Telephone-based Intervention Improves Quality of Life Among Family Caregivers of Persons with Dementia in Malaysia: The Mediating Role of Caregiver Burden

Telephone-based Intervention Improves Quality of Life Among Family Caregivers of Persons with Dementia in Malaysia: The Mediating Role of Caregiver Burden | 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 Telephone-based Intervention Improves Quality of Life Among Family Caregivers of Persons with Dementia in Malaysia: The Mediating Role of Caregiver Burden Hashima E Nasreen, Syarifah Amirah binti Syed Ahmad, Marie Tyrrell, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7314107/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Feb, 2026 Read the published version in BMC Geriatrics → Version 1 posted 10 You are reading this latest preprint version Abstract Background Family caregivers (FCs) of persons with dementia (PWD) are increasingly affected by mental and physical health which leads to poor quality of life (QoL). Telephone-based interventions offer flexible solution to support caregivers of PWD but the effectiveness needs further evaluation. This study aimed to assess the effectiveness of a telephone-based intervention in improving QoL among FCs of PWD and to examine the role of caregiver burden as a mediating factor. Methods A randomised controlled trial was conducted involving 121 FCs, divided into intervention (n = 60) and control (n = 61) groups. The intervention group received a 10-week intervention by the healthcare professionals via telephone. Quality of Life were measured using the validated Malay version of Control, Autonomy, Self-Realization and Pleasure (CASP-19) at baseline (T0) and endline (T1). The mean differences of FCs’ QoL between intervention and control groups, and within baseline (T0) and endline (T1) were analyse using mixed-ANOVA. Intention-to-treat (ITT) analysis was performed to determine the independent effect of the intervention on QoL, and mediation analysis was conducted using the multiple linear regressions. Results Participants in the intervention group showed a statistically significant improvement in QoL (β = 5.00, 95% CI 2.21–7.78, p = 0.001). Mediation analysis revealed that caregiver burden mediated the relationship between the telephone-based intervention and QoL. Additionally, reduction of caregiver burden was observed to mediate the relationship between telephone-based intervention and reduced anxiety symptoms. Conclusion Telephone-based intervention shows promising results in improving the QoL among FCs of PWD. Significant mediation effect suggests the importance of targeting FC’s caregiver burden for optimal intervention effectiveness. Trial registration: ISRCTN14565552 (retrospectively registered), registered on 23 September 2023 ( https://www.isrctn.com/ISRCTN14565552 ) Telephone-based intervention Quality of life Family caregiver Dementia Mediation analysis Figures Figure 1 Figure 2 Figure 3 Background According to the World Health Organization (WHO), approximately 55 million people are living with dementia, a number that is projected triple to 139 million by 2050 [1]. In Asian countries, the prevalence of persons with dementia (PWD) above 65 years old reported ranging from 4-8% [2–4]. As Malaysia is projected to become an ageing nation by 2030, with an estimated 15.3% of population aged 60 years and above, the number of PWD is predicted to increase by 312%. Of these persons, an estimated 8-11% will require 24-hour care and full dependency [5]. These raises concerns not only about the quality of life (QoL) of PWD and their daily functioning but may create substantial emotional and psychological strain on family caregivers (FCs) particularly those in primary caregiving roles. Numerous studies have found that FCs to PWD often face a range of caregiving related stressors including emotional distress [6], burden [7], social stigma [8], feelings of helplessness [9], and caregiver burnout [10]. This prolonged exposure to distress may result in clinically significant anxiety which affects their overall well-being and QoL [11–13]. In a local Malaysian study, Nasreen et al. [14] reported prevalence of caregiver burden among FCs of PWD to be 69.4%, depressive symptoms to be 32.2% and anxiety symptoms 32.2%. According to Kai et al. [15], QoL among caregivers of PWD is a crucial component reflecting individuals’ perceptions on their position in life. Furthermore, in Malaysia, QoL of older adults often demonstrate the importance of social dimensions such as relationships with spouse, siblings and adult children [16–18] Despite the growing awareness of mental health issues in Malaysia, especially after the pandemic of COVID-19, interventions often focused predominantly on the PWD [19–23], with insufficient attention given to the mental health of the caregivers of PWD. Although several support services for the FCs are available, such as focus group discussion [24,25] and online education [26,27], their effectiveness may be hindered by challenges such as logistical constraints, limited accessibility or unstable internet connections [28,29] particularly in underserved areas. As a result, telephone-based intervention emerged as a potential approach to overcome these challenges [30,31]. In some countries such as USA, Germany and Hong Kong [32–34], telephone-based interventions were found to effectively improve FC’s well-being. Unfortunately, its role in supporting FCs of PWD remains limited, both in terms of availability and empirical validation especially in low- and middle-income countries in Asia. Additionally, research indicates that FCs’ poor QoL, caregiver burden and anxiety often co-exist and influence one another [35,36]. However, the pathways of the effect of an intervention on outcome variables is unclear [14,34]. Therefore, the primary objective of this study was to measure the effectiveness of telephone-based intervention on improving QoL among FCs of PWD. The secondary objective aimed to analyse the mediating role of caregiver burden on the association between intervention and QoL as well as between intervention and anxiety symptoms. Methods Study design and setting This was a randomised controlled trial (RCT) carried out among FCs of PWD. Participants were recruited from the list of PWD from the psychiatry and memory clinics of Sultan Ahmad Shah Medical Centre (SASMEC), and Hospital Tengku Ampuan Afzan (HTAA), Kuantan, Pahang, and the geriatric clinic at the University Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur. The study adheres to CONSORT 2025 guidelines for reporting the RCT. Participants Participants were eligible for recruitment if they were primary FCs of a person who was diagnosed with dementia at any stage, aged 18 years and above, had been providing care for at least 4 h/day for >6 months, lived in the same household as the PWD, had access to a telephone, were able to read and understand Malay. FCs who reported having major acute medical illness or hearing-impairment were excluded from the study. The sample size was estimated based on the main variables of interest according to the original study [14]. Assuming a current improvement rate of 30% in caregiver burden and depressive symptoms, an expected net improvement of 25-30% with the intervention [37], a significance level of 5%, and power of 80%, the required sample size was 100 participants. For QoL, the sample size was estimated based on expected mean (SD) from the previous literature, 55.58 (17.75) in the treatment group and 50.00 (18.37) in the control group [34], assuming medium effect size (Cohen’s d = 0.5), significance level of 5%, and power of 80%, yielding a required sample size of 51 rounded to 50 participants in each group. Since both variables yielded the same sample size estimate, a total of 100 participants was used in this study. After including the anticipated drop-out of 20%, the final target sample size increased to 120 participants. A total of 380 FCs were screened for eligibility and 121 FCs were successfully enrolled to the study who were randomly assigned to either a intervention or a control group using a 4-block randomisation (Figure 1). Participants in the intervention group received both the telephone-based intervention and standard care, and the control group received standard care only. To minimise the risk of selection bias, the randomisation sequence was generated by an independent statistician who was not involved in the study. The allocation was concealed using sealed opaque envelops to maintain blinding during the process of randomisation. Insert Figure 1 Intervention An intervention booklet called ‘My Caregiver Booklet’, inspired by WHO iSupport manual [38], was developed by the research team. iSupport was designed by WHO to support caregivers to PWD. It is a training and skills programme aimed at improving the well-being of caregivers and enhancing the quality of care provided by FCs to persons living with dementia. The booklet, which contained 10 main topics, as summarised in Table 1, was provided exclusively to FCs in the intervention group. The FCs in the intervention group received the intervention through 10 weekly sessions, each lasting approximately 30 minutes, and delivered via telephone by a designated, trained healthcare professional (Figure 1). The healthcare professionals who delivered the intervention consisted of 5 nurses and 2 occupational therapists. Each telephone call was scheduled at mutually agreed times for both FCs and healthcare staff. Each session began by addressing possible challenges faced by the caregivers in their caregiving roles and concluded with a task to be completed before the next session. Insert Table 1 Data Collection The data was collected at two points of time; baseline i.e., prior to the intervention and end line, after the intervention period, which spanned from August 2022 to August 2024. Data collection was performed by trained research assistants (RAs) who were blinded to group allocation. Background characteristics Background characteristics were collected at baseline on demographic and socio-economic variables, caregiving information, information about PWD, social support and caregiving burden. Demographic and socio-economic variables Demographic and socio-economic characteristics of the FCs included age, sex, religion (Muslim, non-Muslim), education (primary, secondary or tertiary), marital status (unmarried, married, divorced/widowed), occupation (employed, homemaker/unemployed, retired), monthly household income (low income, middle income and high income) and FC’s comorbidities. According to the Department of Statistics Malaysia (DOSM) (2019), households are classified into income groups: low-income (B40: Bottom 40%) for households with a monthly income RM4850 and below; M40 (Middle 40%) for households with monthly income between RM 4851 and RM10,970; and T20 (Top 20%) for households with a monthly income of RM10,971 and above (1 USD = RM4.70 as of date of data collection). Caregiving information Caregiving information included length of caregiving period, hours of caregiving per day, whether caregiving is shared and number of family members involved, and caregiver’s relationship with PWD. Information about the PWD Information about PWD included PWD’s age, sex, and ability to self-care. Social support Perceived social support from family, friends and significant others was assessed using the validated Malay Version of the Multidimensional Scale of Perceived Social Support (MSPSS) [39]. The scale consists of 12 items, equally divided among the three support sources. The 7-point Likert scale were rated (1= Very Strongly Disagree, 2= Strongly Disagree, 3= Mildly Disagree, 4= Neutral, 5= Mildly Agree, 6= Strongly Agree, 7= Very Strongly Agree), with the total score of 7-84, where higher score indicated higher social support. The Cronbach’s alpha of MSPSS in this study was 0.93. Caregiver burden Data on caregivers’ burden were collected using the 22-item validated Malay version of the Zarit Burden Interview [40]. The instrument was rated on a 5-point Likert scale ranging from 0 (Never) to 4 (Nearly Always), with the total score ranging from 0 to 88. Higher score indicates higher level of burden, with a cut off value of >21. Cronbach’s alpha value of the scale in this study was reported as 0.92, indicating good internal consistency and reliability. Outcome measures Caregiver quality of life Caregiver’s QoL was assessed using the validated Malay version of Control, Autonomy, Self-Realization, and Pleasure (CASP-19) scale [41] which includes 19-items assessing 4 domains: control (4-items), autonomy (5-items), self-realization (5 items) and pleasure (5-items). Responses are rated on a 4-point Likert scale ranging from never to often (0-3), with a maximum total score of 57. Higher score represents greater QoL. Cronbach’s alpha of the scale in this study was 0.88 and 0.91 at baseline and endline, respectively. Caregiver anxiety symptoms Caregiver’s anxiety symptoms were assessed using the anxiety subscale of the validated Malay version of the Hospital Anxiety and Depression Scale (HADS) [42]. The anxiety subscales consist of 7 items, scored from 0-3 on each item, the total score being 0 to 21. Higher score indicates higher anxiety symptoms. In our study, the Cronbach`s alpha demonstrated good reliability of 0.84 at baseline and 0.83 at endline. Data Analysis Bivariate analyses, such as independent t-test, Chi-square test and Fisher’s exact test were conducted to compare the baseline characteristics between the intervention and control groups. Mixed ANOVA analysed the mean differences of FCs’ QoL within the groups (baseline vs. post-intervention), between groups (intervention vs. control groups) and the net gain effect of intervention on QoL. Intention-to-treat (ITT) analysis using linear mixed-model for repeated measures was performed to determine the independent effect of the intervention on QoL. ITT included full samples regardless of whether they adhered to or withdrew from the assigned treatment. To examine whether caregiver burden mediated the relationship between intervention and, QoL and anxiety symptoms, a four-step method by Baron and Kenny [43] via multiple regression analysis was used. The first step examined the relationship between the intervention (independent variable) and QoL or anxiety symptoms (dependent variables), which is known as Path C (See figure 3). In the second step, the intervention was regressed on the caregiver burden (mediator) (Path A). The third step is the relationship between the mediator, that is caregiver burden and i) QoL or ii) anxiety symptoms (Path B), and the final step examined the direct effect of telephone-based intervention on QoL or anxiety symptoms with the simultaneous entry of burden (Path C’). Four criteria must be met in order to establish mediation using the regression analysis: paths A, B and C must be significant, while path C´ should be either less significant (indicating partial mediation) or non-significant (indicating full mediation) compared to path C. Separate multiple linear models was analysed for each subscale of social support due to high multi-collinearity between the subscales. A p-value of <0.05 shows the mediation effect is statistically significant. Results Response Rate and Adherence to the Intervention A total of 121 FCs were enrolled in the study. Of these, 60 FCs were randomised to the intervention group and 61 FCs to the control group. During the course of the study, the attrition rate recorded was 13.2% (16 FCs) of which 9.1% (11 FCs) was from the intervention group, and 4.1% (5 FCs) from the control group. As a result, 86.8% (105 FCs) completed both the baseline and endline assessments in the study. Baseline Characteristics of the Participants Baseline characteristics of participating FCs and PWD are presented in Table 2. More than half of the FCs were women (69%), Muslim (67%), married (74%), employed (54%) and had low household income (56%). Except for participants’ gender and dyadic relationships, no significant differences on any other characteristics between the intervention and control groups were found. Significantly more women and adult children were found as primary caregiver in the intervention group compared to the control group. Regarding health-related conditions, a higher prevalence of chronic morbidities, such as hypertension, diabetes or arthritis, was observed among FCs in the intervention group compared to those in the control group. The two groups had similar mean scores on social support and QoL at baseline. The mean age of the PWD between intervention and control group was comparable (M=75 years in intervention group and M=76 years in control group). In terms of gender distribution, most of the PWD in this study were women (63%). The proportion of PWD who were able to perform self-care was similar across both groups. No significant difference was observed on demographic characteristics of PWD between intervention and control groups (data not shown). Insert Table 2 Intervention Effects There were no significant changes in mean score of QoL from baseline to post-intervention and between intervention and control groups (Table 3, Figure 2). However, the interaction between participation in intervention and time showed a positive gain score of 5.02 in QoL indicating that there was an increased score of 5.02 in QoL after receiving the intervention with a moderate effect size of 0.11. Insert Table 3 Insert Figure 2 An intention-to-treat analysis using a linear mixed model for repeated measures was conducted to evaluate the independent effect of intervention on QoL over time while controlling the covariates, such as FC’s gender, religion, comorbidity, household income and their relationship with the PWD (Table 4). Neither the intervention nor the time had any effect on QoL independently. However, interaction between intervention and time showed a significant effect revealed that the score of QoL among FCs in the intervention group (IG) increased by 5.00 units from T0 (baseline) to T1 (post-intervention) (β=5.00, 95% CI 2.21 – 7.78, p=0.001) compared to the control group (CG). Insert Table 4 Mediation Analysis A series of linear regression analyses were conducted to examine the mediating role of caregiver burden on the association between the telephone-based intervention and QoL. Results showed that path C was significant, (B = 3.794, SE= 1.410, p= 0.008), indicating that the telephone-based intervention had a positive association with QoL before considering the mediator. In the second step (path A), the telephone-based intervention was negatively associated with caregiver burden (B = -7.090, SE= 1.848, p<0.001), indicating reduction in caregiver burden. In the third step, caregiver burden was negatively associated with QoL (B = -0.203, SE= 0.042, p<0.001) (Path B). In the final step, when the caregiver burden was controlled for in the linear regression model, direct effect of telephone-based intervention on QoL (Path C’) was reduced and lost statistical significance (B = 2.330, SE= 1.341, p= 0.085). The reduction and non-significant effect of the telephone-based intervention on QoL suggested that caregiver burden mediated the effect of the intervention on QoL (Table 5). Insert Table 5 Mediation analysis further revealed that caregiver burden also mediated the relationship between the telephone-based intervention and anxiety symptoms. In line with the first criterion, the intervention demonstrated a significant effect on FCs’ anxiety symptoms (B = -1.801, SE= 0.640, p=0.006) (Path C). Similarly, in path B, FCs’ burden also showed a significant direct association with anxiety symptoms (B = 0.095, SE= 0.020, p<0.001). When caregiver burden was included as mediator in the regression model (Path C’), the direct effect of the telephone-based intervention on anxiety symptoms became non-significant (B = -1.021, SE= 0.626, p=106) (Table 5). The full mediation pathway of the relationship between intervention, and anxiety symptoms and QoL, with caregiver burden as mediator is illustrated in Figure 3. Insert Figure 3 Discussion The findings of this study demonstrated that the telephone-based intervention had a significant effect in improving QoL among FCs of PWD. The effectiveness in reducing caregiver burden, anxiety symptoms and psychological distress was reported in a previous study [ 44 ]. Additionally, the results of the current study showed that caregiver burden mediates the effect of the telephone-based intervention on QoL and anxiety symptoms, suggesting that the intervention reduces anxiety and improves QoL directly and indirectly through the reduction of caregiver burden. These findings are consistent with previous studies conducted in Germany [ 34 ] which showed a 24% overall improvement in FC’s QoL. A randomised controlled trial in Italy [ 45 ], found that a telephone-based psychological intervention had a positive effect on caregiver burden, post-traumatic stress symptoms and depression after 4-weeks’ intervention period, however QoL outcomes were not reported. In contrast, the telephone-based intervention in the current study in Malaysia did not show a significant effect on depression, but was effective in improving other outcomes such as anxiety, caregiver burden and psychological distress after the 14-weeks intervention [ 44 ]. Compared to the smaller effect size on QoL reported by Risch et al. [ 46 ], this study shows a moderate effect size, which might be attributed to variations in both the type and duration of the intervention. Risch et al. [ 45 ] employed psychotherapeutic intervention over a period of 8-weeks, which may have limited the intervention’s impact on QoL. However, the study shows a significant improvement on caregiver’s QoL in physical health but not mental health. In relation to the delivery method of the intervention, Topfler and Meishcner [ 47 , 48 ] have shown that telephone-based cognitive behavioural therapy (TEL-CBT) had positive impact on caregivers` QoL and their ability to cope with caregiving situations. The results enhance flexibility benefits for telephone-based intervention with reduction of facility usage and costs in terms of transportation for both FCs and healthcare providers. Previous literature indicates that caregivers` mental health is associated with increased emotional and physical burden [ 17 , 49 ]. By targeting caregiver burden through telephone-based intervention, FCs may regain emotional stability and develop internal resilience, which in turn enhance their capacity to provide sustained care and improve their QoL and anxiety symptoms. As reported by López-Martínez et al. [ 50 ], caregiver burden shows mediating effect of the association between coping responses and caregiver’s anxiety symptoms. Although the intervention in the present study was delivered via telephone, it also included several coping components, such as problem-solving engagements, building a positive mindset and emotional regulation strategies. In a cross-sectional study in China, social support was found as the mediating role between caregiver burden and QoL in FCs of PWD. These findings show that social support can influence how caregiver burden impacts FCs of PWD’s overall well-being [ 35 , 36 ]. Other research by Srivastava et al. [ 51 ], identified a negative association between caregiver burden and QoL, suggesting that burden may moderate the effectiveness of psychotherapy interventions aimed at enhancing QoL. However, this moderating effect was not empirically tested within the study. In Malaysia, where mental health services for PWD and their caregivers are still evolving in terms of accessibility and cultural acceptance, this study contributes to the local evidence base by highlighting a community-centred approach to mental healthcare. Furthermore, it aligns with the government’s Health Research Priorities for 12th Malaysia Plan 2021–2025 on mental health promotion and supports the SDG 3, highlighting good health and well-being by focusing on both preventive and responsive care. A systematic review by Moyle [ 32 ], suggests that the benefits of telephone-based interventions might decline after 6-months. In Italy, De Stefeno et al. [ 45 ] found that the benefits of a four-week telephone-based psychological intervention had disappeared by the six-month follow-up. To enhance the sustainability of such interventions, researchers and clinicians should continuously include flexible adaptations, such as ad-hoc counselling options and periodic booster sessions, to maintain long-term effectiveness [ 34 , 52 ]. Future research should consider the long-term impact of interventions and how the intervention can be sustained over time. Despite concern about long-term sustainability of interventions, some studies reported encouraging outcome after 6-month treatment where FCs who received telephone-based intervention were found to have lower overall pre-death grief, fewer physical symptoms such as less rheumatic pain and higher acceptance of loss of their loved one with dementia [ 46 ]. A key strength of this study lies in its contribution to understanding the psychological mechanisms through which telephone-based interventions influence outcomes. All measurement instruments used for data collection were locally validated, enhancing the cultural relevance and the validity of the results. However, it is important to acknowledge several possible limitations. First, the specific stages of dementia of the PWD were not classified as FCs of persons across all stages of dementia, mild, moderate and severe, were included in the study. FCs who care for PWD with moderate to severe stages experienced greater physical and psychological burden due to behavioural changes and higher dependency on daily routines [ 53 – 55 ]. Additionally, both healthcare providers and FCs might have faced challenges in scheduling intervention sessions, which could have led to delays, increased stress and inconsistencies in the delivery of the intervention. Conclusion In conclusion, this research demonstrates that the telephone-based interventions can effectively improve QoL among FCs of PWD, with caregiver burden playing a significant mediating role in the relationship between the intervention and anxiety symptoms as well as QoL. By understanding the underlying mechanisms, it not only strengthens theoretical clarity, but also facilitates the development of more effective interventions to address the comprehensive needs of FCs to PWDs. Abbreviations PWD Persons with dementia RCT Randomised control trial FCs Family caregivers QoL Quality of life IG Intervention group CG Control group CASP Control, Autonomy, Self-Realization and Pleasure ITT Intention-to-treat WHO World Health Organization RA Research Assistant DOSM Department of Statistics Malaysia MPSS Multidimensional Scale of Perceived Social Support TEL-CBT Telephone-based cognitive behavioural therapy SDG Sustainable development goal Declarations Ethical approval and consent to participate The study was approved by the Malaysia Medical Research and Ethics Committee [NMRR-22-00137-BUY(IRR)], the IIUM Research Ethics committee [IREC 2022-007] and the Research Ethics committee of Universiti Kebangsaan Malaysia [UKM PPI/111/8/JEP-2022-328]. Informed consent was obtained after providing detailed information about the purpose and type of the study, interventions, procedures and protocols, and risks as well as benefits for participating in the project. The intervention may introduce some stress or anxiety as it affects participant’s schedule-works. However, higher dose of flexibility to adjust participants’ time for delivering the intervention may minimize those risks. The participants were ensured anonymity and confidentiality of their data. The research was conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable Availability of data and materials The dataset generated and analysed during the current study are not publicly available due to confidentiality issues but are available from the corresponding author on reasonable request. Competing interests All authors declare that there are no personal, organizational, or financial conflicts of interest. Funding Not Applicable Authors’ contributions Hashima E Nasreen (H.E.N.) was the principal investigator in this study and primarily conceptualized the research. H.E.N., Zarina Nahar Kabir (Z.N.K.), Mohd Aznan Md Aris (M.A.M.A.), and Karimah Hanim Abd Aziz (K.H.A.A.) participated in the planning and conception of the research questions. . Nora Mat Zin (N.M.Z.) helped implementing the telephone-intervention for the family caregivers of PWD. Syarifah Amirah binti Syed Ahmad (S.A.B.S.A.) involved in data collection of the study. H.E.N. and S.A.B.S.A. analysed the data. S.A.B.S.A. drafted the manuscript, while H.E.N., Z.N.K., Marie Tyrell (M.T.) and S.A.B.S.A. critically reviewed and revised the manuscript for important intellectual content. All authors read and approved the final version of the manuscript. Acknowledgments The authors would like to thank all the healthcare staff involved in delivering the intervention to the family caregivers to PWD. We also express our gratitude to all family caregivers to PWD who participated in the study for their time, energy and support throughout the projects. Authors’ information Hashima E Nasreen, MBBS, MPH, PhD, Associate Professor of Epidemiology, Department of Community Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia Syarifah Amirah Binti Syed Ahmad, Candidate for Doctor of Philosophy in Health Science, Department of Community Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia Zarina Nahar Kabir, PhD, Associate Professor of Public Health and Principal Researcher, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden Karimah Hanim Abd Aziz, MD, DrPH, Assistant Professor, Department of Community Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia Nora Mat Zin, MD, MMeD, Associate Professor, Department of Psychiatry, Faculty of Medicine, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia Mohd Aznan Md Arid, MBBS, MMeD, Professor, Department of Family Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia Marie Tyrrell, Associate Professor, Sophiahemmet Högskola, Valhallavägen, Stockholm, Sweden References World Health Organization. Global status report on the public health response to dementia. Geneva: World Health Organization. 2021;251. Available from: https://digitalcommons.fiu.edu/cgi/viewcontent.cgi?article=1962&context=srhreports Qi S, Yin P, Zhang H, Zhang Q, Xiao Y, Deng Y, et al. Prevalence of Dementia in China in 2015: A Nationwide Community-Based Study. Front Public Health. 2021 Nov 2;9. Yin Y, Tam HL, Quint J, Chen M, Ding R, Zhang X. Epidemiology of Dementia in China in 2010–2020: A Systematic Review and Meta-Analysis. Healthcare (Switzerland). 2024;12(3):334. Lee J, Meijer E, Langa KM, Ganguli M, Varghese M, Banerjee J, et al. Prevalence of dementia in India: National and state estimates from a nationwide study. Alzheimer’s & Dementia. 2023;19(7):2898–912. Alzheimer Disease Foundation. Dementia cases set to rise 312 per cent by 2050: Is Malaysia prepared? . Available from: https://www.adfm.org.my/dementia-cases-set-to-rise-312-per-cent-by-2050-is-malaysia-prepared/ Caputo A. The emotional experience of caregiving in dementia: Feelings of guilt and ambivalence underlying narratives of family caregivers. Dementia. 2021;20(7):2248–60. Tu JY, Jin G, Chen JH, Chen YC. Caregiver Burden and Dementia: A Systematic Review of Self-Report Instruments. Journal of Alzheimer’s Disease. 2022;86(4):1527–43; doi:10.3233/JAD-215082 Duangjina T, Hershberger PE, Gruss V, Fritschi C. Resilience in family caregivers of Asian older people with dementia: An integrative review. J Adv Nurs. 2024;81(1):156–70; doi:10.1111/jan.16272 Ng CKM, Leung DKY, Cai X, Wong GHY. Perceived Help-Seeking Difficulty, Barriers, Delay, and Burden in Carers of People with Suspected Dementia. International Journal of Environmental Research and Public Health. 2021;18(6):2956. Chan CY, Cheung G, Martinez-Ruiz A, Chau PYK, Wang K, Yeoh EK, et al. Caregiving burnout of community-dwelling people with dementia in Hong Kong and New Zealand: a cross-sectional study. BMC Geriatr. 2021;21(1):1–15; doi:10.1186/s12877-021-02153-6 Hwang Y, Kim J. Influence of caregivers’ psychological well-being on the anxiety and depression of care recipients with dementia. Geriatr Nurs. 2024;55:44–51. Wang S, Huang Y, Fan AYN, Ho MH, Davidson PM. Factors influencing the psychosocial well-being of people with dementia and their informal caregivers: A systematic review of dyadic studies. Int J Ment Health Nurs. 2024;33(3):560–81; doi:10.1111/inm.13279 Ang JP; K;, Koh EBY;, Pang NTP;, Mat Saher Z, Pin Tan K, Kiat Ang J, et al. Relationship of Psychological Flexibility and Mindfulness to Caregiver Burden, and Depressive and Anxiety Symptoms in Caregivers of People with Dementia. International Journal of Environmental Research and Public Health. 2023;20(5):4232. Available from: https://www.mdpi.com/1660-4601/20/5/4232/htm Nasreen HE, Tyrrell M, Vikström S, Craftman Å, Syed Ahmad SAB, Zin NM, et al. Caregiver burden, mental health, quality of life and self-efficacy of family caregivers of persons with dementia in Malaysia: baseline results of a psychoeducational intervention study. BMC Geriatr. 2024;24(1):1–12; doi:10.1186/s12877-024-05221-9 Kai I, Ohi G, Kobayashi Y, Ishizaki T, Hisata M, Kiuchi M. Quality of life: a possible health index for the elderly. Asia-Pacific journal of public health / Asia-Pacific Academic Consortium for Public Health. 1991;5(3):221–7. Rizal Abdul Manaf M, Helma Firdaus M, Fairuz Md Teridi N. Introduction Quality of Life and its associated factors among Patient with Dementia Caregivers: A Cross-Sectional Study in Geriatric Clinic, Hospital Kuala Lumpur, Malaysia. 2024. Hu YL, Chang CC, Lee CH, Liu CH, Chen YJ, Su JA, et al. Associations between Affiliate Stigma and Quality of Life among Caregivers of Individuals with Dementia: Mediated Roles of Caregiving Burden and Psychological Distress. Asian Journal of Social Health and Behavior. 2023;6(2):64–71. Contreras ML, Mioshi E, Kishita N. Factors Related to the Quality of Life in Family Carers of People With Dementia: A Meta-Analysis. J Geriatr Psychiatry Neurol. 2021;34(5):482–500. Available from: https://pubmed.ncbi.nlm.nih.gov/32394770/ Canevelli M, Bruno G, Cesari M. Providing Simultaneous COVID-19–sensitive and Dementia-Sensitive Care as We Transition from Crisis Care to Ongoing Care. J Am Med Dir Assoc. 2020;21(7):968. Cuffaro L, Di Lorenzo F, Bonavita S, Tedeschi G, Leocani L, Lavorgna L. Dementia care and COVID-19 pandemic: a necessary digital revolution. Neurological Sciences. 2020;41(8):1977–9. Farkhondeh V, Decarli C. White matter hyperintensities in diverse populations: A systematic review of literature in the United States. Cereb Circ Cogn Behav. 2024;6:100204; doi:10.1016/j.cccb.2024.100204 Paplikar A, Rajagopalan J, Alladi S. Care for dementia patients and caregivers amid COVID-19 pandemic. Cereb Circ Cogn Behav. 2022;3:100040. Quail Z, Bolton L, Massey K. Digital delivery of non-pharmacological intervention programmes for people living with dementia during the COVID-19 pandemic. BMJ Case Reports CP. 2021;14(6):e242550. Dombestein H, Norheim A, Aase K. How to stay motivated: A focus group study of Norwegian caregivers’ experiences with community healthcare services to their parents with dementia. Health Soc Care Community. 2022;30(1):235–43; doi:10.1111/hsc.13396 Sadavoy J, Sajedinejad S, Chiu M. A quasi-experimental study of the effectiveness of the Reitman Centre CARERS group intervention on family caregivers of persons with dementia. Int J Geriatr Psychiatry. 2021;36(6):811–21; doi:10.1002/gps.5481 Fossey J, Charlesworth G, Fowler JA, Frangou E, Pimm TJ, Dent J, et al. Online Education and Cognitive Behavior Therapy Improve Dementia Caregivers’ Mental Health: A Randomized Trial. J Am Med Dir Assoc. 2021 Jul 1 [cited 2025;22(7):1403-1409. Baruah U, Loganathan S, Shivakumar P, Pot AM, Mehta KM, Gallagher-Thompson D, et al. Adaptation of an online training and support program for caregivers of people with dementia to Indian cultural setting. Asian J Psychiatr. 2021;59:102624. Ramirez M, Duran MC, Pabiniak CJ, Hansen KE, Kelley A, Ralston JD, et al. Family Caregiver Needs and Preferences for Virtual Training to Manage Behavioral and Psychological Symptoms of Dementia: Interview Study. JMIR Aging. 2021;4(1):e24965. Wen Y, Xing Y, Ding Y, Xu W, Wang X. Challenges of conducting of online educational programs for family caregivers of people with dementia living at home: An integrative review. Int J Nurs Sci. 2023;10(1):121–8. Possin KL, Sideman AB, Dulaney S, Lee K, Merrilees J, Bonasera S, et al. The Care Ecosystem: The Effectiveness and Implementation of Telephone-Based Collaborative Dementia Care. Alzheimer’s & Dementia. 2022;18(S9):e063938; doi:10.1002/alz.063938 Wang Y, Xiao LD, Yu Y, Huang R, You H, Liu M. An individualized telephone-based care support program for rural family caregivers of people with dementia: study protocol for a cluster randomized controlled trial. BMC Geriatr. 2021;21(1):1–11; doi:10.1186/s12877-021-02575-2 Kwok T, Wong B, Ip I, Chui K, Young D, Ho F. Telephone-delivered psychoeducational intervention for Hong Kong Chinese dementia caregivers: A single-blinded randomized controlled trial. Clin Interv Aging. 2013;8:1191–7; doi:10.2147/CIA.S48264 Tremont G, Davis JD, Papandonatos GD, Ott BR, Fortinsky RH, Gozalo P, et al. Psychosocial telephone intervention for dementia caregivers: A randomized, controlled trial. Alzheimer’s & Dementia. 2015;11(5):541–8. Meichsner F, Töpfer NF, Reder M, Soellner R, Wilz G. Telephone-Based Cognitive Behavioral Intervention Improves Dementia Caregivers’ Quality of Life. Am J Alzheimers Dis Other Demen. 2019;34(4):236–46. del-Pino-Casado R, Priego-Cubero E, López-Martínez C, Orgeta V. Subjective caregiver burden and anxiety in informal caregivers: A systematic review and meta-analysis. PLoS One. 2021;16(3):e0247143. Han A. Effects of Mindfulness-Based Interventions on Depressive Symptoms, Anxiety, Stress, and Quality of Life in Family Caregivers of Persons Living with Dementia: A Systematic Review and Meta-analysis. Res Aging. 2022;44(7–8):494–509; doi:10.1177/01640275211043486?download=true Tremont G, Davis J, Papandonatos GD, Grover C, Ott BR, Fortinsky RH, et al. A telephone intervention for dementia caregivers: Background, design, and baseline characteristics. Contemp Clin Trials. 2013;36(2):338–47. World Health Organization. iSupport for dementia: Training and support manual for carers of people with dementia. 2018. Ng CG, Nurasikin MS, Loh HS, Anne Yee HA, Zainal NZ. Factorial validation of the Malay version of multidimensional scale of perceived social support among a group of psychiatric patients. Malaysian Journal of Psychiatry. 2012;21(2):17-26. Shim VK, Ng CG, Drahman I. Validation of the Malay version of Zarit burden interview (MZBI). Malaysian Journal of Psychiatry. 2017;26(2):3-18. Nalathamby N, Morgan K, Mat S, Tan PJ, Kamaruzzaman SB, Tan MP. Validation of the CASP-19 Quality of Life Measure in Three Languages in Malaysia. Journal of Tropical Psychology. 2017;7:e4. Yahya F, J ZOIM, 2015 undefined. Validation of the Malay version of hospital anxiety and depression scale (HADS) in Hospital Universiti Sains Malaysia. 2015;22(2):80–2. Baron RM, Kenny DA. The Moderator-Mediator Variable Distinction in Social Psychological Research. Conceptual, Strategic, and Statistical Considerations. J Pers Soc Psychol. 1986 Dec;51(6):1173–82. Ahmad SABS, Kabir ZN, Tyrrell M, Craftman Å, Nasreen HE. Efficacy of a Telephone-Intervention on Caregiving Burden and Mental Health among Family Caregivers of Persons with Dementia in Malaysia: A Randomized Controlled Trial. International Journal of Environmental Research and Public Health. 2024;21(10):1354. De Stefano M, Esposito S, Iavarone A, Carpinelli Mazzi M, Siciliano M, Buonanno D, et al. Effects of Phone-Based Psychological Intervention on Caregivers of Patients with Early-Onset Alzheimer’s Disease: A Six-Months Study during the COVID-19 Emergency in Italy. Brain Science. 2022;12(3):310. Risch AK, Lechner-Meichsner F, Wilz G. Telephone-Based Acceptance and Commitment Therapy for Caregivers of Persons with Dementia: Results of a Randomized Controlled Trial. Clin Gerontol [Internet]. 2024 Oct 21 [cited 2025 Jun 28]; Available from: https://www.tandfonline.com/doi/pdf/10.1080/07317115.2024.2393307 Töpfer NF, Wrede N, Theurer C, Wilz G. Face-to-face versus telephone-based cognitive-behavioral therapy for family caregivers of people with dementia. J Clin Psychol. 2023;79(10):2270–87; doi:10.1002/jclp.23538 Meichsner F, Töpfer NF, Reder M, Soellner R, Wilz G. Telephone-Based Cognitive Behavioral Intervention Improves Dementia Caregivers’ Quality of Life. Am J Alzheimers Dis Other Demen. 2019;34(4):236–46; doi:10.1177/1533317518822100 Vrettos I, Anagnostopoulos F, Voukelatou P, Panayiotou S, Kyvetos A, Nikas A, et al. Factors associated with health-related quality of life of informal caregivers of older patients and the mediating role of subjective caregivers’ burden. Psychogeriatrics. 2023;23(2):286–97; doi;10.1111/psyg.12930 López-Martínez C, Orgeta V, Frías-Osuna A, del-Pino-Casado R. Coping and anxiety symptoms in family carers of dependent older people: Mediation and moderation effects of subjective caregiver burden. Journal of Nursing Scholarship. 2024;56(3):371–81; doi:10.1111/jnu.12957 Srivastava G, Tripathi RK, Tiwari SC, Singh B, Tripathi SM. Caregiver burden and quality of life of key caregivers of patients with dementia. Indian J Psychol Med. 2016;38(2):133–6. Bartels SL, van Knippenberg RJM, Köhler S, Ponds RW, Myin-Germeys I, Verhey FRJ, et al. The necessity for sustainable intervention effects: lessons-learned from an experience sampling intervention for spousal carers of people with dementia. Aging Ment Health. 2020;24(12):2082–93; doi:10.1080/13607863.2019.1647130 Tay RY, Tan JYS, Hum AYM. Factors Associated With Family Caregiver Burden of Home-Dwelling Patients With Advanced Dementia. J Am Med Dir Assoc. 2022;23(7):1248–56. García-Martín V, de Hoyos-Alonso MC, Delgado-Puebla R, Ariza-Cardiel G, del Cura-González I. Burden in caregivers of primary care patients with dementia: influence of neuropsychiatric symptoms according to disease stage (NeDEM project). BMC Geriatr. 2023;23(1):1–12; doi:10.1186/s12877-023-04234-0 Ozcan M, Akyar İ. Caregivers’ experiences of patients with moderate-stage Alzheimer’s disease: a qualitative study. Psychogeriatrics. 2021;21(5):763–72; doi:10.1111/psyg.12736 Tables Table 1. Topics and contents included in “My Caregiver Booklet” Sessions Topics Contents Session 1 Introduction Rapport building, risk appraisal, challenges and positive aspects of caregiving Session 2 Introduction to dementia Information about dementia: types, stages and challenges Session 3 Being a family caregiver I Support caregivers to understand their role as caregivers Session 4 Being a family caregiver II Coach caregivers on utilization of accessible tools and strategies for their recreation Session 5 Mental strategies and mind-set Assist the caregivers about mental strategies and ways of thinking Session 6 Free choice of topic Topic that caregivers themselves felt they wanted to discuss Session 7 Activities Support caregivers to utilise activities strategically Session 8 Behavioural and psychological symptoms in dementia (BPSD) Help caregivers to manage BPSD Session 9 Eat and sleep Help caregivers to identify appropriate strategies to solve problems related to eating and sleeping Session 10 Continued resources Encourage to utilise the existing support system in the family, community and the government system Table 2. Baseline characteristics of family caregivers and persons with dementia Total n = 121 Intervention n = 60 Control n = 61 p value BACKGROUND VARIABLES Family caregivers’ socioeconomic characteristics Age (years), Mean (SD) 51.6 (12.7) 50.1 (12.4) 53.1 (12.9) .185 Gender (%) Male Female 30.6 69.4 18.3 81.7 42.6 57.4 .004 Religion (%) Muslim Non-Muslim 66.9 33.1 75.0 25.0 59.0 41.7 .057 Education (%) Primary Secondary Tertiary 13.2 39.7 47.1 15.0 33.3 51.7 11.5 45.9 42.6 .365 Marital status (%) Unmarried Married Divorced/widowed 18.2 73.6 8.3 18.3 71.7 10.0 18.0 75.4 6.6 .553 Occupation (%) Employed Homemaker/unemployed Retired 54.5 35.5 10.0 45.0 43.3 11.7 63.9 27.9 8.2 .111 Monthly HH income (RM)*, (%) low income (RM10959) 56.2 35.5 8.3 60 31.7 8.3 52.5 39.3 8.2 .667 Comorbidities (%) Yes No 55.2 44.8 67.3 32.7 44.6 55.4 .020 Caregiving information Length of caregiving (months), Mean (SD) 47.9 (42.8) 40.7 (34.3) 55.1 (49.0) .064 Hours of caregiving/day, Mean (SD) 18.6 (6.9) 18.8 (6.9) 18.4 (7.1) .800 Shared caregiving by other family members (%) 60.3 56.7 63.9 .414 Relationship with person with dementia (%) Spouse Adult child In-laws 27.3 62.8 9.9 21.7 73.3 5.0 32.8 52.5 14.8 .041 Social support, Mean (SD) Total Social Support 59.3 (17.1) 58.6 (16.8) 59.9 (17.6) .682 Family support 21.4 (6.4) 21.3 (6.0) 21.5 (6.7) .891 Friend support 16.1 (7.3) 16.0 (7.5) 16.3 (7.2) .844 Significant other support 21.7 (6.5) 21.3 (6.9) 22.2 (6.1) .466 OUTCOME VARIABLES Caregiver Burden, Mean (SD) 11.7 (8.2) 12.6 (8.1) 10.8 (8.2) .227 Quality of Life (QoL), Mean (SD) 40.6 (10.4) 39.4 (10.5) 41.7 (10.3) .237 Anxiety Symptoms, Mean (SD) 6.2 (4.6) 6.9 (4.3) 5.5 (4.9) .090 *USD 1 = RM4.70 (based on 2022 exchange rate at time of data collection) Table 3. Mixed ANOVA showing mean scores and gain score on QoL by intervention groups (N=105) Mean Score (SD) Gain Score p-value Net Gain Score (95% CI) p-value Effect size (partial h 2) T0 (Baseline) T1 (post-intervention) Quality of Life Intervention 39.43 (10.98) 42.86 (10.11) 3.43 0.198 5.02 (2.20-7.83) 0.001 0.108 Control 42.29 (10.01) 40.70 (11.34) -1.59 Difference -2.86 2.16 p-value 0.859 *Gain score= post-intervention score – baseline score *Net gain score= gain score (intervention)- gain score (control) partial h 2 : small effect ( h 2 =0.01 to 0.06), moderate effect ( h 2 >0.06 to 0.14), large effect ( h 2 >0.14) (Richardson, 20 Table 4. Linear mixed model showing the effect of intervention on caregiver’s quality of life (N=121). Unadjusted Adjusted b Std. error 95% CI p value b Std. error 95% CI p value QoL IG (ref: CG) -2.24 1.91 -6.02 – 1.54 0.244 -0.95 1.76 -4.43 – 2.52 0.590 T1 (ref: T0) -1.44 0.96 -3.35 – 0.47 0.137 -1.40 0.96 -3.31 – 0.51 0.149 IG T1 (ref: CG T0) 4.87 1.40 2.09 – 7.66 0.001 5.00 1.40 2.21 – 7.78 0.001 IG: Intervention group, CG: Control group, T0: Baseline, T1: Post-intervention Table 5. Multiple linear regression models with and without caregiver burden as mediator in the association between telephone-based intervention and the outcome variables (Caregiver’s QoL and anxiety symptoms). Model without Caregiver Burden as mediator Model with Caregiver Burden as mediator Outcome B (SE) β p B (SE) β p Quality of life 1 3.794 0.176 0.008 2.330 0.108 0.085 Anxiety Symptoms 2 -1.801 -0.203 0.006 -1.021 -0.115 0.106 1 Regression analyses were adjusted for caregiver’s religion, household income, comorbidity, social support and QoL at baseline. 2 Regression analyses were adjusted for caregiver’s religion, marital status, social support and anxiety symptoms at baseline. Additional Declarations No competing interests reported. Supplementary Files CONSORT2025editablechecklist.docx ComparativeAnalysis.docx Cite Share Download PDF Status: Published Journal Publication published 12 Feb, 2026 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 14 Oct, 2025 Reviews received at journal 13 Oct, 2025 Reviewers agreed at journal 24 Sep, 2025 Reviews received at journal 25 Aug, 2025 Reviewers agreed at journal 25 Aug, 2025 Reviewers invited by journal 25 Aug, 2025 Editor assigned by journal 25 Aug, 2025 Editor invited by journal 22 Aug, 2025 Submission checks completed at journal 20 Aug, 2025 First submitted to journal 20 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7314107","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":506611424,"identity":"2359fb59-9d47-467d-9644-15700c5d33e2","order_by":0,"name":"Hashima E Nasreen","email":"","orcid":"","institution":"International Islamic University Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Hashima","middleName":"E","lastName":"Nasreen","suffix":""},{"id":506611425,"identity":"073efb74-55b7-4fad-9657-ecbd5f204e1c","order_by":1,"name":"Syarifah Amirah binti Syed Ahmad","email":"data:image/png;base64,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","orcid":"","institution":"International Islamic University Malaysia","correspondingAuthor":true,"prefix":"","firstName":"Syarifah","middleName":"Amirah binti Syed","lastName":"Ahmad","suffix":""},{"id":506611426,"identity":"da1d1897-a407-4ebc-acd6-c24ea14153e2","order_by":2,"name":"Marie Tyrrell","email":"","orcid":"","institution":"Sophiahemmet Högskola","correspondingAuthor":false,"prefix":"","firstName":"Marie","middleName":"","lastName":"Tyrrell","suffix":""},{"id":506611427,"identity":"1f77e028-26f4-4c3f-b6b4-8c4e08b88dc7","order_by":3,"name":"Nora Mat Zin","email":"","orcid":"","institution":"International Islamic University Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Nora","middleName":"Mat","lastName":"Zin","suffix":""},{"id":506611428,"identity":"b80b28a3-2d48-469a-9f64-6f2dba4d6538","order_by":4,"name":"Karimah Hanim Abd Aziz","email":"","orcid":"","institution":"International Islamic University Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Karimah","middleName":"Hanim Abd","lastName":"Aziz","suffix":""},{"id":506611429,"identity":"cac44d6c-0c9b-4fd7-b2cf-6d5c37d0287f","order_by":5,"name":"Mohd Aznan Md Aris","email":"","orcid":"","institution":"International Islamic University Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Mohd","middleName":"Aznan Md","lastName":"A","suffix":"Md"},{"id":506611430,"identity":"e0e62dbe-e7ab-413b-a1e4-75f91aaa3e2d","order_by":6,"name":"Zarina Nahar Kabir","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Zarina","middleName":"Nahar","lastName":"Kabir","suffix":""}],"badges":[],"createdAt":"2025-08-07 03:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7314107/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7314107/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-026-07066-w","type":"published","date":"2026-02-12T15:58:24+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90463901,"identity":"fa2cbab6-4096-43c6-ab71-cec41d812808","added_by":"auto","created_at":"2025-09-03 05:06:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":24152,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of the study procedures\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7314107/v1/aa3c863f7ca68e5bd2bfdba7.png"},{"id":90465769,"identity":"61ef10c2-0101-4e9b-8e3e-7d954b692ebc","added_by":"auto","created_at":"2025-09-03 05:32:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18837,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEffect of interaction between time and participation in intervention on Quality of Life\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7314107/v1/891f8a8ff7fef58fe5319ef9.png"},{"id":90466073,"identity":"6d01870e-8f57-4758-9b11-f68b2e8e31e4","added_by":"auto","created_at":"2025-09-03 05:32:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":18633,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverall mediation model illustrating the effect of the telephone-based intervention on caregivers’ quality of life and anxiety symptoms mediated by caregiver burden. The standardised path coefficient (B) was shown along the arrows. The significant effect was (p\u0026lt;0.05).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7314107/v1/84c6381d734584643c3fa88e.png"},{"id":102786723,"identity":"0897c4eb-3cf5-4212-8ce7-87eb2497532f","added_by":"auto","created_at":"2026-02-16 16:14:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1616862,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7314107/v1/60272c86-eb3b-4806-abc7-b5282b87a636.pdf"},{"id":90465749,"identity":"8e96272a-2422-41c1-807d-66c83cba6297","added_by":"auto","created_at":"2025-09-03 05:31:59","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":34739,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2025editablechecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-7314107/v1/155c3425da991088d32342f0.docx"},{"id":90463904,"identity":"395eac1b-bd0e-4513-8ab3-01542e8d7ad7","added_by":"auto","created_at":"2025-09-03 05:06:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26291,"visible":true,"origin":"","legend":"","description":"","filename":"ComparativeAnalysis.docx","url":"https://assets-eu.researchsquare.com/files/rs-7314107/v1/25465ee43eed83dd9f42948f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Telephone-based Intervention Improves Quality of Life Among Family Caregivers of Persons with Dementia in Malaysia: The Mediating Role of Caregiver Burden","fulltext":[{"header":"Background","content":"\u003cp\u003eAccording to the World Health Organization (WHO), approximately 55 million people are living with dementia, a number that is projected triple to 139 million by 2050 [1]. In Asian countries, the prevalence of persons with dementia (PWD) above 65 years old reported ranging from 4-8% [2–4]. As Malaysia is projected to become an ageing nation by 2030, with an estimated 15.3% of population aged 60 years and above, the number of PWD is predicted to increase by 312%. Of these persons, an estimated 8-11% will require 24-hour care and full dependency [5]. These raises concerns not only about the quality of life (QoL) of PWD and their daily functioning but may create substantial emotional and psychological strain on family caregivers (FCs) particularly those in primary caregiving roles.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNumerous studies have found that FCs to PWD often face a range of caregiving related stressors including emotional distress [6], burden [7], social stigma [8], feelings of helplessness [9], and caregiver burnout [10]. This prolonged exposure to distress may result in clinically significant anxiety which affects their overall well-being and QoL [11–13]. In a local Malaysian study, Nasreen et al. [14] reported prevalence of caregiver burden among FCs of PWD to be 69.4%, depressive symptoms to be 32.2% and anxiety symptoms 32.2%. According to Kai et al. [15], QoL among caregivers of PWD is a crucial component reflecting individuals’ perceptions on their position in life. Furthermore, in Malaysia, QoL of older adults often demonstrate the importance of social dimensions such as relationships with spouse, siblings and adult children [16–18]\u003c/p\u003e\n\u003cp\u003eDespite the growing awareness of mental health issues in Malaysia, especially after the pandemic of COVID-19, interventions often focused predominantly on the PWD [19–23], with insufficient attention given to the mental health of the caregivers of PWD. Although several support services for the FCs are available, such as focus group discussion [24,25] and online education [26,27], their effectiveness may be hindered by challenges such as logistical constraints, limited accessibility or unstable internet connections [28,29] particularly in underserved areas. As a result, telephone-based intervention emerged as a potential approach to overcome these challenges [30,31].\u003c/p\u003e\n\u003cp\u003eIn some countries such as USA, Germany and Hong Kong [32–34], telephone-based interventions were found to effectively improve FC’s well-being. Unfortunately, its role in supporting FCs of PWD remains limited, both in terms of availability and empirical validation especially in low- and middle-income countries in Asia. Additionally, research indicates that FCs’ poor QoL, caregiver burden and anxiety often co-exist and influence one another [35,36]. However, the pathways of the effect of an intervention on outcome variables is unclear [14,34]. Therefore, the primary objective of this study was to measure the effectiveness of telephone-based intervention on improving QoL among FCs of PWD. The secondary objective aimed to analyse the mediating role of caregiver burden on the association between intervention and QoL as well as between intervention and anxiety symptoms.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy design and setting\u003c/h2\u003e\n\u003cp\u003eThis was a randomised controlled trial (RCT) carried out among FCs of PWD. Participants were recruited from the list of PWD from the psychiatry and memory clinics of Sultan Ahmad Shah Medical Centre (SASMEC), and Hospital Tengku Ampuan Afzan (HTAA), Kuantan, Pahang, and the geriatric clinic at the University Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur. The study adheres to CONSORT 2025 guidelines for reporting the RCT.\u003c/p\u003e\n\u003ch2\u003eParticipants\u003c/h2\u003e\n\u003cp\u003eParticipants were eligible for recruitment if they were primary FCs of a person who was diagnosed with dementia at any stage, aged 18 years and above, had been providing care for at least 4 h/day for \u0026gt;6 months, lived in the same household as the PWD, had access to a telephone, were able to read and understand Malay. FCs who reported having major acute medical illness or hearing-impairment were excluded from the study.\u003c/p\u003e\n\u003cp\u003eThe sample size was estimated based on the main variables of interest according to the original study [14]. \u0026nbsp;Assuming a current improvement rate of 30% in caregiver burden and depressive symptoms, an expected net improvement of 25-30% with the intervention [37], a significance level of 5%, and power of 80%, the required sample size was 100 participants. For QoL, the sample size was estimated based on expected mean (SD) from the previous literature, 55.58 (17.75) in the treatment group and 50.00 (18.37) in the control group [34], assuming medium effect size (Cohen\u0026rsquo;s d = 0.5), significance level of 5%, and power of 80%, yielding a required sample size of 51 rounded to 50 participants in each group. Since both variables yielded the same sample size estimate, a total of 100 participants was used in this study. After including the anticipated drop-out of 20%, the final target sample size increased to 120 participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA total of 380 FCs were screened for eligibility and 121 FCs were successfully enrolled to the study who were randomly assigned to either a intervention or a control group using a 4-block randomisation (Figure 1). Participants in the intervention group received both the telephone-based intervention and standard care, and the control group received standard care only. To minimise the risk of selection bias, the randomisation sequence was generated by an independent statistician who was not involved in the study. The allocation was concealed using sealed opaque envelops to maintain blinding during the process of randomisation.\u003c/p\u003e\n\u003cp\u003eInsert Figure 1\u003c/p\u003e\n\u003ch2\u003eIntervention\u003c/h2\u003e\n\u003cp\u003eAn intervention booklet called \u0026lsquo;My Caregiver Booklet\u0026rsquo;, inspired by WHO iSupport manual [38], was developed by the research team. iSupport was designed by WHO to support caregivers to PWD. It is a training and skills programme aimed at improving the well-being of caregivers and enhancing the quality of care provided by FCs to persons living with dementia. The booklet, which contained 10 main topics, as summarised in Table 1, was provided exclusively to FCs in the intervention group. \u0026nbsp;The FCs in the intervention group received the intervention through 10 weekly sessions, each lasting approximately 30 minutes, and delivered via telephone by a designated, trained healthcare professional (Figure 1). The healthcare professionals who delivered the intervention consisted of 5 nurses and 2 occupational therapists. \u0026nbsp;Each telephone call was scheduled at mutually agreed times for both FCs and healthcare staff. \u0026nbsp;Each session began by addressing possible challenges faced by the caregivers in their caregiving roles and concluded with a task to be completed before the next session. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInsert Table 1\u003c/p\u003e\n\u003ch2\u003eData Collection\u003c/h2\u003e\n\u003cp\u003eThe data was collected at two points of time; baseline i.e., prior to the intervention and end line, after the intervention period, which spanned from August 2022 to August 2024. \u0026nbsp;Data collection was performed by trained research assistants (RAs) who were blinded to group allocation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBackground characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBackground characteristics were collected at baseline on demographic and socio-economic variables, caregiving information, information about PWD, social support and caregiving burden.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDemographic and socio-economic variables\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic and socio-economic characteristics of the FCs included age, sex, religion (Muslim, non-Muslim), education (primary, secondary or tertiary), marital status (unmarried, married, divorced/widowed), occupation (employed, homemaker/unemployed, retired), monthly household income (low income, middle income and high income) and FC\u0026rsquo;s comorbidities. According to the Department of Statistics Malaysia (DOSM) (2019), households are classified into income groups: \u0026nbsp;low-income (B40: Bottom 40%) for households with a monthly income RM4850 and below; M40 (Middle 40%) for households with monthly income between RM 4851 and RM10,970; and T20 (Top 20%) for households with a monthly income of RM10,971 and above (1 USD = RM4.70 as of date of data collection).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCaregiving information\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCaregiving information included length of caregiving period, hours of caregiving per day, whether caregiving is shared and number of family members involved, and caregiver\u0026rsquo;s relationship with PWD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInformation about the PWD\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformation about PWD included PWD\u0026rsquo;s age, sex, and ability to self-care. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocial support\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePerceived social support from family, friends and significant others was assessed using the validated Malay Version of the Multidimensional Scale of Perceived Social Support (MSPSS) [39]. The scale consists of 12 items, equally divided among the three support sources. \u0026nbsp;The 7-point Likert scale were rated (1= Very Strongly Disagree, 2= Strongly Disagree, 3= Mildly Disagree, 4= Neutral, 5= Mildly Agree, 6= Strongly Agree, 7= Very Strongly Agree), with the total score of 7-84, where higher score indicated higher social support. The Cronbach\u0026rsquo;s alpha of MSPSS in this study was 0.93.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCaregiver burden\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData on caregivers\u0026rsquo; burden were collected using the 22-item validated Malay version of the Zarit Burden Interview [40]. The instrument was rated on a 5-point Likert scale ranging from 0 (Never) to 4 (Nearly Always), with the total score ranging from 0 to 88. Higher score indicates higher level of burden, with a cut off value of \u0026gt;21. Cronbach\u0026rsquo;s alpha value of the scale in this study was reported as 0.92, indicating good internal consistency and reliability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOutcome measures\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCaregiver quality of life\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCaregiver\u0026rsquo;s QoL was assessed using the validated Malay version of Control, Autonomy, Self-Realization, and Pleasure (CASP-19) scale [41] which includes 19-items assessing 4 domains: control (4-items), autonomy (5-items), self-realization (5 items) and pleasure (5-items). Responses are rated on a 4-point Likert scale ranging from never to often (0-3), with a maximum total score of 57. Higher score represents greater QoL. Cronbach\u0026rsquo;s alpha of the scale in this study was 0.88 and 0.91 at baseline and endline, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCaregiver anxiety symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCaregiver\u0026rsquo;s anxiety symptoms were assessed using the anxiety subscale of the validated Malay version of the Hospital Anxiety and Depression Scale (HADS) [42]. The anxiety subscales consist of 7 items, scored from 0-3 on each item, the total score being 0 to 21. Higher score indicates higher anxiety symptoms. In our study, the Cronbach`s alpha demonstrated good reliability of 0.84 at baseline and 0.83 at endline.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eBivariate analyses, such as independent t-test, Chi-square test and Fisher\u0026rsquo;s exact test were conducted to compare the baseline characteristics between the intervention and control groups. \u0026nbsp;Mixed ANOVA analysed the mean differences of FCs\u0026rsquo; QoL within the groups (baseline vs. post-intervention), between groups (intervention vs. control groups) and the net gain effect of intervention on QoL. \u0026nbsp;Intention-to-treat (ITT) analysis using linear mixed-model for repeated measures was performed to determine the independent effect of the intervention on QoL. ITT included full samples regardless of whether they adhered to or withdrew from the assigned treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo \u0026nbsp; examine whether caregiver burden mediated the relationship between intervention and, QoL and anxiety symptoms, a four-step method by Baron and Kenny [43] via multiple regression analysis was used. The first step examined the relationship between the intervention (independent variable) and QoL or anxiety symptoms (dependent variables), which is known as Path C (See figure 3). In the second step, the intervention was regressed on the caregiver burden (mediator) (Path A). The third step is the relationship between the mediator, that is caregiver burden and i) QoL or ii) anxiety symptoms (Path B), and the final step examined the direct effect of telephone-based intervention on QoL or anxiety symptoms with the simultaneous entry of burden (Path C\u0026rsquo;). Four criteria must be met in order to establish mediation using the regression analysis: paths A, B and C must be significant, while path C\u0026acute; should be either less significant (indicating partial mediation) or non-significant (indicating full mediation) compared to path C. Separate multiple linear models was analysed for each subscale of social support due to high multi-collinearity between the subscales. A p-value of \u0026lt;0.05 shows the mediation effect is statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eResponse Rate and Adherence to the Intervention\u003c/h2\u003e\n\u003cp\u003eA total of 121 FCs were enrolled in the study. Of these, 60 FCs were randomised to the intervention group and 61 FCs to the control group. During the course of the study, the attrition rate recorded was 13.2% (16 FCs) of which 9.1% (11 FCs) was from the intervention group, and 4.1% (5 FCs) from the control group. As a result, 86.8% (105 FCs) completed both the baseline and endline assessments in the study.\u003c/p\u003e\n\u003ch2\u003eBaseline Characteristics of the Participants\u003c/h2\u003e\n\u003cp\u003eBaseline characteristics of participating FCs and PWD are presented in Table 2. More than half of the FCs were women (69%), Muslim (67%), married (74%), employed (54%) and had low household income (56%). Except for participants’ gender and dyadic relationships, no significant differences on any other characteristics between the intervention and control groups were found. Significantly more women and adult children were found as primary caregiver in the intervention group compared to the control group. Regarding health-related conditions, a higher prevalence of chronic morbidities, such as hypertension, diabetes or arthritis, was observed among FCs in the intervention group compared to those in the control group. The two groups had similar mean scores on social support and QoL at baseline. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean age of the PWD between intervention and control group was comparable (M=75 years in intervention group and M=76 years in control group). In terms of gender distribution, most of the PWD in this study were women (63%). The proportion of PWD who were able to perform self-care was similar across both groups. No significant difference was observed on demographic characteristics of PWD between intervention and control groups (data not shown).\u003c/p\u003e\n\u003cp\u003eInsert Table 2\u003c/p\u003e\n\u003ch2\u003eIntervention Effects\u003c/h2\u003e\n\u003cp\u003eThere were no significant changes in mean score of QoL from baseline to post-intervention and between intervention and control groups (Table 3, Figure 2). However, the interaction between participation in intervention and time showed a positive gain score of 5.02 in QoL indicating that there was an increased score of 5.02 in QoL after receiving the intervention with a moderate effect size of 0.11.\u003c/p\u003e\n\u003cp\u003eInsert Table 3\u003c/p\u003e\n\u003cp\u003eInsert Figure 2\u003c/p\u003e\n\u003cp\u003eAn intention-to-treat analysis using a linear mixed model for repeated measures was conducted to evaluate the independent effect of intervention on QoL over time while controlling the covariates, such as FC’s gender, religion, comorbidity, household income and their relationship with the PWD (Table 4). Neither the intervention nor the time had any effect on QoL independently. However, interaction between intervention and time showed a significant effect revealed that the score of QoL among FCs in the intervention group (IG) increased by 5.00 units from T0 (baseline) to T1 (post-intervention) (β=5.00, 95% CI 2.21 – 7.78, p=0.001) compared to the control group (CG).\u003c/p\u003e\n\u003cp\u003eInsert Table 4\u003c/p\u003e\n\u003ch2\u003eMediation Analysis\u003c/h2\u003e\n\u003cp\u003eA series of linear regression analyses were conducted to examine the mediating role of caregiver burden on the association between the telephone-based intervention and QoL. Results showed that path C was significant, (B = 3.794, SE= 1.410, p= 0.008), indicating that the telephone-based intervention had a positive association with QoL before considering the mediator. In the second step (path A), the telephone-based intervention was negatively associated with caregiver burden (B = -7.090, SE= 1.848, p\u0026lt;0.001), indicating reduction in caregiver burden. In the third step, caregiver burden was negatively associated with QoL (B = -0.203, SE= 0.042, p\u0026lt;0.001) (Path B). In the final step, when the caregiver burden was controlled for in the linear regression model, direct effect of telephone-based intervention on QoL (Path C’) was reduced and lost statistical significance (B = 2.330, SE= 1.341, p= 0.085). The reduction and non-significant effect of the telephone-based intervention on QoL suggested that caregiver burden mediated the effect of the intervention on QoL (Table 5).\u003c/p\u003e\n\u003cp\u003eInsert Table 5\u003c/p\u003e\n\u003cp\u003eMediation analysis further revealed that caregiver burden also mediated the relationship between the telephone-based intervention and anxiety symptoms. In line with the first criterion, the intervention demonstrated a significant effect on FCs’ anxiety symptoms (B = -1.801, SE= 0.640, p=0.006) (Path C). Similarly, in path B, FCs’ burden also showed a significant direct association with anxiety symptoms (B = 0.095, SE= 0.020, p\u0026lt;0.001). When caregiver burden was included as mediator in the regression model (Path C’), the direct effect of the telephone-based intervention on anxiety symptoms became non-significant (B = -1.021, SE= 0.626, p=106) (Table 5). The full mediation pathway of the relationship between intervention, and anxiety symptoms and QoL, with caregiver burden as mediator is illustrated in Figure 3.\u003c/p\u003e\n\u003cp\u003eInsert Figure 3\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study demonstrated that the telephone-based intervention had a significant effect in improving QoL among FCs of PWD. The effectiveness in reducing caregiver burden, anxiety symptoms and psychological distress was reported in a previous study [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Additionally, the results of the current study showed that caregiver burden mediates the effect of the telephone-based intervention on QoL and anxiety symptoms, suggesting that the intervention reduces anxiety and improves QoL directly and indirectly through the reduction of caregiver burden.\u003c/p\u003e\u003cp\u003eThese findings are consistent with previous studies conducted in Germany [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] which showed a 24% overall improvement in FC\u0026rsquo;s QoL. A randomised controlled trial in Italy [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], found that a telephone-based psychological intervention had a positive effect on caregiver burden, post-traumatic stress symptoms and depression after 4-weeks\u0026rsquo; intervention period, however QoL outcomes were not reported. In contrast, the telephone-based intervention in the current study in Malaysia did not show a significant effect on depression, but was effective in improving other outcomes such as anxiety, caregiver burden and psychological distress after the 14-weeks intervention [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCompared to the smaller effect size on QoL reported by Risch et al. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], this study shows a moderate effect size, which might be attributed to variations in both the type and duration of the intervention. Risch et al. [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] employed psychotherapeutic intervention over a period of 8-weeks, which may have limited the intervention\u0026rsquo;s impact on QoL. However, the study shows a significant improvement on caregiver\u0026rsquo;s QoL in physical health but not mental health. In relation to the delivery method of the intervention, Topfler and Meishcner [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] have shown that telephone-based cognitive behavioural therapy (TEL-CBT) had positive impact on caregivers` QoL and their ability to cope with caregiving situations. The results enhance flexibility benefits for telephone-based intervention with reduction of facility usage and costs in terms of transportation for both FCs and healthcare providers.\u003c/p\u003e\u003cp\u003ePrevious literature indicates that caregivers` mental health is associated with increased emotional and physical burden [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. By targeting caregiver burden through telephone-based intervention, FCs may regain emotional stability and develop internal resilience, which in turn enhance their capacity to provide sustained care and improve their QoL and anxiety symptoms. As reported by L\u0026oacute;pez-Mart\u0026iacute;nez et al. [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], caregiver burden shows mediating effect of the association between coping responses and caregiver\u0026rsquo;s anxiety symptoms. Although the intervention in the present study was delivered via telephone, it also included several coping components, such as problem-solving engagements, building a positive mindset and emotional regulation strategies. In a cross-sectional study in China, social support was found as the mediating role between caregiver burden and QoL in FCs of PWD. These findings show that social support can influence how caregiver burden impacts FCs of PWD\u0026rsquo;s overall well-being [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Other research by Srivastava et al. [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], identified a negative association between caregiver burden and QoL, suggesting that burden may moderate the effectiveness of psychotherapy interventions aimed at enhancing QoL. However, this moderating effect was not empirically tested within the study.\u003c/p\u003e\u003cp\u003eIn Malaysia, where mental health services for PWD and their caregivers are still evolving in terms of accessibility and cultural acceptance, this study contributes to the local evidence base by highlighting a community-centred approach to mental healthcare. Furthermore, it aligns with the government\u0026rsquo;s Health Research Priorities for 12th Malaysia Plan 2021\u0026ndash;2025 on mental health promotion and supports the SDG 3, highlighting good health and well-being by focusing on both preventive and responsive care.\u003c/p\u003e\u003cp\u003eA systematic review by Moyle [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], suggests that the benefits of telephone-based interventions might decline after 6-months. In Italy, De Stefeno et al. [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] found that the benefits of a four-week telephone-based psychological intervention had disappeared by the six-month follow-up. To enhance the sustainability of such interventions, researchers and clinicians should continuously include flexible adaptations, such as ad-hoc counselling options and periodic booster sessions, to maintain long-term effectiveness [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Future research should consider the long-term impact of interventions and how the intervention can be sustained over time. Despite concern about long-term sustainability of interventions, some studies reported encouraging outcome after 6-month treatment where FCs who received telephone-based intervention were found to have lower overall pre-death grief, fewer physical symptoms such as less rheumatic pain and higher acceptance of loss of their loved one with dementia [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA key strength of this study lies in its contribution to understanding the psychological mechanisms through which telephone-based interventions influence outcomes. All measurement instruments used for data collection were locally validated, enhancing the cultural relevance and the validity of the results. However, it is important to acknowledge several possible limitations. First, the specific stages of dementia of the PWD were not classified as FCs of persons across all stages of dementia, mild, moderate and severe, were included in the study. FCs who care for PWD with moderate to severe stages experienced greater physical and psychological burden due to behavioural changes and higher dependency on daily routines [\u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Additionally, both healthcare providers and FCs might have faced challenges in scheduling intervention sessions, which could have led to delays, increased stress and inconsistencies in the delivery of the intervention.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this research demonstrates that the telephone-based interventions can effectively improve QoL among FCs of PWD, with caregiver burden playing a significant mediating role in the relationship between the intervention and anxiety symptoms as well as QoL. By understanding the underlying mechanisms, it not only strengthens theoretical clarity, but also facilitates the development of more effective interventions to address the comprehensive needs of FCs to PWDs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePWD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePersons with dementia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRandomised control trial\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFCs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFamily caregivers\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQoL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality of life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntervention group\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCASP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eControl, Autonomy, Self-Realization and Pleasure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eITT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntention-to-treat\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eResearch Assistant\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDOSM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDepartment of Statistics Malaysia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMPSS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMultidimensional Scale of Perceived Social Support\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTEL-CBT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTelephone-based cognitive behavioural therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSDG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSustainable development goal\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approval and consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Malaysia Medical Research and Ethics Committee [NMRR-22-00137-BUY(IRR)], the IIUM Research Ethics committee [IREC 2022-007] and the Research Ethics committee of Universiti Kebangsaan Malaysia [UKM PPI/111/8/JEP-2022-328]. Informed consent was obtained after providing detailed information about the purpose and type of the study, interventions, procedures and protocols, and risks as well as benefits for participating in the project. The intervention may introduce some stress or anxiety as it affects participant\u0026rsquo;s schedule-works. However, higher dose of flexibility to adjust participants\u0026rsquo; time for delivering the intervention may minimize those risks. The participants were ensured anonymity and confidentiality of their data. The research was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe dataset generated and analysed during the current study are not publicly available due to confidentiality issues but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eAll authors declare that there are no personal, organizational, or financial conflicts of interest.\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eHashima E Nasreen (H.E.N.) was the principal investigator in this study and primarily conceptualized the research. H.E.N., Zarina Nahar Kabir (Z.N.K.), Mohd Aznan Md Aris (M.A.M.A.), and Karimah Hanim Abd Aziz (K.H.A.A.) participated in the planning and conception of the research questions. . Nora Mat Zin (N.M.Z.) helped implementing the telephone-intervention for the family caregivers of PWD. Syarifah Amirah binti Syed Ahmad (S.A.B.S.A.) involved in data collection of the study. H.E.N. and S.A.B.S.A. analysed the data. S.A.B.S.A. drafted the manuscript, while H.E.N., Z.N.K., Marie Tyrell (M.T.) and S.A.B.S.A. critically reviewed and revised the manuscript for important intellectual content. All authors read and approved the final version of the manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the healthcare staff involved in delivering the intervention to the family caregivers to PWD. We also express our gratitude to all family caregivers to PWD who participated in the study for their time, energy and support throughout the projects. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; information\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHashima E Nasreen, MBBS, MPH, PhD, Associate Professor of Epidemiology, Department of Community Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia\u003c/p\u003e\n\u003cp\u003eSyarifah Amirah Binti Syed Ahmad, Candidate for Doctor of Philosophy in Health Science, Department of Community Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia\u003c/p\u003e\n\u003cp\u003eZarina Nahar Kabir, PhD, Associate Professor of Public Health and Principal Researcher, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden\u003c/p\u003e\n\u003cp\u003eKarimah Hanim Abd Aziz, MD, DrPH, Assistant Professor, Department of Community Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia\u003c/p\u003e\n\u003cp\u003eNora Mat Zin, MD, MMeD, Associate Professor, Department of Psychiatry, Faculty of Medicine, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia\u003c/p\u003e\n\u003cp\u003eMohd Aznan Md Arid, MBBS, MMeD, Professor, Department of Family Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia\u003c/p\u003e\n\u003cp\u003eMarie Tyrrell, Associate Professor, Sophiahemmet H\u0026ouml;gskola, Valhallav\u0026auml;gen, Stockholm, Sweden\u003cstrong\u003e\u003cbr\u003e \u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organization. Global status report on the public health response to dementia. Geneva: World Health Organization. 2021;251. Available from: https://digitalcommons.fiu.edu/cgi/viewcontent.cgi?article=1962\u0026amp;context=srhreports\u003c/li\u003e\n \u003cli\u003eQi S, Yin P, Zhang H, Zhang Q, Xiao Y, Deng Y, et al. Prevalence of Dementia in China in 2015: A Nationwide Community-Based Study. Front Public Health. 2021 Nov 2;9.\u003c/li\u003e\n \u003cli\u003eYin Y, Tam HL, Quint J, Chen M, Ding R, Zhang X. Epidemiology of Dementia in China in 2010\u0026ndash;2020: A Systematic Review and Meta-Analysis. Healthcare (Switzerland). 2024;12(3):334.\u003c/li\u003e\n \u003cli\u003eLee J, Meijer E, Langa KM, Ganguli M, Varghese M, Banerjee J, et al. Prevalence of dementia in India: National and state estimates from a nationwide study. Alzheimer\u0026rsquo;s \u0026amp; Dementia. 2023;19(7):2898\u0026ndash;912.\u003c/li\u003e\n \u003cli\u003eAlzheimer Disease Foundation. Dementia cases set to rise 312 per cent by 2050: Is Malaysia prepared? . Available from: https://www.adfm.org.my/dementia-cases-set-to-rise-312-per-cent-by-2050-is-malaysia-prepared/\u003c/li\u003e\n \u003cli\u003eCaputo A. The emotional experience of caregiving in dementia: Feelings of guilt and ambivalence underlying narratives of family caregivers. Dementia. 2021;20(7):2248\u0026ndash;60.\u003c/li\u003e\n \u003cli\u003eTu JY, Jin G, Chen JH, Chen YC. Caregiver Burden and Dementia: A Systematic Review of Self-Report Instruments. Journal of Alzheimer\u0026rsquo;s Disease. 2022;86(4):1527\u0026ndash;43; doi:10.3233/JAD-215082\u003c/li\u003e\n \u003cli\u003eDuangjina T, Hershberger PE, Gruss V, Fritschi C. Resilience in family caregivers of Asian older people with dementia: An integrative review. J Adv Nurs. 2024;81(1):156\u0026ndash;70; doi:10.1111/jan.16272\u003c/li\u003e\n \u003cli\u003eNg CKM, Leung DKY, Cai X, Wong GHY. Perceived Help-Seeking Difficulty, Barriers, Delay, and Burden in Carers of People with Suspected Dementia. International Journal of Environmental Research and Public Health. 2021;18(6):2956.\u003c/li\u003e\n \u003cli\u003eChan CY, Cheung G, Martinez-Ruiz A, Chau PYK, Wang K, Yeoh EK, et al. Caregiving burnout of community-dwelling people with dementia in Hong Kong and New Zealand: a cross-sectional study. BMC Geriatr. 2021;21(1):1\u0026ndash;15; doi:10.1186/s12877-021-02153-6\u003c/li\u003e\n \u003cli\u003eHwang Y, Kim J. Influence of caregivers\u0026rsquo; psychological well-being on the anxiety and depression of care recipients with dementia. Geriatr Nurs. 2024;55:44\u0026ndash;51.\u003c/li\u003e\n \u003cli\u003eWang S, Huang Y, Fan AYN, Ho MH, Davidson PM. Factors influencing the psychosocial well-being of people with dementia and their informal caregivers: A systematic review of dyadic studies. Int J Ment Health Nurs. 2024;33(3):560\u0026ndash;81; doi:10.1111/inm.13279\u003c/li\u003e\n \u003cli\u003eAng JP; K;, Koh EBY;, Pang NTP;, Mat Saher Z, Pin Tan K, Kiat Ang J, et al. Relationship of Psychological Flexibility and Mindfulness to Caregiver Burden, and Depressive and Anxiety Symptoms in Caregivers of People with Dementia. International Journal of Environmental Research and Public Health. 2023;20(5):4232. Available from: https://www.mdpi.com/1660-4601/20/5/4232/htm\u003c/li\u003e\n \u003cli\u003eNasreen HE, Tyrrell M, Vikstr\u0026ouml;m S, Craftman \u0026Aring;, Syed Ahmad SAB, Zin NM, et al. Caregiver burden, mental health, quality of life and self-efficacy of family caregivers of persons with dementia in Malaysia: baseline results of a psychoeducational intervention study. BMC Geriatr. 2024;24(1):1\u0026ndash;12; doi:10.1186/s12877-024-05221-9\u003c/li\u003e\n \u003cli\u003eKai I, Ohi G, Kobayashi Y, Ishizaki T, Hisata M, Kiuchi M. Quality of life: a possible health index for the elderly. Asia-Pacific journal of public health / Asia-Pacific Academic Consortium for Public Health. 1991;5(3):221\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eRizal Abdul Manaf M, Helma Firdaus M, Fairuz Md Teridi N. Introduction Quality of Life and its associated factors among Patient with Dementia Caregivers: A Cross-Sectional Study in Geriatric Clinic, Hospital Kuala Lumpur, Malaysia. 2024.\u003c/li\u003e\n \u003cli\u003eHu YL, Chang CC, Lee CH, Liu CH, Chen YJ, Su JA, et al. Associations between Affiliate Stigma and Quality of Life among Caregivers of Individuals with Dementia: Mediated Roles of Caregiving Burden and Psychological Distress. Asian Journal of Social Health and Behavior. 2023;6(2):64\u0026ndash;71.\u003c/li\u003e\n \u003cli\u003eContreras ML, Mioshi E, Kishita N. Factors Related to the Quality of Life in Family Carers of People With Dementia: A Meta-Analysis. J Geriatr Psychiatry Neurol. 2021;34(5):482\u0026ndash;500. Available from: https://pubmed.ncbi.nlm.nih.gov/32394770/\u003c/li\u003e\n \u003cli\u003eCanevelli M, Bruno G, Cesari M. Providing Simultaneous COVID-19\u0026ndash;sensitive and Dementia-Sensitive Care as We Transition from Crisis Care to Ongoing Care. J Am Med Dir Assoc. 2020;21(7):968.\u003c/li\u003e\n \u003cli\u003eCuffaro L, Di Lorenzo F, Bonavita S, Tedeschi G, Leocani L, Lavorgna L. Dementia care and COVID-19 pandemic: a necessary digital revolution. Neurological Sciences. 2020;41(8):1977\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eFarkhondeh V, Decarli C. White matter hyperintensities in diverse populations: A systematic review of literature in the United States. Cereb Circ Cogn Behav. 2024;6:100204; doi:10.1016/j.cccb.2024.100204\u003c/li\u003e\n \u003cli\u003ePaplikar A, Rajagopalan J, Alladi S. Care for dementia patients and caregivers amid COVID-19 pandemic. Cereb Circ Cogn Behav. 2022;3:100040.\u003c/li\u003e\n \u003cli\u003eQuail Z, Bolton L, Massey K. Digital delivery of non-pharmacological intervention programmes for people living with dementia during the COVID-19 pandemic. BMJ Case Reports CP. 2021;14(6):e242550.\u003c/li\u003e\n \u003cli\u003eDombestein H, Norheim A, Aase K. How to stay motivated: A focus group study of Norwegian caregivers\u0026rsquo; experiences with community healthcare services to their parents with dementia. Health Soc Care Community. 2022;30(1):235\u0026ndash;43; doi:10.1111/hsc.13396\u003c/li\u003e\n \u003cli\u003eSadavoy J, Sajedinejad S, Chiu M. A quasi-experimental study of the effectiveness of the Reitman Centre CARERS group intervention on family caregivers of persons with dementia. Int J Geriatr Psychiatry. 2021;36(6):811\u0026ndash;21; doi:10.1002/gps.5481\u003c/li\u003e\n \u003cli\u003eFossey J, Charlesworth G, Fowler JA, Frangou E, Pimm TJ, Dent J, et al. Online Education and Cognitive Behavior Therapy Improve Dementia Caregivers\u0026rsquo; Mental Health: A Randomized Trial. J Am Med Dir Assoc. 2021 Jul 1 [cited 2025;22(7):1403-1409.\u003c/li\u003e\n \u003cli\u003eBaruah U, Loganathan S, Shivakumar P, Pot AM, Mehta KM, Gallagher-Thompson D, et al. Adaptation of an online training and support program for caregivers of people with dementia to Indian cultural setting. Asian J Psychiatr. 2021;59:102624.\u003c/li\u003e\n \u003cli\u003eRamirez M, Duran MC, Pabiniak CJ, Hansen KE, Kelley A, Ralston JD, et al. Family Caregiver Needs and Preferences for Virtual Training to Manage Behavioral and Psychological Symptoms of Dementia: Interview Study. JMIR Aging. 2021;4(1):e24965.\u003c/li\u003e\n \u003cli\u003eWen Y, Xing Y, Ding Y, Xu W, Wang X. Challenges of conducting of online educational programs for family caregivers of people with dementia living at home: An integrative review. Int J Nurs Sci. 2023;10(1):121\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003ePossin KL, Sideman AB, Dulaney S, Lee K, Merrilees J, Bonasera S, et al. The Care Ecosystem: The Effectiveness and Implementation of Telephone-Based Collaborative Dementia Care. Alzheimer\u0026rsquo;s \u0026amp; Dementia. 2022;18(S9):e063938; doi:10.1002/alz.063938\u003c/li\u003e\n \u003cli\u003eWang Y, Xiao LD, Yu Y, Huang R, You H, Liu M. An individualized telephone-based care support program for rural family caregivers of people with dementia: study protocol for a cluster randomized controlled trial. BMC Geriatr. 2021;21(1):1\u0026ndash;11; doi:10.1186/s12877-021-02575-2\u003c/li\u003e\n \u003cli\u003eKwok T, Wong B, Ip I, Chui K, Young D, Ho F. Telephone-delivered psychoeducational intervention for Hong Kong Chinese dementia caregivers: A single-blinded randomized controlled trial. Clin Interv Aging. 2013;8:1191\u0026ndash;7; doi:10.2147/CIA.S48264\u003c/li\u003e\n \u003cli\u003eTremont G, Davis JD, Papandonatos GD, Ott BR, Fortinsky RH, Gozalo P, et al. Psychosocial telephone intervention for dementia caregivers: A randomized, controlled trial. Alzheimer\u0026rsquo;s \u0026amp; Dementia. 2015;11(5):541\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eMeichsner F, T\u0026ouml;pfer NF, Reder M, Soellner R, Wilz G. Telephone-Based Cognitive Behavioral Intervention Improves Dementia Caregivers\u0026rsquo; Quality of Life. Am J Alzheimers Dis Other Demen. 2019;34(4):236\u0026ndash;46.\u003c/li\u003e\n \u003cli\u003edel-Pino-Casado R, Priego-Cubero E, L\u0026oacute;pez-Mart\u0026iacute;nez C, Orgeta V. Subjective caregiver burden and anxiety in informal caregivers: A systematic review and meta-analysis. PLoS One. 2021;16(3):e0247143.\u003c/li\u003e\n \u003cli\u003eHan A. Effects of Mindfulness-Based Interventions on Depressive Symptoms, Anxiety, Stress, and Quality of Life in Family Caregivers of Persons Living with Dementia: A Systematic Review and Meta-analysis. Res Aging. 2022;44(7\u0026ndash;8):494\u0026ndash;509; doi:10.1177/01640275211043486?download=true\u003c/li\u003e\n \u003cli\u003eTremont G, Davis J, Papandonatos GD, Grover C, Ott BR, Fortinsky RH, et al. A telephone intervention for dementia caregivers: Background, design, and baseline characteristics. Contemp Clin Trials. 2013;36(2):338\u0026ndash;47.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. iSupport for dementia: Training and support manual for carers of people with dementia. 2018.\u003c/li\u003e\n \u003cli\u003eNg CG, Nurasikin MS, Loh HS, Anne Yee HA, Zainal NZ. Factorial validation of the Malay version of multidimensional scale of perceived social support among a group of psychiatric patients. Malaysian Journal of Psychiatry. 2012;21(2):17-26.\u003c/li\u003e\n \u003cli\u003eShim VK, Ng CG, Drahman I. Validation of the Malay version of Zarit burden interview (MZBI). Malaysian Journal of Psychiatry. 2017;26(2):3-18.\u003c/li\u003e\n \u003cli\u003eNalathamby N, Morgan K, Mat S, Tan PJ, Kamaruzzaman SB, Tan MP. Validation of the CASP-19 Quality of Life Measure in Three Languages in Malaysia. Journal of Tropical Psychology. 2017;7:e4.\u003c/li\u003e\n \u003cli\u003eYahya F, J ZOIM, 2015 undefined. Validation of the Malay version of hospital anxiety and depression scale (HADS) in Hospital Universiti Sains Malaysia. 2015;22(2):80\u0026ndash;2.\u003c/li\u003e\n \u003cli\u003eBaron RM, Kenny DA. The Moderator-Mediator Variable Distinction in Social Psychological Research. Conceptual, Strategic, and Statistical Considerations. J Pers Soc Psychol. 1986 Dec;51(6):1173\u0026ndash;82.\u003c/li\u003e\n \u003cli\u003eAhmad SABS, Kabir ZN, Tyrrell M, Craftman \u0026Aring;, Nasreen HE. Efficacy of a Telephone-Intervention on Caregiving Burden and Mental Health among Family Caregivers of Persons with Dementia in Malaysia: A Randomized Controlled Trial. International Journal of Environmental Research and Public Health. 2024;21(10):1354.\u003c/li\u003e\n \u003cli\u003eDe Stefano M, Esposito S, Iavarone A, Carpinelli Mazzi M, Siciliano M, Buonanno D, et al. Effects of Phone-Based Psychological Intervention on Caregivers of Patients with Early-Onset Alzheimer\u0026rsquo;s Disease: A Six-Months Study during the COVID-19 Emergency in Italy. Brain Science. 2022;12(3):310.\u003c/li\u003e\n \u003cli\u003eRisch AK, Lechner-Meichsner F, Wilz G. Telephone-Based Acceptance and Commitment Therapy for Caregivers of Persons with Dementia: Results of a Randomized Controlled Trial. Clin Gerontol [Internet]. 2024 Oct 21 [cited 2025 Jun 28]; Available from: https://www.tandfonline.com/doi/pdf/10.1080/07317115.2024.2393307\u003c/li\u003e\n \u003cli\u003eT\u0026ouml;pfer NF, Wrede N, Theurer C, Wilz G. Face-to-face versus telephone-based cognitive-behavioral therapy for family caregivers of people with dementia. J Clin Psychol. 2023;79(10):2270\u0026ndash;87; doi:10.1002/jclp.23538\u003c/li\u003e\n \u003cli\u003eMeichsner F, T\u0026ouml;pfer NF, Reder M, Soellner R, Wilz G. Telephone-Based Cognitive Behavioral Intervention Improves Dementia Caregivers\u0026rsquo; Quality of Life. Am J Alzheimers Dis Other Demen. 2019;34(4):236\u0026ndash;46; doi:10.1177/1533317518822100\u003c/li\u003e\n \u003cli\u003eVrettos I, Anagnostopoulos F, Voukelatou P, Panayiotou S, Kyvetos A, Nikas A, et al. Factors associated with health-related quality of life of informal caregivers of older patients and the mediating role of subjective caregivers\u0026rsquo; burden. Psychogeriatrics. 2023;23(2):286\u0026ndash;97; doi;10.1111/psyg.12930\u003c/li\u003e\n \u003cli\u003eL\u0026oacute;pez-Mart\u0026iacute;nez C, Orgeta V, Fr\u0026iacute;as-Osuna A, del-Pino-Casado R. Coping and anxiety symptoms in family carers of dependent older people: Mediation and moderation effects of subjective caregiver burden. Journal of Nursing Scholarship. 2024;56(3):371\u0026ndash;81; doi:10.1111/jnu.12957\u003c/li\u003e\n \u003cli\u003eSrivastava G, Tripathi RK, Tiwari SC, Singh B, Tripathi SM. Caregiver burden and quality of life of key caregivers of patients with dementia. Indian J Psychol Med. 2016;38(2):133\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eBartels SL, van Knippenberg RJM, K\u0026ouml;hler S, Ponds RW, Myin-Germeys I, Verhey FRJ, et al. The necessity for sustainable intervention effects: lessons-learned from an experience sampling intervention for spousal carers of people with dementia. Aging Ment Health. 2020;24(12):2082\u0026ndash;93; doi:10.1080/13607863.2019.1647130\u003c/li\u003e\n \u003cli\u003eTay RY, Tan JYS, Hum AYM. Factors Associated With Family Caregiver Burden of Home-Dwelling Patients With Advanced Dementia. J Am Med Dir Assoc. 2022;23(7):1248\u0026ndash;56.\u003c/li\u003e\n \u003cli\u003eGarc\u0026iacute;a-Mart\u0026iacute;n V, de Hoyos-Alonso MC, Delgado-Puebla R, Ariza-Cardiel G, del Cura-Gonz\u0026aacute;lez I. Burden in caregivers of primary care patients with dementia: influence of neuropsychiatric symptoms according to disease stage (NeDEM project). BMC Geriatr. 2023;23(1):1\u0026ndash;12; doi:10.1186/s12877-023-04234-0\u003c/li\u003e\n \u003cli\u003eOzcan M, Akyar İ. Caregivers\u0026rsquo; experiences of patients with moderate-stage Alzheimer\u0026rsquo;s disease: a qualitative study. Psychogeriatrics. 2021;21(5):763\u0026ndash;72; doi:10.1111/psyg.12736\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Topics and contents included in \u0026ldquo;My Caregiver Booklet\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"676\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSessions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTopics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eSession 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003eIntroduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003eRapport building, risk appraisal, challenges and positive aspects of caregiving\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eSession 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003eIntroduction to dementia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003eInformation about dementia: types, stages and challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eSession 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003eBeing a family caregiver I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003eSupport caregivers to understand their role as caregivers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eSession 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003eBeing a family caregiver II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003eCoach caregivers on utilization of accessible tools and strategies for their recreation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eSession 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003eMental strategies and mind-set\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003eAssist the caregivers about mental strategies and ways of thinking\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eSession 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003eFree choice of topic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003eTopic that caregivers themselves felt they wanted to discuss\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eSession 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003eActivities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003eSupport caregivers to utilise activities strategically\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eSession 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003eBehavioural and psychological symptoms in dementia (BPSD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003eHelp caregivers to manage BPSD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eSession 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003eEat and sleep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003eHelp caregivers to identify appropriate strategies to solve problems related to eating and sleeping\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eSession 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003eContinued resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 372px;\"\u003e\n \u003cp\u003eEncourage to utilise the existing support system in the family, community and the government system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 2. Baseline characteristics of family caregivers and persons with dementia\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en = 121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003cp\u003en = 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003en = 61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003eBACKGROUND VARIABLES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily caregivers\u0026rsquo; socioeconomic characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eAge (years), Mean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e51.6 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e50.1 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e53.1 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.185\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eGender (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003cp\u003e69.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003cp\u003e81.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42.6\u003c/p\u003e\n \u003cp\u003e57.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eReligion (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003cp\u003eNon-Muslim\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e66.9\u003c/p\u003e\n \u003cp\u003e33.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e75.0\u003c/p\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59.0\u003c/p\u003e\n \u003cp\u003e41.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.057\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eEducation (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003cp\u003eSecondary\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003cp\u003e39.7\u003c/p\u003e\n \u003cp\u003e47.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15.0\u003c/p\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e51.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003cp\u003e45.9\u003c/p\u003e\n \u003cp\u003e42.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.365\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eMarital status (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eUnmarried\u003c/p\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDivorced/widowed\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003cp\u003e73.6\u003c/p\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003cp\u003e71.7\u003c/p\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18.0\u003c/p\u003e\n \u003cp\u003e75.4\u003c/p\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eOccupation (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003cp\u003eHomemaker/unemployed\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRetired\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e54.5\u003c/p\u003e\n \u003cp\u003e35.5\u003c/p\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e45.0\u003c/p\u003e\n \u003cp\u003e43.3\u003c/p\u003e\n \u003cp\u003e11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63.9\u003c/p\u003e\n \u003cp\u003e27.9\u003c/p\u003e\n \u003cp\u003e8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.111\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMonthly HH income (RM)*, (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003elow income (\u0026lt;RM4581)\u003cbr\u003e\u0026nbsp;middle income (RM4581-RM10959)\u003c/p\u003e\n \u003cp\u003ehigh income (\u0026gt;RM10959)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e56.2\u003cbr\u003e\u0026nbsp;35.5\u003cbr\u003e\u0026nbsp;8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;60\u003cbr\u003e\u0026nbsp;31.7\u003cbr\u003e\u0026nbsp;8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;52.5\u003cbr\u003e\u0026nbsp;39.3\u003cbr\u003e\u0026nbsp;8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.667\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eComorbidities (%)\u003c/em\u003e\u003cbr\u003e\u0026nbsp;Yes\u003cbr\u003e\u0026nbsp;No\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;55.2\u003cbr\u003e\u0026nbsp;44.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;67.3\u003cbr\u003e\u0026nbsp;32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e44.6\u003cbr\u003e\u0026nbsp;55.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiving information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eLength of caregiving (months), Mean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e47.9 (42.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e40.7 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e55.1 (49.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eHours of caregiving/day, Mean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e18.6 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e18.8 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e18.4 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.800\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eShared caregiving by other family members (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e60.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e56.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e63.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.414\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eRelationship with person with dementia (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eSpouse\u003c/p\u003e\n \u003cp\u003eAdult child\u003c/p\u003e\n \u003cp\u003eIn-laws\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27.3\u003c/p\u003e\n \u003cp\u003e62.8\u003c/p\u003e\n \u003cp\u003e9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21.7\u003c/p\u003e\n \u003cp\u003e73.3\u003c/p\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32.8\u003c/p\u003e\n \u003cp\u003e52.5\u003c/p\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.041\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial support, Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal Social Support\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e59.3 (17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e58.6 (16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e59.9 (17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.682\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003eFamily support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e21.4 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e21.3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21.5 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.891\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003eFriend support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e16.1 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e16.0 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e16.3 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.844\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003eSignificant other support\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e21.7 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e21.3 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e22.2 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.466\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003eOUTCOME VARIABLES\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiver Burden, Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;11.7 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e12.6 (8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10.8 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.227\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality of Life (QoL), Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e40.6 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e39.4 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e41.7 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.237\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety Symptoms, Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e6.2 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e6.9 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5.5 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*USD 1 = RM4.70 (based on 2022 exchange rate at time of data collection)\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eMixed ANOVA showing mean scores and gain score on QoL by intervention groups (N=105)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"884\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Score (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGain Score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNet Gain Score\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEffect size\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(partial\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eh\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e2)\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT0 (Baseline)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT1 (post-intervention)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality of Life\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e39.43 (10.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e42.86 (10.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e3.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.198\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.02\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(2.20-7.83)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;0.108\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e42.29 (10.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e40.70 (11.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e-2.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.859\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*Gain score= post-intervention score \u0026ndash; baseline score\u003cbr\u003e\u0026nbsp;*Net gain score= gain score (intervention)- gain score (control)\u0026nbsp;\u003cbr\u003e\u0026nbsp;partial\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eh\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e: small effect (\u003c/strong\u003e\u003cstrong\u003eh\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e=0.01 to 0.06), moderate effect (\u003c/strong\u003e\u003cstrong\u003eh\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026gt;0.06 to 0.14), large effect (\u003c/strong\u003e\u003cstrong\u003eh\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026gt;0.14) (Richardson, 20\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Linear mixed model showing the effect of intervention on caregiver\u0026rsquo;s quality of life (N=121).\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eUnadjusted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eAdjusted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003eStd. error\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003eb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eStd. error\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQoL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eIG (ref: CG)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;-2.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e-6.02 \u0026ndash; 1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e-0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-4.43 \u0026ndash; 2.52 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e0.590\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eT1 (ref: T0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e-1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e-3.35 \u0026ndash; 0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e-1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-3.31 \u0026ndash; 0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eIG \u003cimg width=\"11\" height=\"19\" src=\"data:image/png;base64,R0lGODlhCwATAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEABgAKAAkAhAAAAABmtjoAADpmkDpmtjqQkDqQ22YAAGY6AGZmkGZmtma222a2/5A6ANv///+2Zv/bkP//tv//2wECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwUs4EMAJAkpjtQEJSQwZISMLlzKw2GUrcDygMihoOPJdq4FSbUzvQAiICThCAEAOw==\" alt=\"image\"\u003e\u0026nbsp;T1 (ref: CG \u003cimg width=\"11\" height=\"19\" src=\"data:image/png;base64,R0lGODlhCwATAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEABgAKAAkAhAAAAABmtjoAADpmkDpmtjqQkDqQ22YAAGY6AGZmkGZmtma222a2/5A6ANv///+2Zv/bkP//tv//2wECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwUs4EMAJAkpjtQEJSQwZISMLlzKw2GUrcDygMihoOPJdq4FSbUzvQAiICThCAEAOw==\" alt=\"image\"\u003e\u0026nbsp;T0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e4.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2.09 \u0026ndash; 7.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.21 \u0026ndash; 7.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIG: Intervention group, CG: Control group, T0: Baseline, T1: Post-intervention\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Multiple linear regression models with and without caregiver burden as mediator in the association between telephone-based intervention and the outcome variables (Caregiver\u0026rsquo;s QoL and anxiety symptoms).\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003eModel without Caregiver Burden as mediator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eModel with Caregiver Burden as mediator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eB (SE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026beta;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eB (SE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026beta;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eQuality of life\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e3.794\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2.330\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eAnxiety Symptoms\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e-1.801\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e-0.203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e-1.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e-0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Regression analyses were adjusted for caregiver\u0026rsquo;s religion, household income, comorbidity, social support and QoL at baseline.\u003cbr\u003e\u003csup\u003e2\u003c/sup\u003e Regression analyses were adjusted for caregiver\u0026rsquo;s religion, marital status, social support and anxiety symptoms at baseline.\u003c/p\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-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Telephone-based intervention, Quality of life, Family caregiver, Dementia, Mediation analysis","lastPublishedDoi":"10.21203/rs.3.rs-7314107/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7314107/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eFamily caregivers (FCs) of persons with dementia (PWD) are increasingly affected by mental and physical health which leads to poor quality of life (QoL). Telephone-based interventions offer flexible solution to support caregivers of PWD but the effectiveness needs further evaluation. This study aimed to assess the effectiveness of a telephone-based intervention in improving QoL among FCs of PWD and to examine the role of caregiver burden as a mediating factor.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA randomised controlled trial was conducted involving 121 FCs, divided into intervention (n\u0026thinsp;=\u0026thinsp;60) and control (n\u0026thinsp;=\u0026thinsp;61) groups. The intervention group received a 10-week intervention by the healthcare professionals via telephone. Quality of Life were measured using the validated Malay version of Control, Autonomy, Self-Realization and Pleasure (CASP-19) at baseline (T0) and endline (T1). The mean differences of FCs\u0026rsquo; QoL between intervention and control groups, and within baseline (T0) and endline (T1) were analyse using mixed-ANOVA. Intention-to-treat (ITT) analysis was performed to determine the independent effect of the intervention on QoL, and mediation analysis was conducted using the multiple linear regressions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eParticipants in the intervention group showed a statistically significant improvement in QoL (β\u0026thinsp;=\u0026thinsp;5.00, 95% CI 2.21\u0026ndash;7.78, p\u0026thinsp;=\u0026thinsp;0.001). Mediation analysis revealed that caregiver burden mediated the relationship between the telephone-based intervention and QoL. Additionally, reduction of caregiver burden was observed to mediate the relationship between telephone-based intervention and reduced anxiety symptoms.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eTelephone-based intervention shows promising results in improving the QoL among FCs of PWD. Significant mediation effect suggests the importance of targeting FC\u0026rsquo;s caregiver burden for optimal intervention effectiveness.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eISRCTN14565552 (retrospectively registered), registered on 23 September 2023 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.isrctn.com/ISRCTN14565552\u003c/span\u003e\u003cspan address=\"https://www.isrctn.com/ISRCTN14565552\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e","manuscriptTitle":"Telephone-based Intervention Improves Quality of Life Among Family Caregivers of Persons with Dementia in Malaysia: The Mediating Role of Caregiver Burden","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-03 05:06:28","doi":"10.21203/rs.3.rs-7314107/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-14T16:22:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-13T07:34:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5140085303399173584657513851147646475","date":"2025-09-24T07:30:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T19:13:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240274741724606428055004960511047121514","date":"2025-08-25T17:50:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-25T05:40:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-25T04:16:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-22T13:10:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-20T15:36:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-08-20T15:28:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2aa3ed52-9d02-4cac-b726-9ade40467351","owner":[],"postedDate":"September 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:14:23+00:00","versionOfRecord":{"articleIdentity":"rs-7314107","link":"https://doi.org/10.1186/s12877-026-07066-w","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2026-02-12 15:58:24","publishedOnDateReadable":"February 12th, 2026"},"versionCreatedAt":"2025-09-03 05:06:28","video":"","vorDoi":"10.1186/s12877-026-07066-w","vorDoiUrl":"https://doi.org/10.1186/s12877-026-07066-w","workflowStages":[]},"version":"v1","identity":"rs-7314107","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7314107","identity":"rs-7314107","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}