = 422) Characters Total (%) CD-RISC Score P Value Median IQR Age (years) (Mean + SD: 38.03 + 12.3) 18–25 26–40 41–60 > 60 61 (14.5) 178 (42.2) 158 (37.4) 25 (5.9) 71 69 71 72 13 19 13 0.422 8 Sex Male Female 216 (51.2) 206 (48.8) 72 69 17 13 0.184 Religion Hindu Buddhist Muslim 349 (82.7) 44 (10.4) 2 (0.5) 71 71 66 16 11 12 14 0.492 Christian 27 (6.4) 65 Education Literate Elementary (up to 8) Secondary (12) Bachelor Master and above 88 (20.9) 39 (9.2) 188 (44.5) 84 (19.9) 23 (5.5) 72 69 69 69 75 10 16 13 25 0.431 19 Marital Status Married Unmarried 323 (76.5) 99 (23.5) 70 72 15 19 0.221 Any chronic disease Yes No 45 (10.7) 377 (89.3) 72 70 14 16 0.359 Perceived health status Very good Good Average Poor Very Poor 46 (10.9) 194 (46) 174 (41.2) 6 (1.4) 2 (0.5) 74 73 67 65 45 21 10 15 13 0.000 63 Type of Family Nuclear Joint 186 (44.1) 236 (55.9) 71 70 14 15 0.35 History of Caregiving Yes No 173 (59) 249 (41) 71 70 16 13 0.997 Relationship with Patient Offsprings Parents Spouse Siblings Other relatives 227(53.7) 43(10.1) 67 (15.8) 33(7.8) 52(12.3) 70 68 71 72 70 20 9 13 7 0.46 11 Duration of Caregiving Less than or equal to 6 months More than 6 months 126(29.9) 296(70.1) 72 70 11 18 0.284 Patient Factors A significant association was observed between patient diagnosis and caregiver resilience (p = 0.002). Caregivers of patients with cardiopulmonary conditions presented the highest resilience scores (median 75) with low variability. Those caring for patients with chronic kidney disease presented the greatest variability in resilience scores, whereas those caring for patients with cancer and neurological conditions presented intermediate levels. Patient age, sex, number of conditions, and performance status were not significantly associated with caregiver resilience. Table 2 . Table 2 Patient Characteristics and Association with Caregiver Resilience (n = 422) Characters Total (%) CD-RISC Score P value Median IQR Age (years) (Mean + SD: 58.7 + 20) 18–25 26–40 41–60 > 60 35 (8.3) 45 (10.7) 118 (28) 224 (53.1) 68 69 70 72 13 12 16 0.22 15 Sex Female Male 230 (54.5) 192 (45.5) 71 69 14 16 0.351 Diagnosis Cancer Cardiopulmonary Neurological CKD Frailty Others 189 (44.8) 56 (13.3) 73 (17.3) 50 (11.8) 15 (3.6) 39 (9.2) 70 75 69 72 71 66 18 10 17 24 16 0.002 15 Conditions Single condition More than one condition 411 (97.4) 11 (2.6) 70 74 16 20 0.933 Patient’s performance Better (ECOG, 0–2) Poor (ECOG, 3–4) 276 (65.4) 146 (34.6) 70 71 17 13 0.716 Discussion Caregiving in Nepal Our evaluation of 422 caregivers of patients needing palliative care via the Nepali version of the Connor–Davidson Resilience Scale revealed substantial heterogeneity in resilience capacity (range 13–100, median 70.5). Although the CD-RISC has demonstrated strong psychometric properties across diverse populations and cultural contexts in multiple Western studies, our study revealed no significant associations with resilience levels. 18 , 19 This finding corresponds with recent evidence from Cao et al. and Levasseur et al., which highlights that in resource-limited settings with culturally mandated caregiving, contextual factors may be more predictive than individual demographics are. 20,21 In Nepalese society, family caregivers function as informal healthcare providers, managing complex medical, physical, and psychological care responsibilities within a resource-limited healthcare system. 22 In Nepal, the healthcare system has limited palliative care services, a challenging geographic area, and cultural expectations that position caregiving as a moral obligation. Primary Determinants of Resilience Self-Perceived Health Status In this study, the most significant association with caregiver resilience was self-perceived health status (p < 0.001). Caregivers who rated their health as "very good" or "good" demonstrated significantly higher resilience scores (median 74 and 73, respectively) than those who reported "average," "poor," or "very poor" health, indicating a clear dose‒response relationship. This relationship operates through several mechanisms: healthy caregivers are better able to handle physical demands, maintain their energy levels, and solve problems efficiently. According to the stress process model, the link between caring stressors and outcomes is influenced by caregiver health resources. 23 Recent studies have confirmed that greater resilience is correlated with lower caregiver burden and perceived stress, whereas caregiver health indicators have shown notable changes during healthcare crises. 24,25 This aligns with Antonovsky's (1987) salutogenesis framework, which emphasizes factors that promote human health and well-being. 26 In Nepal's underresourced healthcare system, characterized by limited preventive services and cultural expectations of caregiver self-sacrifice, these findings underscore caregiver health as a key intervention point. This finding is consistent with the biopsychosocial model of health, which suggests that subjective health perceptions can be more predictive of outcomes than objective measures are. Patient Diagnosis Patient diagnosis was significantly associated with caregiver resilience (p = 0.002), with distinct patterns across conditions: Cardiopulmonary conditions presented the highest resilience scores (median 75) with low variability, likely reflecting disease normalization as “natural aging” and predictable symptom patterns enabling effective management routines. The lower resilience scores associated with neurological conditions might be due to unique challenges, including progressive cognitive decline, behavioral symptoms requiring 24-hour vigilance, and unpredictable disease trajectories, leading to chronic stress. 27 This lower score can be correlated with the concept of ambiguous loss, where caregivers grieve for someone who is physically present but psychologically absent. This is particularly correlated with the caregivers of dementia patients. 28 , 29 Chronic kidney disease exhibited the greatest resilience variability, likely reflecting heterogeneous responses to complex treatment regimens ranging from dietary management to dialysis, with outcomes varying by treatment access and financial resources. 30 , 31 Caregivers of cancer patients face stigma-related challenges, with cultural beliefs associating cancer with karma or inevitable death, leading to family secrecy and social isolation that compound practical caregiving burdens. Recent research on cancer caregivers confirms that family resilience moderates the relationship between caregiver burden and quality of life, supporting targeted interventions for this population. 32 Study Limitations The cross-sectional design limits causal inference. Convenience sampling from healthcare facilities may overrepresent caregivers with better access. The CD-RISC may not capture all culturally relevant aspects of resilience. Conclusion This study identified caregiver self-perceived health status and patient diagnosis as key determinants of resilience among Nepali family caregivers. The robust health resilience association underscores treating caregiver health as integral to patient care, whereas diagnosis-specific resilience patterns highlight the need for targeted interventions. The findings emphasize that supporting family caregivers represents both an ethical imperative and a practical necessity for effective healthcare delivery in resource-constrained settings. Comprehensive approaches addressing individual, community, and system-level factors are essential for harnessing family caregivers' contributions to healthcare delivery in Nepal and similar contexts globally. Future longitudinal and qualitative research is needed to understand resilience mechanisms and evaluate interventions in our multidimensional context. Declarations Ethics approval and consent to participate The study was approved by the Institutional Review Committee of Patan Academy of Health Sciences (Ref. No: FLW2309051795), and written and verbal informed consent was obtained from all participants before data collection. Availability of Data and materials The data that support the findings of this study will be made available from the corresponding author upon request. Consent for Publication Written and verbal informed consent was obtained from all participants before data collection for publication. Competing interest The authors declare no conflicts of interest related to this manuscript. Funding This study did not receive any external funding. Authors’ contributions RKG, KPB, and RNG wrote the main manuscript. RKG, KB, RP data collection RKG, PKA, JT analysis of results All authors reviewed the manuscript. Acknowledgements The authors sincerely thank the caregivers who shared their time and stories with compassion and honesty. They are deeply grateful to the teams at Patan Academy of Health Sciences, Green Pasture Hospital, Hospice Nepal, Bhaktapur Cancer Hospital, and Makawanpur Community-Based Palliative Care for their support throughout the study. Appreciation is also extended to the data collectors and administrative staff for their efforts, and to the Institutional Review Committee of Patan Academy of Health Sciences for ethical approval. Special appreciation to our families for their continuous encouragement during the research process. References Limardi, S., Stievano, A., Rocco, G., Vellone, E., & Alvaro, R. Caregiver resilience in palliative care: A research protocol. Journal of advanced nursing , 2016; 72 (2):421-433. Doi:10.1111/jan.12829 Hudson PL, Trauer T, Graham S, et al. A systematic review of instruments related to family caregivers of palliative care patients. 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BMC Public Health . 2024;24(1). doi:10.1186/s12889-024-18321-3 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Dec, 2025 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 16 Oct, 2025 Reviews received at journal 14 Oct, 2025 Reviewers agreed at journal 24 Sep, 2025 Reviews received at journal 16 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers invited by journal 13 Sep, 2025 Editor invited by journal 12 Sep, 2025 Editor assigned by journal 11 Sep, 2025 Submission checks completed at journal 11 Sep, 2025 First submitted to journal 09 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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07:05:51","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":89565,"visible":true,"origin":"","legend":"","description":"","filename":"fbe9945c50654397b0df6b481ea54a051structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7570773/v1/2afc3549d85d9d15913858ee.xml"},{"id":91818870,"identity":"4895b63b-e88c-4128-b1dc-a46d4495614e","added_by":"auto","created_at":"2025-09-22 07:05:29","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101078,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7570773/v1/c6fd52b333efb62ef959f63a.html"},{"id":98244112,"identity":"21dab26b-b26a-42d6-81d9-95482efb34c3","added_by":"auto","created_at":"2025-12-15 16:13:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":949948,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7570773/v1/7f0db5dd-f9b1-4e66-8b4b-316b7fb17d3e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Resilience among Caregivers of Patients with Palliative Care Needs and Its Associated Factors: Using the CD-RISC Tool","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe global burden of chronic noncommunicable diseases and aging populations has led to an unprecedented increase in palliative care needs. Approximately 56.8\u0026nbsp;million people worldwide require palliative care, including 31.1\u0026nbsp;million people before the end of life and 25.7\u0026nbsp;million people near death. These patients present complex needs requiring prolonged care, creating substantial physical, financial, and psychosocial/emotional burdens on their caregivers.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCaregivers, who may or may not be family members, lay individuals in close supportive roles who share the illness experience and undertake vital care work and emotional management. \u003csup\u003e2\u0026ndash;7\u003c/sup\u003eFor sustainable long-term care, caregivers require resilience\u0026mdash;an internal psychological resource that helps reduce emotional distress and maintain or restore mental health.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eResilience varies across cultures, societies, and geographical contexts, with different impacts on individuals. \u003csup\u003e9\u0026ndash;12\u003c/sup\u003eCaregiver resilience enables care recipients to remain within their social environments, reducing formal resource utilization and delaying or preventing institutional admissions.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Despite its importance, the World Health Organization classifies Nepal as having isolated palliative care services (Level 3a), facing unique challenges due to cultural diversity, limited healthcare infrastructure, and socioeconomic disparities.\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eRecent systematic reviews underscore the necessity of investigating factors contributing to caregiver burden within local community settings, thereby supporting the appropriateness of culturally specific research methodologies.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Research on caregiver resilience in Nepal remains limited. This study explores caregiver resilience and its associated factors to inform evidence-based strategies for supporting caregivers and enhancing holistic patient care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted from 2023\u0026ndash;2024 across five palliative care centers in Nepal: the Patan Academy of Health Sciences (Lalitpur), the Green Pasture Hospital (Pokhara), Hospice Nepal, the Makawanpur Community-based Palliative Care program area, and Bhaktapur Cancer Hospital. These sites provide formal palliative care services, with Makawanpur representing a rural geographic setting.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Review Committee, Patan Academy of Health Sciences (Reference No. FLW2309051795). Written and verbal informed consent was obtained from all participants.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eParticipants and Sampling\u003c/h3\u003e\n\u003cp\u003eFamily caregivers of patients needing palliative care composed the study population. The inclusion criteria were age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, providing care for \u0026gt;\u0026thinsp;1 month, and the ability to read and write in Nepali. Caregivers with mental health disorders or a history of psychiatric conditions were excluded.\u003c/p\u003e\u003cp\u003eThe sample size was calculated assuming 0.5 prevalence, a 5% margin of error, and a 95% confidence interval, yielding 384 participants. To account for potential nonresponse, the sample was increased to 422 (10% buffer). Eligible participants were conveniently sampled upon expressing interest and providing consent.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003ePatient identification\u003c/h2\u003e\u003cp\u003ePalliative care patients were identified via the Supportive and Palliative Care Indicator Tool for Low-Income Settings (SPICT-LIS).\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Patient performance status was assessed via the Eastern Cooperative Oncology Group (ECOG) scale.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCaregiver assessment\u003c/h2\u003e\u003cp\u003eThe Nepalese version of the Connor-Davidson Resilience Scale (CD-RISC) was administered to assess caregiver resilience.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e The CD-RISC is a 25-item instrument grounded in stress, coping, and adaptation research.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e The\u003c/sup\u003e CD-RISC has demonstrated strong psychometric properties across diverse populations and cultural contexts. The items are scored on a 5-point scale (0\u0026ndash;4), with higher scores indicating greater resilience. \u003csup\u003e18,19\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDemographic Data\u003c/h3\u003e\n\u003cp\u003eComprehensive demographic information, including age, sex, education, marital status, health status, and duration of caregiving, was collected for both patients and caregivers.\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe data were analyzed via SPSS version 20. Descriptive statistics of the study variables. Given the nonnormal distribution of resilience scores, nonparametric tests were used to examine associations between resilience and demographic characteristics. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 with 95% confidence intervals.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eCaregiver characteristics\u003c/h2\u003e\u003cp\u003eThe study included 422 caregivers with a mean age of 38.03 years (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3). Males comprised 51.2% of the participants. The duration of care ranged from 1 month to 27 years. Most caregivers were Hindu (82.7%), married (76.5%), and had secondary education (44.5%). The majority lived in joint families (55.9%) and had no chronic diseases (89.3%). Blood relatives (parents, children, grandparents) constituted 64% of the caregivers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePatient characteristics\u003c/h2\u003e\u003cp\u003eThe patients had a mean age of 58 years (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;20), with 53.1% being older than 60 years. The age range was 5\u0026ndash;98 years, with 54.5% being female. The most common conditions requiring palliative care were cancer (44.8%), followed by neurological diseases (17.3%) and chronic obstructive pulmonary disease. Most patients (97.4%) had single conditions, and 65.4% had better performance status (ECOG 0\u0026ndash;2).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eResilience scores\u003c/h2\u003e\u003cp\u003e\u003cb\u003eThe\u003c/b\u003e CD-RISC scores ranged from 13\u0026ndash;100, with a median of 70.5, indicating substantial heterogeneity in resilience capacity among caregivers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eFactors associated with caregiver resilience\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003eCaregiver Factors\u003c/h2\u003e\u003cp\u003eThe perceived health status of the caregiver was strongly associated with resilience \u003cem\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/em\u003e Caregivers who rated their health as \"very good\" or \"good\" demonstrated significantly higher resilience scores (median 74 and 73, respectively) than those who reported \"average\" (67), \"poor\" (65), or \"very poor\" (45) health, indicating a graded relationship.\u003c/p\u003e\u003cp\u003eNo other caregiver demographic characteristics (age, sex, education, marital status, religion, family type, caregiving history, or relationship with the patient) were significantly associated with resilience scores.\u003c/p\u003e\u003cp\u003eTable\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\u003eCharacteristics of Caregivers and Association with Resilience (n\u0026thinsp;=\u0026thinsp;422)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCharacters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eCD-RISC Score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIQR\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e (Mean\u0026thinsp;+\u0026thinsp;SD: 38.03\u0026thinsp;+\u0026thinsp;12.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e18\u0026ndash;25\u003c/p\u003e\u003cp\u003e26\u0026ndash;40\u003c/p\u003e\u003cp\u003e41\u0026ndash;60\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e61 (14.5)\u003c/p\u003e\u003cp\u003e178 (42.2)\u003c/p\u003e\u003cp\u003e158 (37.4)\u003c/p\u003e\u003cp\u003e25 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003cp\u003e69\u003c/p\u003e\u003cp\u003e71\u003c/p\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003cp\u003e19\u003c/p\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.422\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e216 (51.2)\u003c/p\u003e\u003cp\u003e206 (48.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.184\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHindu\u003c/p\u003e\u003cp\u003eBuddhist\u003c/p\u003e\u003cp\u003eMuslim\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e349 (82.7)\u003c/p\u003e\u003cp\u003e44 (10.4)\u003c/p\u003e\u003cp\u003e2 (0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003cp\u003e71\u003c/p\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003cp\u003e11\u003c/p\u003e\u003cp\u003e12\u003c/p\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.492\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChristian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (6.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLiterate\u003c/p\u003e\u003cp\u003eElementary (up to 8)\u003c/p\u003e\u003cp\u003eSecondary (12)\u003c/p\u003e\u003cp\u003eBachelor\u003c/p\u003e\u003cp\u003eMaster and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e88 (20.9)\u003c/p\u003e\u003cp\u003e39 (9.2)\u003c/p\u003e\u003cp\u003e188 (44.5)\u003c/p\u003e\u003cp\u003e84 (19.9)\u003c/p\u003e\u003cp\u003e23 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003cp\u003e69\u003c/p\u003e\u003cp\u003e69\u003c/p\u003e\u003cp\u003e69\u003c/p\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003cp\u003e16\u003c/p\u003e\u003cp\u003e13\u003c/p\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.431\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003cp\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e323 (76.5)\u003c/p\u003e\u003cp\u003e99 (23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.221\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAny chronic disease\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45 (10.7)\u003c/p\u003e\u003cp\u003e377 (89.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.359\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerceived health status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVery good\u003c/p\u003e\u003cp\u003eGood\u003c/p\u003e\u003cp\u003eAverage\u003c/p\u003e\u003cp\u003ePoor\u003c/p\u003e\u003cp\u003eVery Poor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e46 (10.9)\u003c/p\u003e\u003cp\u003e194 (46)\u003c/p\u003e\u003cp\u003e174 (41.2)\u003c/p\u003e\u003cp\u003e6 (1.4)\u003c/p\u003e\u003cp\u003e2 (0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e74\u003c/p\u003e\u003cp\u003e73\u003c/p\u003e\u003cp\u003e67\u003c/p\u003e\u003cp\u003e65\u003c/p\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21\u003c/p\u003e\u003cp\u003e10\u003c/p\u003e\u003cp\u003e15\u003c/p\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eType of Family\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNuclear\u003c/p\u003e\u003cp\u003eJoint\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e186 (44.1)\u003c/p\u003e\u003cp\u003e236 (55.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHistory of Caregiving\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e173 (59)\u003c/p\u003e\u003cp\u003e249 (41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.997\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRelationship with Patient\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOffsprings\u003c/p\u003e\u003cp\u003eParents\u003c/p\u003e\u003cp\u003eSpouse\u003c/p\u003e\u003cp\u003eSiblings\u003c/p\u003e\u003cp\u003eOther relatives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e227(53.7)\u003c/p\u003e\u003cp\u003e43(10.1)\u003c/p\u003e\u003cp\u003e67 (15.8)\u003c/p\u003e\u003cp\u003e33(7.8)\u003c/p\u003e\u003cp\u003e52(12.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e70\u003c/p\u003e\u003cp\u003e68\u003c/p\u003e\u003cp\u003e71\u003c/p\u003e\u003cp\u003e72\u003c/p\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003cp\u003e9\u003c/p\u003e\u003cp\u003e13\u003c/p\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of Caregiving\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLess than or equal to 6 months\u003c/p\u003e\u003cp\u003eMore than 6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e126(29.9)\u003c/p\u003e\u003cp\u003e296(70.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.284\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003ePatient Factors\u003c/h2\u003e\u003cp\u003eA significant association was observed between patient diagnosis and caregiver resilience \u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.002).\u003c/em\u003e Caregivers of patients with cardiopulmonary conditions presented the highest resilience scores (median 75) with low variability. Those caring for patients with chronic kidney disease presented the greatest variability in resilience scores, whereas those caring for patients with cancer and neurological conditions presented intermediate levels.\u003c/p\u003e\u003cp\u003ePatient age, sex, number of conditions, and performance status were not significantly associated with caregiver resilience.\u003c/p\u003e\u003cp\u003eTable\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\u003ePatient Characteristics and Association with Caregiver Resilience (n\u0026thinsp;=\u0026thinsp;422)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCharacters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eCD-RISC Score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIQR\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e (Mean\u0026thinsp;+\u0026thinsp;SD: 58.7\u0026thinsp;+\u0026thinsp;20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e18\u0026ndash;25\u003c/p\u003e\u003cp\u003e26\u0026ndash;40\u003c/p\u003e\u003cp\u003e41\u0026ndash;60\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e35 (8.3)\u003c/p\u003e\u003cp\u003e45 (10.7)\u003c/p\u003e\u003cp\u003e118 (28)\u003c/p\u003e\u003cp\u003e224 (53.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e68\u003c/p\u003e\u003cp\u003e69\u003c/p\u003e\u003cp\u003e70\u003c/p\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003cp\u003e12\u003c/p\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e230 (54.5)\u003c/p\u003e\u003cp\u003e192 (45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.351\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCancer\u003c/p\u003e\u003cp\u003eCardiopulmonary\u003c/p\u003e\u003cp\u003eNeurological\u003c/p\u003e\u003cp\u003eCKD\u003c/p\u003e\u003cp\u003eFrailty\u003c/p\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e189 (44.8)\u003c/p\u003e\u003cp\u003e56 (13.3)\u003c/p\u003e\u003cp\u003e73 (17.3)\u003c/p\u003e\u003cp\u003e50 (11.8)\u003c/p\u003e\u003cp\u003e15 (3.6)\u003c/p\u003e\u003cp\u003e39 (9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e70\u003c/p\u003e\u003cp\u003e75\u003c/p\u003e\u003cp\u003e69\u003c/p\u003e\u003cp\u003e72\u003c/p\u003e\u003cp\u003e71\u003c/p\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003cp\u003e10\u003c/p\u003e\u003cp\u003e17\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eConditions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle condition\u003c/p\u003e\u003cp\u003eMore than one condition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e411 (97.4)\u003c/p\u003e\u003cp\u003e11 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.933\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient\u0026rsquo;s performance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBetter (ECOG, 0\u0026ndash;2)\u003c/p\u003e\u003cp\u003ePoor (ECOG, 3\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e276 (65.4)\u003c/p\u003e\u003cp\u003e146 (34.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.716\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eCaregiving in Nepal\u003c/h2\u003e\u003cp\u003eOur evaluation of 422 caregivers of patients needing palliative care via the Nepali version of the Connor\u0026ndash;Davidson Resilience Scale revealed substantial heterogeneity in resilience capacity (range 13\u0026ndash;100, median 70.5). Although the CD-RISC has demonstrated strong psychometric properties across diverse populations and cultural contexts in multiple Western studies, our study revealed no significant associations with resilience levels.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e This finding corresponds with recent evidence from Cao et al. and Levasseur et al., which highlights that in resource-limited settings with culturally mandated caregiving, contextual factors may be more predictive than individual demographics are. \u003csup\u003e20,21\u003c/sup\u003eIn Nepalese society, family caregivers function as informal healthcare providers, managing complex medical, physical, and psychological care responsibilities within a resource-limited healthcare system.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e In Nepal, the healthcare system has limited palliative care services, a challenging geographic area, and cultural expectations that position caregiving as a moral obligation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003ePrimary Determinants of Resilience\u003c/h2\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003eSelf-Perceived Health Status\u003c/h2\u003e\u003cp\u003eIn this study, the most significant association with caregiver resilience was self-perceived health status (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Caregivers who rated their health as \"very good\" or \"good\" demonstrated significantly higher resilience scores (median 74 and 73, respectively) than those who reported \"average,\" \"poor,\" or \"very poor\" health, indicating a clear dose‒response relationship.\u003c/p\u003e\u003cp\u003eThis relationship operates through several mechanisms: healthy caregivers are better able to handle physical demands, maintain their energy levels, and solve problems efficiently. According to the stress process model, the link between caring stressors and outcomes is influenced by caregiver health resources.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Recent studies have confirmed that greater resilience is correlated with lower caregiver burden and perceived stress, whereas caregiver health indicators have shown notable changes during healthcare crises. \u003csup\u003e24,25\u003c/sup\u003eThis aligns with Antonovsky's (1987) salutogenesis framework, which emphasizes factors that promote human health and well-being.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e In Nepal's underresourced healthcare system, characterized by limited preventive services and cultural expectations of caregiver self-sacrifice, these findings underscore caregiver health as a key intervention point. This finding is consistent with the biopsychosocial model of health, which suggests that subjective health perceptions can be more predictive of outcomes than objective measures are.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003ePatient Diagnosis\u003c/h2\u003e\u003cp\u003ePatient diagnosis was significantly associated with caregiver resilience (p\u0026thinsp;=\u0026thinsp;0.002), with distinct patterns across conditions:\u003c/p\u003e\u003cp\u003eCardiopulmonary conditions presented the highest resilience scores (median 75) with low variability, likely reflecting disease normalization as \u0026ldquo;natural aging\u0026rdquo; and predictable symptom patterns enabling effective management routines.\u003c/p\u003e\u003cp\u003eThe lower resilience scores associated with neurological conditions might be due to unique challenges, including progressive cognitive decline, behavioral symptoms requiring 24-hour vigilance, and unpredictable disease trajectories, leading to chronic stress.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e This lower score can be correlated with the concept of ambiguous loss, where caregivers grieve for someone who is physically present but psychologically absent. This is particularly correlated with the caregivers of dementia patients.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eChronic kidney disease exhibited the greatest resilience variability, likely reflecting heterogeneous responses to complex treatment regimens ranging from dietary management to dialysis, with outcomes varying by treatment access and financial resources.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCaregivers of cancer patients face stigma-related challenges, with cultural beliefs associating cancer with karma or inevitable death, leading to family secrecy and social isolation that compound practical caregiving burdens. Recent research on cancer caregivers confirms that family resilience moderates the relationship between caregiver burden and quality of life, supporting targeted interventions for this population.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eStudy Limitations\u003c/h2\u003e\u003cp\u003eThe cross-sectional design limits causal inference. Convenience sampling from healthcare facilities may overrepresent caregivers with better access. The CD-RISC may not capture all culturally relevant aspects of resilience.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identified caregiver self-perceived health status and patient diagnosis as key determinants of resilience among Nepali family caregivers. The robust health resilience association underscores treating caregiver health as integral to patient care, whereas diagnosis-specific resilience patterns highlight the need for targeted interventions.\u003c/p\u003e\u003cp\u003eThe findings emphasize that supporting family caregivers represents both an ethical imperative and a practical necessity for effective healthcare delivery in resource-constrained settings. Comprehensive approaches addressing individual, community, and system-level factors are essential for harnessing family caregivers' contributions to healthcare delivery in Nepal and similar contexts globally. Future longitudinal and qualitative research is needed to understand resilience mechanisms and evaluate interventions in our multidimensional context.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Committee of Patan Academy of Health Sciences (Ref. No: FLW2309051795), and written and verbal informed consent was obtained from all participants before data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study will be made available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten and verbal informed consent was obtained from all participants before data collection for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest related to this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRKG, KPB, and RNG wrote the main manuscript.\u003c/p\u003e\n\u003cp\u003eRKG, KB, RP data collection\u003c/p\u003e\n\u003cp\u003eRKG, PKA, JT analysis of results\u003c/p\u003e\n\u003cp\u003eAll authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely thank the caregivers who shared their time and stories with compassion and honesty. They are deeply grateful to the teams at Patan Academy of Health Sciences, Green Pasture Hospital, Hospice Nepal, Bhaktapur Cancer Hospital, and Makawanpur Community-Based Palliative Care for their support throughout the study. Appreciation is also extended to the data collectors and administrative staff for their efforts, and to the Institutional Review Committee of Patan Academy of Health Sciences for ethical approval. Special appreciation to our families for their continuous encouragement during the research process.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLimardi, S., Stievano, A., Rocco, G., Vellone, E., \u0026amp; Alvaro, R. Caregiver resilience in palliative care: A research protocol. \u003cem\u003eJournal of advanced nursing\u003c/em\u003e, 2016;\u003cem\u003e72\u003c/em\u003e(2):421-433. Doi:10.1111/jan.12829\u003c/li\u003e\n\u003cli\u003eHudson PL, Trauer T, Graham S, et al. 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Associations Between Resilience, Community Belonging, and Social Participation Among Community-Dwelling Older Adults: Results From the Eastern Townships Population Health Survey. \u003cem\u003eArch Phys Med Rehabil\u003c/em\u003e. 2017;98(12):2422-2432. doi:10.1016/j.apmr.2017.03.025\u003c/li\u003e\n\u003cli\u003eKunwar D , Lamichhane S , Pradhan N , et al. The Study of Burden of Family Caregivers of Patients Living with Psychiatric Disorders in Remote Area of Nepal. \u003cem\u003eKathmandu Univ Med J (KUMJ)\u003c/em\u003e. 2020;18(70):144-148.URL\u003c/li\u003e\n\u003cli\u003ePearlin LI, Mullan JT, Semple SJ, Skaff MM. Caregiving and the Stress Process: An Overview of Concepts and Their Measures.The Gerontologist.1990;30(5);583-594. Doi: 10.1093/geront/30.5.583\u003c/li\u003e\n\u003cli\u003eGeschke K, Steinmetz A, Fellgiebel A, Wuttke-Linnemann A. 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Springer International Publishing; 2016:25-40. doi:10.1007/978-3-319-04600-6_4\u003c/li\u003e\n\u003cli\u003eBoss P. \u003cem\u003eAmbiguous Loss: Learning to Live with Unresolved Grief\u003c/em\u003e.; 2009. doi:10.4159/9780674028586\u003c/li\u003e\n\u003cli\u003eDupuis, S. L., Wiersma, E., \u0026amp; Loiselle, L. Pathologizing behavior: Meanings of behaviors in dementia care. \u003cem\u003eJournal of Aging Studies\u003c/em\u003e.2012; \u003cem\u003e26\u003c/em\u003e(2):162-173. doi:10.1016/j.jaging.2011.12.001\u003c/li\u003e\n\u003cli\u003ePaulson D, Lichtenberg PA. The Paulson-Lichtenberg Frailty Index: Evidence for a self-report measure of frailty. \u003cem\u003eAging Ment Health\u003c/em\u003e. 2015;19(10):892-901. doi: 10.1080/13607863.2014.986645\u003c/li\u003e\n\u003cli\u003eMetzger M, Yoder J, Fitzgibbon K, Blackhall L, Abdel-Rahman E. Nephrology and Palliative Care Collaboration in the Care of Patients With Advanced Kidney Disease: Results of a Clinician Survey. \u003cem\u003eKidney Med\u003c/em\u003e. 2021;3(3):368-377.e1. doi: 10.1016/j.xkme.2021.01.008\u003c/li\u003e\n\u003cli\u003eChu WM, Tsai HB, Chen YC, Hung KY, Cheng SY, Lin CP. Palliative Care for Adult Patients Undergoing Hemodialysis in Asia: Challenges and Opportunities. \u003cem\u003eJournal of Hospice and Palliative Care\u003c/em\u003e. 2024;27(1):1-10. doi: 10.14475/jhpc.2024.27.1.1\u003c/li\u003e\n\u003cli\u003eCui P, Yang M, Hu H, et al. The impact of caregiver burden on quality of life in family caregivers of patients with advanced cancer: a moderated mediation analysis of the role of psychological distress and family resilience. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2024;24(1). doi:10.1186/s12889-024-18321-3\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Caregivers, CD-RISC, LMIC, Nepal, Palliative Care, Resilience","lastPublishedDoi":"10.21203/rs.3.rs-7570773/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7570773/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe increasing incidence of patients requiring palliative care warrants holistic care approaches for patients where caregivers play vital roles. Understanding caregiver resilience and its determinants is crucial for developing targeted interventions to strengthen care for both patients and their caregivers.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo assess resilience levels among caregivers of palliative care patients and identify associated factors via the Connor\u0026ndash;Davidson Resilience Scale (CD-RISC).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted across five palliative care centers in Nepal from 2023\u0026ndash;2024. The participants included 422 family caregivers of palliative care patients identified via the Supportive and Palliative Care Indicator Tool for Low-Income Settings (SPICT-LIS). Data were collected via demographic questionnaires and the Nepalese version of the CD-RISC. Statistical analysis was performed via nonparametric tests, with significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe caregivers had a mean age of 38.03 years (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3), with 51.2% being male. The resilience scores ranged from 13\u0026ndash;100 (median 70.5). Caregiver resilience was significantly associated with perceived health status (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and patient diagnosis (p\u0026thinsp;=\u0026thinsp;0.002). Caregivers with \"very good\" or \"good\" perceived health demonstrated higher resilience scores (median 74 and 73, respectively). Those caring for patients with cardiopulmonary conditions presented the highest resilience (median 75), whereas chronic kidney disease caregivers presented the greatest variability in resilience scores.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eCaregivers\u0026rsquo; self-perceived health status and patient diagnosis were found to be key determinants of resilience. These findings highlight the importance of addressing caregiver health as an integral component of patient care and developing diagnosis-specific support interventions for caregivers for the holistic care of patients.\u003c/p\u003e","manuscriptTitle":"Resilience among Caregivers of Patients with Palliative Care Needs and Its Associated Factors: Using the CD-RISC Tool","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-22 06:57:12","doi":"10.21203/rs.3.rs-7570773/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-16T15:42:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-15T03:10:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"90178379146812069691311387701823398390","date":"2025-09-24T07:42:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-16T22:39:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184415497254541283089357773517233242335","date":"2025-09-15T13:23:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-13T12:33:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-12T05:01:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-11T06:18:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-11T06:16:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-09-09T07:27:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d87c68f9-51ad-4b3c-9059-3a44ffcfdee0","owner":[],"postedDate":"September 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:06:25+00:00","versionOfRecord":{"articleIdentity":"rs-7570773","link":"https://doi.org/10.1186/s12904-025-01967-0","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2025-12-10 15:57:07","publishedOnDateReadable":"December 10th, 2025"},"versionCreatedAt":"2025-09-22 06:57:12","video":"","vorDoi":"10.1186/s12904-025-01967-0","vorDoiUrl":"https://doi.org/10.1186/s12904-025-01967-0","workflowStages":[]},"version":"v1","identity":"rs-7570773","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7570773","identity":"rs-7570773","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}