Perceived Caregiver Strain in Carers of Patients Living with Heart Failure in Collectivist Societies

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BUCK This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8870946/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Informal caregivers represent the backbone of community-based Heart Failure management, providing nearly 90% of long-term in-home care. Within the caregiving science framework, they function as primary care partners and essential contributors to dyadic illness management. However, the high care dependency associated with Heart Failure, coupled with limited formal system support, places these caregivers at elevated risk for caregiver burden, role strain, and adverse psychosocial outcomes. The aim of this seconday analysis is to identify predictors of caregiver strain among informal caregivers of patients living with Heart Failure in a collectivist society. Methods 108 patient caregiver who completed questionnaires on caregiver strain, social support, quality of life, caregiving context and needs, caregivers’ appraisal of dyadic relationship quality, and dyadic typology. Bivariate analyses were conducted to examine associations between caregiver strain and relevant sociodemographic, clinical, and relational variables. Variables significant at the bivariate level were subsequently entered into a multivariable linear regression model to identify independent predictors of caregiver strain. Results On average 37.73 ± 50.67 hours were dedicated for caregiving by informal caregivers. In this sample, decreased caregiver strain was associated with increased patient symptomatology while significant association was identified between increased caregiver strain and poor perceived dyadic relationship quality. A higher feeling of being stressed in caregiving, a lower mental quality of life, and a lower caregiver perceived relationship quality explained about 63% of the variance in Caregiver Strain. Conclusion Findings from this study underscore the central role of caregiver strain within the Heart Failure caregiving dyad and highlight the need for systematic assessment of caregiver burden in clinical practice. By proactively identifying caregiver strain and addressing modifiable psychosocial and relational determinants, healthcare professionals can enhance caregiving effectiveness, support adaptive dyadic functioning, and safeguard caregivers’ psychological and physical well-being. Integrating caregiver-focused education on self-care, symptom management, structured discharge planning, and longitudinal follow-up into routine Heart Failure care may promote more sustainable informal caregiving in collectivist contexts. Dyads Informal Caregivers Perceived Caregiver Strain Informal Caregivers Collectivist Societies Background Informal caregivers [ICs] are individuals voluntarily caring for a relative or a friend facing a disease, disability, or any condition requiring particular attention ( 1 ). They provide around 90% of in-home long-term care needed by adults and play a key role in supporting the wellbeing and care of people living with chronic illnesses ( 2 ). Families develop familial homeostasis or a typical dynamic and routine, that is often disrupted when a member of that family is diagnosed with a chronic illness. While taking care of a loved family member could generate feelings of emotional fulfillment and a sense of accomplishment, ICs often face health hurdles and emotional strains of their own ( 3 ). Chronic illness diagnoses alter roles and responsibilities within the family unit and causes feelings of uncertainty, anxiety, depression, resentment, among others ( 4 , 5 ). This is especially true in patients living with Heart Failure [HF] and their ICs. The high care dependency and the lack of formal support for the caregiving role have increased the prevalence of caregiver burden and strain ( 5 ). Studies have demonstrated that HF caregivers experienced reduced quality of life, and caregiving had a negative impact on their physical and emotional health ( 6 – 8 ) as well as social and career life leaving them to struggle with a huge economic burden ( 9 , 10 ). In HF patients, higher caregiver burden is associated with reduced quality of delivered care and, consequently, reduced patients’ health ( 11 ). Notably, the impact of collectivist societies on HF caregiver outcomes is not well understood. Caregiving experiences differ significantly among cultural and ethnic groups ( 12 ). Cultural values and norms influence the perception of the caregiving role in terms of the role being an expected part of one’s life course ( 12 ). Cultural embeddedness of caregiving also influences whether caregiving is viewed as a choice or an expected duty ( 13 , 14 ). Values such as familism and family devotion sustain and even mandate caregiving responsibilities and strongly prevent caregivers from saying no to caregiving. This is the case in collectivist cultures present in Lebanon and the Middle East and North Africa [MENA] region. Arabs generally thrive on a large repertoire of family relations; the extended family is the most powerful social institution of the MENA region ( 15 ). These strong family bonds can influence the experience of caregiving, concepts of caregiver distress or burden, and caregiver illness beliefs ( 16 ). Even though people from the Middle East are racially diverse, shared values and behaviors are not uncommon. This includes the significance of family cohesion, family roles and responsibilities, and participative attitudes towards health and illness ( 17 ). Yet, even when social and individual ties are strong, this may not protect ICs from caregiver burnout ( 9 ). Therefore, the aim of this analysis was to describe caregiver strain among caregivers of patients living with HF and identify predictors of strain in a collectivist society like Lebanon. Methods Study Design This is a secondary analysis of a correlational descriptive study done on 108 patient-caregiver dyads with the aim of identifying dyadic determinants of self-care in HF care dyads in the parent study. The aim of this secondary analysis was to describe caregiver strain among caregivers of patients living with HF and identify predictors of strain in a collectivist society like Lebanon. In the parent study, we studied dyadic determinants of self-care in HF care dyads [patients and their ICs] through the unique anthropologic lens of a collectivist society where care is seen as a family commitment. Knowledge from this study will provide evidence which will help place caregivers’ health at the core of caregiving processes. By preventing or addressing caregiver strain, healthcare practitioners can improve the outcomes for ICs and support the psychological and physical well-being of both patients and their ICs. Participants and Procedures A convenience sample of 108 patient-caregiver dyads were recruited. Assuming a medium anticipated effect size of 0.15, a desired statistical power level of 0.8, a probability level of 0.05 for a multiple regression with 8 predictors, a minimum sample size of 108 subjects was needed. HF patients were included in the study if they spoke Arabic, had confirmed HF with Reduced Ejection Fraction [left ventricular ejection fraction less than or equal to 40%] or symptomatic HF with Preserved Ejection Fraction [echocardiographic evidence of diastolic dysfunction] for at least 3 months prior to inclusion in the study, and at the time of data collection had an IC who assisted with their self-care. HF patients were excluded from the study if they were clinically unstable, in an acute exacerbation, had a concomitant terminal illness such as cardiogenic shock, documented dementia, and documented severe psychological illness [excluding depression] or any impairment [any uncorrected visual or hearing problems] that would impede them from performing self-care. ICs in this study were defined as the person [regardless of his/her status in the family] who provided the most informal care to the patient. These were identified by the HF patient, designated as the primary caregiver, were present with the HF patient in the hospital visit, and provided consent to participate in the study. The parent study received ethical approval by the institutional review board of the data collection site. Data confidentiality was maintained all throughout the data collection phase. Information that identified participants directly was not collected. Questionnaires were stored in a locked cabinet in the primary investigator’s office and electronic files were stored in the primary investigator’s password protected computer. Data Collection and Instruments The sample was recruited from a coronary care inpatient unit and at outpatient cardiology specialty clinics at Lebanon’s largest tertiary medical center for the parent study. A trained research assistant interviewed the dyads to obtain information on patient and caregiver demographics such as gender, age, marital status, number of persons in the household, education, employment, and income. The average time required to complete the questionnaires was 30 minutes for ICs and 20 minutes for the patient. Information on the etiology and duration of the chronic illness, number of hospital readmissions in the past year, and an unweighted index of the number of comorbid medical conditions were obtained through a detailed medical record review. Information on the IC’s living status, perceived relationship with the patient, number of persons in the household and number of rooms excluding the bathroom and kitchen, caregiving duration and hours spent caregiving per week, other family obligations, available household help, and dyadic type were obtained. Modified Caregiver Strain Index. The modified Caregiver Strain Index [mCSI] is a 13-item tool that can quickly screen for strain related to care provision. The mCSI is a more recent version of the Caregiver Strain Index developed in 1983. Scoring ranges from 0 to 26 with higher scores indicating a higher level of caregiver strain ( 18 ). Cronbach’s alpha was 0.9 and the test-retest reliability coefficient was 0.88. The mCSI has been translated into Chinese and has been shown to be valid and reliable in Chinese caregivers [Cronbach’s alpha was 0.91] ( 19 ). In this study, the Arabic version of the mCSI had a Cronbach’s alpha of 0.870. Carers of Older People in Europe Index . Social Support was assessed using the 15-item Carers of Older People in Europe Index [COPE] ( 20 ). This index consists of three subscales: the negative impact of caregiving [7 items], positive values of caregiving [4 items], and quality of support [4 items]. A validation study of the 15-item version of the COPE among nearly 6000 caregivers of elderly people from six European countries [Germany, Greece, Italy, Poland, Sweden and United Kingdom] revealed three subscales for caregiving with a Cronbach's alpha varying from 0.64 to 0.83 ( 20 ). Caregiver Quality of Life . The Arabic version of the short-form 12 was used to measure quality of life of ICs in this sample ( 21 ). The composite physical and mental health scores were computed. Scores ranged from 0 to 100, with higher scores indicating better physical and mental health. Caregiving Type . This is a one item question that asked caregivers to choose their caregiving type among three options: whether they provided minimal, moderate, or full care to their HF patient. Caregiver Perceived Quality of the Dyadic Relationship . This is one item question generated from the COPE index that asked caregivers whether they had a good relationship with the person they care for. Answers were on a Likert scale ranging from 1 to 4, with higher scores indicating greater perceived relationship quality. Caregiver Dyadic Typology. Caregiver dyadic types were assessed using the Dyadic HF Care Types ( 22 ) where they were asked to choose what best describes their relationship with their counterpart in terms of how they take care of the disease. Response options were categorized into one of four categories: Patient oriented category where the patient takes care of his/her HF without input from the caregiver; Caregiver oriented category where the caregiver takes care of the HF patient without any input from the patient him/herself; Collaborative category where both the patient and the caregiver take care of the patient together; and Complementary category where both the patient and the caregiver take care of different aspects of HF ( 22 ). Data Analysis Data analysis was performed using the Statistical Package for the Social Sciences version 29.0 in several steps. An alpha of 0.05 was used in all analyses. First, we analyzed sociodemographic and clinical characteristics of the study participants using descriptive statistics [Means and Standard Deviations]. Scores on perceived caregiver strain were compared across patient and caregiver demographic and clinical characteristics using independent t test and analysis of variance tests or Pearson r as appropriate. Descriptive statistics were analyzed on all data to assess for normality, linearity, homoscedasticity, multicollinearity, and singularity. Multicollinearity was tested using VIF; scores greater than 4 were judged indicative of multicollinearity ( 23 ). The mCSI score was then used as the outcome variables to create the best regression model using significant variables from the univariate analyses. Results Sample Characteristics A total of 108 HF Arabic speaking patients [mean age 63.54 years, 29.6% females, 81.55% married] and ICs [mean age 49.37 years, 85.2% females, 82.2% married] were included [please refer to Table 1 for Sample Characteristics]. Caregivers in this sample were spouses [52.4%] or children [40.8%] of patients they cared for and provided care for an average of 8.53 ± 7.75 years and for a mean of 37.73 ± 50.67 hours per week. Almost half of the caregivers [46.9%] reported providing minimal care while approximately 35% reported providing full care for their patient. Table 1 Sample Characteristics Variable Mean ± SD or n [%] Caregiver Patient Age in years 49.37 ± 13.69 63.54 ± 10.52 Male Gender 16 [14.8] 76 [70.4] Marital Status Single 17 [15.9] 6 [5.6] Married 88 [82.2] 88 [81.55] Widowed 1 [0.9] 1 [0.9] Divorced 1 [0.9] 13 [12.0] Education Less than High School 33 [32.3] 40 [38.5] High School 28 [27.5] 31 [29.8] University Degree 40 [39.2] 33 [31.7] Employment Status [ Employed ] 41 [39.4] 32 [31.0] Income Dollars per year 6 to 12,000 35 [38] 31 [30.7] 12 to 15,000 21 [20.8] 21 [20.8] More than 15,000 49 [48.5] 49 [48.5] More than 80% of the patient/caregiver dyads lived in the same household, with most being unemployed and having less than a university degree education .The majority [86.8%] of ICs reported having an often or always good relationship with the person they cared for while 96.2% of patients reported having an often or always good relationship with their caregiver. About18% of the ICs reported that the HF care was collaborative or complementary, that is both members of the dyad assumed care of the patient’s health together or took care of different aspects of patient’s health jointly. About 30% of caregivers reported that the care is done solely by the patient while 34.3% of the ICs reported that the care is done only by them. An alarming 68.6% of the dyads in this sample were considered discordant and did not agree on how and by whom [by patient, caregiver, or jointly] the care is being provided [please refer to Table 2 for Caregiving Setting]. Table 2 Caregiving Setting Caregiving Setting Mean ± SD; n [%] Dyad Relationship Type Husband/Wife 54 [52.4] Children 42 [40.8] Brother/Sister 7 [6.8] Caregiver Perceived Quality of the Dyad Relationship Poor 14 [13.2] Strong 92 [86.8] Patient Perceived Quality of the Dyad Relationship Poor 4 [3.8] Strong 101 [96.2] Dyadic Type [ Discordant ] 72 [68.6] Patient Oriented 32 [29.6] Caregiver Oriented 37 [34.3] Collaborative 23 [21.3] Complementary 16 [14.8] Caregiving Type Minimal Care 38 [46.9] Moderate Care 14 [17.3] Full Care 29 [35.8] Living Status In the same household 90 [83.3] In different houses but same building 7 [6.5] Walking distance 3 [2.8] 10-minute drive 4 [3.7] 30-minute drive 3 [2.8] 1 hour drive 1 [0.9] Duration of Caregiving [years] 8.53 ± 7.75 Number of Caregiving Hours / Week 37.73 ± 50.67 Perceived Caregiver Strain Described Caregiver strain, measured using mCSI, was average in this sample with a mean of 11.32 ± 6.94. About three quarters of the sample reported having sleep pattern disturbances sometimes or on a regular basis and 67.3% thought that caregiving was inconvenient. More than half of the sample of caregivers thought that caregiving was confining. The majority denied having to have major family modifications while 32.7% reported that there have been changes in their personal plans secondary to their caregiving roles. More than 40% of the sample reported having other demands on their time in addition to caregiving. About half the sample reported that some behaviors were upsetting to them at times or on a regular basis. Almost 60% of the caregivers felt completely overwhelmed at times or on a regular basis [please refer to Table 3 for Caregiver Strain]. Table 3 Caregiver Strain Caregiver Strain Index Regular Sometimes No My sleep is disturbed 41 [38.3] 41 [38.3] 25 [23.4] Caregiving is inconvenient 35 [32.7] 37 [34.6] 35 [32.7] Caregiving is a physical strain 42 [39.3] 18 [16.8] 47 [43.9] Caregiving is confining 47 [43.9] 14 [13.1] 46 [43.0] There have been family modifications 23 [21.5] 16 [15.0] 68 [63.6] There have been changes in personal plans 35 [32.7] 23 [21.5] 49 [45.8] There have been other demands on my time 44 [41.1] 25 [23.4] 38 [35.5] There have been emotional adjustments 34 [31.8] 16 [15.0] 57 [53.3] Some behavior is upsetting 24 [22.4] 32 [29.9] 51 [47.7] It is upsetting to find the person I care for has changed so much from their former self 51 [47.7] 17 [15.9] 39 [36.4] There have been work adjustments 20 [18.7] 15 [14.0] 72 [67.3] Caregiving is a financial strain 28 [26.4] 17 [16.0] 61 [57.5] I feel completely overwhelmed 25 [23.4] 38 [35.5] 44 [41.1] Identifying Predictor Variables of Caregiver Strain Scores on mCSI were compared across patient and caregiver demographic and clinical characteristics using independent t test and analysis of variance tests as appropriate [please refer to Table 4 for Predictor Variables]. Table 4 Predictor Variables Variables Category Mean ± SD or Pearson’s r Caregiver Gender Male 9.67 ± 8.20 Female 11.59 ± 6.73 Patient Gender Male 11.41 ± 7.01 Female 11.10 ± 6.89 Caregiver Marital Status Married 11.44 ± 6.82 Single 10.47 ± 7.71 Patient Marital Status Married 11.64 ± 6.80 Single 9.84 ± 7.60 Caregiver Employment Working 11.23 ± 7.49 Unemployed 11.55 ± 6.65 Patient Employment Working 12.08 ± 6.92 Unemployed 10.00 ± 6.91 Caregiving Type Minimal 9.82 ± 7.16 Moderate 13.38 ± 5.61 Full Care 13.75 ± 6.16 Dyadic Typology Patient Oriented 8.28 ± 6.35 ** Caregiver Oriented 14.97 ± 5.60 ** Collaborative 10.68 ± 6.42 Complementary 10.06 ± 7.67 Caregiver Perceived Quality of the Dyad Relation Poor 16.07 ± 4.82 ** Strong 10.71 ± 6.9 ** Patient Symptomatology Asymptomatic 12.69 ± 6.21 * Symptomatic 9.90 ± 7.43 * Caregiver Social Support Scale Positive Value 0.129 Negative Impact 0.774 ** Quality of Support -0.168 Caregiver Quality of Life Physical Quality of Life -0.291 ** Mental Quality of Life -0.536 ** Caregiver Involvement in Self-Care Maintenance 0.125 Perception 0.195 Management 0.298** Patient Involvement in Self-Care Maintenance -0.122 Perception -0.224* Management 0.079 *p < 0.05; **p < 0.001 The type of caregiving provided to the HF patient as perceived by the caregivers significantly affected caregiver strain. Providing full care significantly increased caregiver strain compared to ICs providing minimal care [13.75 ± 6.16 versus 9.82 ± 7.16; F(2,76) = 3.329, p = 0.041]. Likely, dyads with a caregiver-oriented typology had higher caregiver strain when compared to patient oriented typology [14.97 ± 5.60 versus 8.28 ± 6.346; F(3,102) = 6.475; p < 0.001]. Poor perceived caregiver quality of the relationship was also significantly associated with higher caregiver strain [16.07 ± 6 versus 10.71 ± 6.9; p < 0.001]. Unexpectedly, ICs of symptomatic patients [those with New York Heart Association classes III and IV] had lower caregiver strain than ICs of asymptomatic patients [9.90 ± 7.43 versus 12.69 ± 6.21; p = 0.019]. Pearson correlation was used to ascertain correlations between variables such as age, years since HF diagnosis, perceived social support, caregiving duration, caregiving hours, and mCSI score. COPE’s negative impact scale that relates to the IC’s personal feeling of being stressed in caregiving was significantly associated with caregiver strain [Pearson’s r = 0.774; p < 0.001]. Likely, lower caregiver physical or mental quality of life were significantly associated with higher caregiver strain [r = -0.291 and − 0.536 respectively; p < 0.001]. Self-care affected caregiver strain in this sample. The higher the IC’s involvement in self-care management, the higher their strain was [r = 0.298, p = 0.002]. Similarly, the lower the patient self-care monitoring was the more strained were the caregivers [r = -0.224, p = 0.025]. Predictors of Caregiver Strain Different variables were associated with caregiver strain as shown in Table 3 . To explore relationships within the data more thoroughly, the mCSI was used as the outcome variable to create the best regression model using significant variables from the univariate analyses [please refer to Table 5 for Regression Analysis]. Predictors were retained in the regression model if they contributed significantly to the model or were conceptually relevant and did not negatively affect the variance. A higher negative impact from caregiving [denoting high personal feeling of being stressed in caregiving], a lower physical and mental quality of life, and a lower caregiver perceived relationship quality explained about 63% of the variance in Caregiver Strain. Table 5 Regression Analysis Adjusted R2 F Sig. Unstandardized Beta Standardized Beta t Sig. Constant 0.630 44.001 < 0.001 11.657 2.356 .020 Relationship Quality -2.794 − .136 -2.209 .030 Social Support - Negative .960 .601 7.763 < 0.001 Physical Quality of Life − .093 − .120 -1.808 .074 Mental Quality of Life − .113 − .211 -2.839 .006 Discussion We evaluated caregiving strain among ICs of patients living with HF and identified its predictors through secondary analysis of a cross-sectional study that looked at dyadic determinants of self-care. To our knowledge, this is the first study to address perceived caregiving strain in HF patients in collectivist societies such as those in the MENA region. Research on self-care in patients living with cardiac problems has been growing internationally and in Lebanon and the MENA region. In one of the earlier studies on self-care in Lebanon, ICs of patients living with cardiac illness viewed caregiving as a moral and emotional duty to care for the family member stemming from obligation and responsibility towards their patients ( 17 ). Despite this moral obligation, we highlighted moderate levels of caregiver strain among our sample of ICs. Moderate levels of caregiver strain were also reported earlier in a systematic review involving 12 papers with 4659 caregivers from eight Asian countries including one Arabic speaking country ( 24 ). This same trend was seen in ICs of older adults with chronic illnesses living in Iran ( 25 ). This similarity in strain severity could be due to cultural peculiarities and the complex medical profile of HF patients who have multimorbidity and complex self-care needs. We also highlighted the unique roles women play in informal caregiving in collectivist societies like Lebanon. Women caregivers in collectivist societies see themselves in a position of responsibility towards the whole family ( 17 ). This finding is confirmed in this study as over 85% of the ICs were women highlighting caregiving as an expected gender role for women in Lebanon. Other studies on older adults in Lebanon have had similar findings ( 26 ). Although gender was not a significant predictor of caregiver strain, women caregivers were found to have higher caregiver strain than male caregivers, which could be due to the gender role in collectivist societies. This difference and a higher caregiver strain among women caregivers was seen in previous studies in the Lebanese setting ( 27 ). On the contrary, higher levels of strain were reported among male caregivers of Chinese chronically ill patients possibly explained by cultural norms and family structure in China ( 28 ). ICs in this sample provided an average of 37.73 ± 50.67 hours of caregiving per week which is equivalent to a full-time employment. More than a quarter of the ICs reported providing full care for their patient and highlighted that the care was done solely by them with minimal input from the patient; this underscores the high care dependency of patients living with HF. Most of the ICs in this sample were unemployed possibly because the majority are women, and this mirrors the high unemployment rates due to the financial conundrum facing Lebanon. Although not statistically significant, caregivers who were unemployed had higher caregiver strain than those who were employed. This could be because unemployment poses financial burdens and added caregiver strain and going to work may be seen as a respite for ICs. Income and current employment status of the members of the dyad did not have any significant impact on the strain level in this study; however, this was contradicted in a number of studies reporting financial strains and employment to be significantly associated with increased burden ( 24 ). Financial strains were also associated with lower scores on the mental component of the quality of life of Chinese ICs ( 28 ). Higher patient symptomatology was associated with lower caregiver strain in this sample. This contradicts findings of other studies that reported higher burden among ICs caring for patients with moderate to severe HF [New York Heart Association classes III and IV] compared with those caring for patients with mild HF (New York Heart Association classes I and II] ( 29 ). This could be explained by the notion that providing care to a person who is symptomatic and in need can be rewarding for a caregiver, as some studies have shown ( 30 – 32 ) and this can compensate the burden due to caregiving. Interestingly, we found that ICs providing full care to their patients reported significantly higher caregiver strain compared to those providing minimal or moderate care and being in a caregiver-oriented dyadic typology had the highest caregiver strain in this sample. This was not consistent with studies that highlighted that caregiver contributions to self-care maintenance and management were not significant predictors of caregiver burden ( 32 ). Poor quality of the dyadic relationship as perceived by the IC was significantly associated with higher caregiver strain in this sample. Conceptually, relationship quality has been proposed to be a key factor in caregiver burden from caregiving, and caregiver depressive symptoms may significantly confound this relationship ( 33 , 34 ). This was confirmed in a study where relationship quality was positively associated with caregiver benefit and negatively associated with burden and depression ( 35 ). Relationship quality and burden remained associated after controlling for depression. These findings further emphasize the critical role of perceived relationship quality in shaping caregiver strain among dyads living with HF. They highlight the need to move beyond individual-level assessments and incorporate relational evaluations into routine HF care. Systematic assessment of dyadic functioning may allow clinicians to identify caregivers at heightened risk for strain and to design interventions that strengthen relational resilience alongside symptom management. Strength and Limitations This secondary analysis suffers the limitations common to this type of analysis – we were constrained by factors from the parent study such as cross-sectional design, convenience sampling, social desirability in self-report, and recruiting from both inpatient setting with greater patient needs and outpatient setting with lesser needs for caregiving. At the same time, this study has important strengths. To our knowledge, it is among the first in the MENA region to examine perceived caregiver strain in the context of HF while explicitly situating caregiving within a collectivist sociocultural framework. Although cross-sectional studies on caregiver burden have been conducted in other collectivist societies, such as China, and research on caregiver burden exists in countries like Saudi Arabia, prior work in the region has not clearly conceptualized or analytically linked caregiver strain to the underlying collectivist ethos in which caregiving is viewed as a familial and social obligation rather than an individual choice. By foregrounding this cultural lens, our study advances the discourse beyond prevalence estimates to a more contextualized understanding of strain within collectivist societies. Conclusion In this study, we found that different caregiver characteristics influence different dimensions of caregiver strain, and caregivers should be assessed for these potential determinants. HF nurses and physicians in the MENA region should start giving special attention to caregivers of HF patients particularly those who report feeling stressed in caregiving, have poorer quality of life and lower perceived relationship quality because they are more exposed to caregiver strain. Interventions to reduce HF caregiver strain should consider which dimensions of strain is affected in caregivers. Finally, a very important finding in this study is that ICs have less strain when caring for the more functionally dependent or more symptomatic patients as this can compensate the burden due to caregiving. As such, healthcare providers can depend on ICs when patients need them most. Governments in the MENA region should recognize that caregiving is equivalent to a full-time employment and that more than a quarter of the ICs report that the care was done solely by them with minimal input from the patient underscoring the high care dependency of patients living with HF in this part of the world. Abbreviations IC Informal Caregiver HF Heart Failure MENA Middle East and North Africa mCSI modified Caregiver Strain Index COPE Carers of Older People in Europe Index Declarations Ethics Approval and Consent to Participate: This study is in accordance with the Declaration of Helsinki and was approved by the American University of Beirut Institutional Review Board [Approval no. SBS-2018-0529] in December 2018. All participants signed an informed consent prior to the data collection. Clinical Trial Number: Not Applicable. Consent for Publication: Not Applicable. Availability of Data and Materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests: The authors declare that they have no competing interests. Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the University Research Board at the American University of Beirut. Authors' Contributions: AM contributed to Conceptualization, Funding Acquisition, Data Curation, Formal Analysis, Roles/Writing - Original Draft, and Writing - Review and Editing; HD contributed to Writing - Original Draft; HAH and HGB contributed to Writing - Review and Editing Acknowledgements: Authors would like to acknowledge Mrs. Dayana ElChaar and Dr. Melissa Makhoul for their support throughout the data collection process as well as Coronary Care Unit Registered Nurses at the American University of Beirut who supported the tool translation and cultural validation process. References Schulz R, Sherwood PR. Physical and mental health effects of family caregiving. Am J Nurs. 2008;108(9 Suppl):23–7. quiz 7. Adelman RD, Tmanova LL, Delgado D, Dion S, Lachs MS. Caregiver burden: a clinical review. JAMA. 2014;311(10):1052–60. Pan Y, Chen R, Yang D. Relationship between filial obligation and caregiver depression among adult children: A systematic review and meta-analysis. 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Validation of the Chinese Version of the Modified Caregivers Strain Index among Hong Kong Caregivers: An Initiative of Medical Social Workers. Health Soc Work. 2013;38(4):214–21. Balducci C, Mnich E, McKee KJ, Lamura G, Beckmann A, Krevers B, et al. Negative impact and positive value in caregiving: validation of the COPE index in a six-country sample of carers. Gerontologist. 2008;48(3):276–86. Al-Shehri AH, Taha AZ, Bahnassy AA, Salah M. Health-related quality of life in type 2 diabetic patients. Ann Saudi Med. 2008;28(5):352–60. Buck HG, Kitko L, Hupcey JE. Dyadic heart failure care types: qualitative evidence for a novel typology. J Cardiovasc Nurs. 2013;28(6):E37–46. Tabachnick BG, Fidell LS. Using Multivariate Statistics. 6th ed. New Jersey: Pearson; 2013. Isac C, Lee P, Arulappan J. Older adults with chronic illness–caregiver burden in the Asian context: a systematic review. Patient Educ Couns. 2021;104(12):2912–21. Sorayyanezhad A, Nikpeyma N, Nazari S, Sharifi F, Sarkhani N. The relationship of caregiver strain with resilience and hardiness in family caregivers of older adults with chronic disease: a cross-sectional study. BMC Nurs. 2022;21(1):184. Seoud J, Nehme C, Atallah R, Zablit C, Yeretzian J, Levesque L, et al. The health of family caregivers of older impaired persons in Lebanon: an interview survey. Int J Nurs Stud. 2007;44(2):259–72. Charbaji S, Ei Asmar K, McCall SJ, Saad GE, Chaaya M. Caregiver burden and mental health among informal caregivers of older adults in Lebanon. Discov Public Health. 2026;23(1):114. Xie H, Cheng C, Tao Y, Zhang J, Robert D, Jia J, et al. Quality of life in Chinese family caregivers for elderly people with chronic diseases. Health Qual Life Outcomes. 2016;14(1):99. Lahoz R, Proudfoot C, Fonseca AF, Loefroth E, Corda S, Jackson J, et al. Caregivers of Patients with Heart Failure: Burden and the Determinants of Health-Related Quality of Life. Patient Prefer Adherence. 2021;15:1153–64. Anderson EW, White KM. This is what family does: the family experience of caring for serious illness. Am J Hosp Palliat Med. 2018;35:348–54. Hayes C, Bhandari N, Kathe N. Reliability and valid- ity of the medical outcomes study Short Form-12 version 2 (SF-12v2) in adults with non-cancer pain. Healthcare. 2017;5(22). Durante A, Greco A, Annoni AM, Steca P, Alvaro R, Vellone E. Determinants of caregiver burden in heart failure: does caregiver contribution to heart failure patient self-care increase caregiver burden? Eur J Cardiovasc Nurs. 2019;18(8):691–9. Trivedi RB, Piette J, Fihn SD, Edelman D. Examining the interrelatedness of patient and spousal stress in heart failure: conceptual model and pilot data. J Cardiovasc Nurs. 2012;27(1):24–32. Saunders MM. Factors associated with caregiver burden in heart failure family caregivers. West J Nurs Res. 2008;30(8):943–59. Lum HD, Lo D, Hooker S, Bekelman DB. Caregiving in heart failure: Relationship quality is associated with caregiver benefit finding and caregiver burden. Heart Lung. 2014;43(4):306–10. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 Apr, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers invited by journal 25 Mar, 2026 Editor invited by journal 23 Feb, 2026 Editor assigned by journal 19 Feb, 2026 Submission checks completed at journal 19 Feb, 2026 First submitted to journal 13 Feb, 2026 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. 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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-8870946","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":612028414,"identity":"d551d5f6-67e6-4470-9ee1-999350c8a2b6","order_by":0,"name":"Angela MASSOUH","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAt0lEQVRIiWNgGAWjYFAC/gcHPjAwJABZBgwMBQeI0cLD+HAGXIsBcVqYjXlI0sI/7ewxaZuaw3kM7M3bJBgM7hDWInE7L00659jhYgaeY2VALc+IcNftBDPpHLbDiQ0SOWZALYcJ65AHabH4B9Qi/4ZILQa3c4yNGdtAtvAQqcXwdlriw96+9GI2nrRiiwRi/CJ3O/nAgR/frPP42Q9vvPGhgogQgwM2EJFAgoZRMApGwSgYBXgAAPYWOfplHOShAAAAAElFTkSuQmCC","orcid":"","institution":"American University of Beirut","correspondingAuthor":true,"prefix":"","firstName":"Angela","middleName":"","lastName":"MASSOUH","suffix":""},{"id":612028415,"identity":"879387bd-a4c4-4131-971d-df696df311f6","order_by":1,"name":"Hiba DEEK","email":"","orcid":"","institution":"Beirut Arab University","correspondingAuthor":false,"prefix":"","firstName":"Hiba","middleName":"","lastName":"DEEK","suffix":""},{"id":612028418,"identity":"df5ce0d2-c2bb-4f45-93d1-8b2c18700df7","order_by":2,"name":"Huda ABU SAAD HUIJER","email":"","orcid":"","institution":"University of Balamand","correspondingAuthor":false,"prefix":"","firstName":"Huda","middleName":"ABU SAAD","lastName":"HUIJER","suffix":""},{"id":612028420,"identity":"76a43cf0-3664-458e-adac-cef6d9420195","order_by":3,"name":"Harleah G. BUCK","email":"","orcid":"","institution":"University of Iowa","correspondingAuthor":false,"prefix":"","firstName":"Harleah","middleName":"G.","lastName":"BUCK","suffix":""}],"badges":[],"createdAt":"2026-02-13 10:55:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8870946/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8870946/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105566470,"identity":"2841457a-f0e1-4a37-9911-2b61e4f84129","added_by":"auto","created_at":"2026-03-27 12:56:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1198109,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8870946/v1/1df9598c-b52b-4ecf-9839-4a1f5e0a6ae5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perceived Caregiver Strain in Carers of Patients Living with Heart Failure in Collectivist Societies","fulltext":[{"header":"Background","content":"\u003cp\u003eInformal caregivers [ICs] are individuals voluntarily caring for a relative or a friend facing a disease, disability, or any condition requiring particular attention (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). They provide around 90% of in-home long-term care needed by adults and play a key role in supporting the wellbeing and care of people living with chronic illnesses (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Families develop familial homeostasis or a typical dynamic and routine, that is often disrupted when a member of that family is diagnosed with a chronic illness. While taking care of a loved family member could generate feelings of emotional fulfillment and a sense of accomplishment, ICs often face health hurdles and emotional strains of their own (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Chronic illness diagnoses alter roles and responsibilities within the family unit and causes feelings of uncertainty, anxiety, depression, resentment, among others (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This is especially true in patients living with Heart Failure [HF] and their ICs.\u003c/p\u003e \u003cp\u003eThe high care dependency and the lack of formal support for the caregiving role have increased the prevalence of caregiver burden and strain (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Studies have demonstrated that HF caregivers experienced reduced quality of life, and caregiving had a negative impact on their physical and emotional health (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) as well as social and career life leaving them to struggle with a huge economic burden (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In HF patients, higher caregiver burden is associated with reduced quality of delivered care and, consequently, reduced patients\u0026rsquo; health (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Notably, the impact of collectivist societies on HF caregiver outcomes is not well understood.\u003c/p\u003e \u003cp\u003eCaregiving experiences differ significantly among cultural and ethnic groups (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Cultural values and norms influence the perception of the caregiving role in terms of the role being an expected part of one\u0026rsquo;s life course (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Cultural embeddedness of caregiving also influences whether caregiving is viewed as a choice or an expected duty (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Values such as familism and family devotion sustain and even mandate caregiving responsibilities and strongly prevent caregivers from saying no to caregiving. This is the case in collectivist cultures present in Lebanon and the Middle East and North Africa [MENA] region. Arabs generally thrive on a large repertoire of family relations; the extended family is the most powerful social institution of the MENA region (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These strong family bonds can influence the experience of caregiving, concepts of caregiver distress or burden, and caregiver illness beliefs (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Even though people from the Middle East are racially diverse, shared values and behaviors are not uncommon. This includes the significance of family cohesion, family roles and responsibilities, and participative attitudes towards health and illness (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Yet, even when social and individual ties are strong, this may not protect ICs from caregiver burnout (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Therefore, the aim of this analysis was to describe caregiver strain among caregivers of patients living with HF and identify predictors of strain in a collectivist society like Lebanon.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis is a secondary analysis of a correlational descriptive study done on 108 patient-caregiver dyads with the aim of identifying dyadic determinants of self-care in HF care dyads in the parent study. The aim of this secondary analysis was to describe caregiver strain among caregivers of patients living with HF and identify predictors of strain in a collectivist society like Lebanon. In the parent study, we studied dyadic determinants of self-care in HF care dyads [patients and their ICs] through the unique anthropologic lens of a collectivist society where care is seen as a family commitment. Knowledge from this study will provide evidence which will help place caregivers\u0026rsquo; health at the core of caregiving processes. By preventing or addressing caregiver strain, healthcare practitioners can improve the outcomes for ICs and support the psychological and physical well-being of both patients and their ICs.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Procedures\u003c/h3\u003e\n\u003cp\u003eA convenience sample of 108 patient-caregiver dyads were recruited. Assuming a medium anticipated effect size of 0.15, a desired statistical power level of 0.8, a probability level of 0.05 for a multiple regression with 8 predictors, a minimum sample size of 108 subjects was needed. HF patients were included in the study if they spoke Arabic, had confirmed HF with Reduced Ejection Fraction [left ventricular ejection fraction less than or equal to 40%] or symptomatic HF with Preserved Ejection Fraction [echocardiographic evidence of diastolic dysfunction] for at least 3 months prior to inclusion in the study, and at the time of data collection had an IC who assisted with their self-care. HF patients were excluded from the study if they were clinically unstable, in an acute exacerbation, had a concomitant terminal illness such as cardiogenic shock, documented dementia, and documented severe psychological illness [excluding depression] or any impairment [any uncorrected visual or hearing problems] that would impede them from performing self-care. ICs in this study were defined as the person [regardless of his/her status in the family] who provided the most informal care to the patient. These were identified by the HF patient, designated as the primary caregiver, were present with the HF patient in the hospital visit, and provided consent to participate in the study.\u003c/p\u003e \u003cp\u003e The parent study received ethical approval by the institutional review board of the data collection site. Data confidentiality was maintained all throughout the data collection phase. Information that identified participants directly was not collected. Questionnaires were stored in a locked cabinet in the primary investigator\u0026rsquo;s office and electronic files were stored in the primary investigator\u0026rsquo;s password protected computer.\u003c/p\u003e\n\u003ch3\u003eData Collection and Instruments\u003c/h3\u003e\n\u003cp\u003e The sample was recruited from a coronary care inpatient unit and at outpatient cardiology specialty clinics at Lebanon\u0026rsquo;s largest tertiary medical center for the parent study. A trained research assistant interviewed the dyads to obtain information on patient and caregiver demographics such as gender, age, marital status, number of persons in the household, education, employment, and income. The average time required to complete the questionnaires was 30 minutes for ICs and 20 minutes for the patient.\u003c/p\u003e \u003cp\u003eInformation on the etiology and duration of the chronic illness, number of hospital readmissions in the past year, and an unweighted index of the number of comorbid medical conditions were obtained through a detailed medical record review. Information on the IC\u0026rsquo;s living status, perceived relationship with the patient, number of persons in the household and number of rooms excluding the bathroom and kitchen, caregiving duration and hours spent caregiving per week, other family obligations, available household help, and dyadic type were obtained.\u003c/p\u003e \u003cp\u003e\u003cb\u003eModified Caregiver Strain Index.\u003c/b\u003e The modified Caregiver Strain Index [mCSI] is a 13-item tool that can quickly screen for strain related to care provision. The mCSI is a more recent version of the Caregiver Strain Index developed in 1983. Scoring ranges from 0 to 26 with higher scores indicating a higher level of caregiver strain (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Cronbach\u0026rsquo;s alpha was 0.9 and the test-retest reliability coefficient was 0.88. The mCSI has been translated into Chinese and has been shown to be valid and reliable in Chinese caregivers [Cronbach\u0026rsquo;s alpha was 0.91] (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In this study, the Arabic version of the mCSI had a Cronbach\u0026rsquo;s alpha of 0.870.\u003c/p\u003e \u003cp\u003e\u003cb\u003eCarers of Older People in Europe Index\u003c/b\u003e. Social Support was assessed using the 15-item Carers of Older People in Europe Index [COPE] (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This index consists of three subscales: the negative impact of caregiving [7 items], positive values of caregiving [4 items], and quality of support [4 items]. A validation study of the 15-item version of the COPE among nearly 6000 caregivers of elderly people from six European countries [Germany, Greece, Italy, Poland, Sweden and United Kingdom] revealed three subscales for caregiving with a Cronbach's alpha varying from 0.64 to 0.83 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eCaregiver Quality of Life\u003c/b\u003e. The Arabic version of the short-form 12 was used to measure quality of life of ICs in this sample (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The composite physical and mental health scores were computed. Scores ranged from 0 to 100, with higher scores indicating better physical and mental health.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCaregiving Type\u003c/b\u003e. This is a one item question that asked caregivers to choose their caregiving type among three options: whether they provided minimal, moderate, or full care to their HF patient.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCaregiver Perceived Quality of the Dyadic Relationship\u003c/b\u003e. This is one item question generated from the COPE index that asked caregivers whether they had a good relationship with the person they care for. Answers were on a Likert scale ranging from 1 to 4, with higher scores indicating greater perceived relationship quality.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCaregiver Dyadic Typology.\u003c/b\u003e Caregiver dyadic types were assessed using the Dyadic HF Care Types (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) where they were asked to choose what best describes their relationship with their counterpart in terms of how they take care of the disease. Response options were categorized into one of four categories: Patient oriented category where the patient takes care of his/her HF without input from the caregiver; Caregiver oriented category where the caregiver takes care of the HF patient without any input from the patient him/herself; Collaborative category where both the patient and the caregiver take care of the patient together; and Complementary category where both the patient and the caregiver take care of different aspects of HF (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using the Statistical Package for the Social Sciences version 29.0 in several steps. An alpha of 0.05 was used in all analyses. First, we analyzed sociodemographic and clinical characteristics of the study participants using descriptive statistics [Means and Standard Deviations].\u003c/p\u003e \u003cp\u003eScores on perceived caregiver strain were compared across patient and caregiver demographic and clinical characteristics using independent t test and analysis of variance tests or Pearson r as appropriate. Descriptive statistics were analyzed on all data to assess for normality, linearity, homoscedasticity, multicollinearity, and singularity. Multicollinearity was tested using VIF; scores greater than 4 were judged indicative of multicollinearity (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The mCSI score was then used as the outcome variables to create the best regression model using significant variables from the univariate analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSample Characteristics\u003c/h2\u003e \u003cp\u003eA total of 108 HF Arabic speaking patients [mean age 63.54 years, 29.6% females, 81.55% married] and ICs [mean age 49.37 years, 85.2% females, 82.2% married] were included [please refer to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for Sample Characteristics]. Caregivers in this sample were spouses [52.4%] or children [40.8%] of patients they cared for and provided care for an average of 8.53\u0026thinsp;\u0026plusmn;\u0026thinsp;7.75 years and for a mean of 37.73\u0026thinsp;\u0026plusmn;\u0026thinsp;50.67 hours per week. Almost half of the caregivers [46.9%] reported providing minimal care while approximately 35% reported providing full care for their patient.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n [%]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaregiver\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e in years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.37\u0026thinsp;\u0026plusmn;\u0026thinsp;13.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.54\u0026thinsp;\u0026plusmn;\u0026thinsp;10.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e Gender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 [14.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 [70.4]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 [15.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 [5.6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 [82.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 [81.55]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [0.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 [0.9]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [0.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 [12.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 [32.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 [38.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 [27.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 [29.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity Degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 [39.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 [31.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment Status [\u003cb\u003eEmployed\u003c/b\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 [39.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 [31.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome\u003c/b\u003e Dollars per year\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 to 12,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 [38]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 [30.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 to 15,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 [20.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 [20.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 15,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 [48.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 [48.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMore than 80% of the patient/caregiver dyads lived in the same household, with most being unemployed and having less than a university degree education .The majority [86.8%] of ICs reported having an often or always good relationship with the person they cared for while 96.2% of patients reported having an often or always good relationship with their caregiver.\u003c/p\u003e \u003cp\u003eAbout18% of the ICs reported that the HF care was collaborative or complementary, that is both members of the dyad assumed care of the patient\u0026rsquo;s health together or took care of different aspects of patient\u0026rsquo;s health jointly. About 30% of caregivers reported that the care is done solely by the patient while 34.3% of the ICs reported that the care is done only by them. An alarming 68.6% of the dyads in this sample were considered discordant and did not agree on how and by whom [by patient, caregiver, or jointly] the care is being provided [please refer to Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for Caregiving Setting].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCaregiving Setting\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiving Setting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD; n [%]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDyad Relationship Type\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHusband/Wife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 [52.4]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildren\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 [40.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrother/Sister\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 [6.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaregiver Perceived Quality of the Dyad Relationship\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 [13.2]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 [86.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatient Perceived Quality of the Dyad Relationship\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 [3.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 [96.2]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDyadic\u003c/b\u003e Type [\u003cb\u003eDiscordant\u003c/b\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 [68.6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Oriented\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 [29.6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiver Oriented\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 [34.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollaborative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 [21.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 [14.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaregiving Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinimal Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 [46.9]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 [17.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 [35.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiving Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn the same household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 [83.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn different houses but same building\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 [6.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWalking distance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 [2.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10-minute drive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 [3.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-minute drive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 [2.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 hour drive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [0.9]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration\u003c/b\u003e of \u003cb\u003eCaregiving\u003c/b\u003e [years]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.53\u0026thinsp;\u0026plusmn;\u0026thinsp;7.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber\u003c/b\u003e of \u003cb\u003eCaregiving Hours\u003c/b\u003e/ Week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.73\u0026thinsp;\u0026plusmn;\u0026thinsp;50.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerceived Caregiver Strain Described\u003c/h3\u003e\n\u003cp\u003eCaregiver strain, measured using mCSI, was average in this sample with a mean of 11.32\u0026thinsp;\u0026plusmn;\u0026thinsp;6.94. About three quarters of the sample reported having sleep pattern disturbances sometimes or on a regular basis and 67.3% thought that caregiving was inconvenient. More than half of the sample of caregivers thought that caregiving was confining. The majority denied having to have major family modifications while 32.7% reported that there have been changes in their personal plans secondary to their caregiving roles. More than 40% of the sample reported having other demands on their time in addition to caregiving. About half the sample reported that some behaviors were upsetting to them at times or on a regular basis. Almost 60% of the caregivers felt completely overwhelmed at times or on a regular basis [please refer to Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e for Caregiver Strain].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCaregiver Strain\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiver Strain Index\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegular\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMy sleep is disturbed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 [38.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 [38.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 [23.4]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiving is inconvenient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 [32.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 [34.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35 [32.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiving is a physical strain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 [39.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 [16.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47 [43.9]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiving is confining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47 [43.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 [13.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46 [43.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThere have been family modifications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 [21.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 [15.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68 [63.6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThere have been changes in personal plans\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 [32.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 [21.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49 [45.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThere have been other demands on my time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44 [41.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 [23.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38 [35.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThere have been emotional adjustments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 [31.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 [15.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57 [53.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome behavior is upsetting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 [22.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 [29.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 [47.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIt is upsetting to find the person I care for has changed so much from their former self\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 [47.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 [15.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39 [36.4]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThere have been work adjustments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 [18.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 [14.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e72 [67.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiving is a financial strain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 [26.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 [16.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61 [57.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI feel completely overwhelmed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 [23.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 [35.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44 [41.1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eIdentifying Predictor Variables of Caregiver Strain\u003c/h3\u003e\n\u003cp\u003eScores on mCSI were compared across patient and caregiver demographic and clinical characteristics using independent t test and analysis of variance tests as appropriate [please refer to Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e for Predictor Variables].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePredictor Variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or\u003c/p\u003e \u003cp\u003ePearson\u0026rsquo;s r\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCaregiver Gender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.67\u0026thinsp;\u0026plusmn;\u0026thinsp;8.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.59\u0026thinsp;\u0026plusmn;\u0026thinsp;6.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePatient Gender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.41\u0026thinsp;\u0026plusmn;\u0026thinsp;7.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.10\u0026thinsp;\u0026plusmn;\u0026thinsp;6.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCaregiver Marital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.44\u0026thinsp;\u0026plusmn;\u0026thinsp;6.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.47\u0026thinsp;\u0026plusmn;\u0026thinsp;7.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePatient Marital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.64\u0026thinsp;\u0026plusmn;\u0026thinsp;6.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.84\u0026thinsp;\u0026plusmn;\u0026thinsp;7.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCaregiver Employment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.23\u0026thinsp;\u0026plusmn;\u0026thinsp;7.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.55\u0026thinsp;\u0026plusmn;\u0026thinsp;6.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePatient Employment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCaregiving Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinimal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.82\u0026thinsp;\u0026plusmn;\u0026thinsp;7.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.38\u0026thinsp;\u0026plusmn;\u0026thinsp;5.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.75\u0026thinsp;\u0026plusmn;\u0026thinsp;6.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eDyadic Typology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient Oriented\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.28\u0026thinsp;\u0026plusmn;\u0026thinsp;6.35\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaregiver Oriented\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.97\u0026thinsp;\u0026plusmn;\u0026thinsp;5.60\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollaborative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.68\u0026thinsp;\u0026plusmn;\u0026thinsp;6.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.06\u0026thinsp;\u0026plusmn;\u0026thinsp;7.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCaregiver Perceived Quality of the Dyad Relation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.07\u0026thinsp;\u0026plusmn;\u0026thinsp;4.82\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.71\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePatient Symptomatology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsymptomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.69\u0026thinsp;\u0026plusmn;\u0026thinsp;6.21\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSymptomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.90\u0026thinsp;\u0026plusmn;\u0026thinsp;7.43\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCaregiver Social Support Scale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.129\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative Impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.774\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuality of Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCaregiver Quality of Life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical Quality of Life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.291\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental Quality of Life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.536\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCaregiver Involvement in Self-Care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaintenance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.125\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.195\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eManagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.298**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePatient Involvement in Self-Care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaintenance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.122\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.224*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eManagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.079\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe type of caregiving provided to the HF patient as perceived by the caregivers significantly affected caregiver strain. Providing full care significantly increased caregiver strain compared to ICs providing minimal care [13.75\u0026thinsp;\u0026plusmn;\u0026thinsp;6.16 versus 9.82\u0026thinsp;\u0026plusmn;\u0026thinsp;7.16; F(2,76)\u0026thinsp;=\u0026thinsp;3.329, p\u0026thinsp;=\u0026thinsp;0.041]. Likely, dyads with a caregiver-oriented typology had higher caregiver strain when compared to patient oriented typology [14.97\u0026thinsp;\u0026plusmn;\u0026thinsp;5.60 versus 8.28\u0026thinsp;\u0026plusmn;\u0026thinsp;6.346; F(3,102)\u0026thinsp;=\u0026thinsp;6.475; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. Poor perceived caregiver quality of the relationship was also significantly associated with higher caregiver strain [16.07\u0026thinsp;\u0026plusmn;\u0026thinsp;6 versus 10.71\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. Unexpectedly, ICs of symptomatic patients [those with New York Heart Association classes III and IV] had lower caregiver strain than ICs of asymptomatic patients [9.90\u0026thinsp;\u0026plusmn;\u0026thinsp;7.43 versus 12.69\u0026thinsp;\u0026plusmn;\u0026thinsp;6.21; p\u0026thinsp;=\u0026thinsp;0.019].\u003c/p\u003e \u003cp\u003ePearson correlation was used to ascertain correlations between variables such as age, years since HF diagnosis, perceived social support, caregiving duration, caregiving hours, and mCSI score. COPE\u0026rsquo;s negative impact scale that relates to the IC\u0026rsquo;s personal feeling of being stressed in caregiving was significantly associated with caregiver strain [Pearson\u0026rsquo;s r\u0026thinsp;=\u0026thinsp;0.774; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. Likely, lower caregiver physical or mental quality of life were significantly associated with higher caregiver strain [r = -0.291 and \u0026minus;\u0026thinsp;0.536 respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001].\u003c/p\u003e \u003cp\u003eSelf-care affected caregiver strain in this sample. The higher the IC\u0026rsquo;s involvement in self-care management, the higher their strain was [r\u0026thinsp;=\u0026thinsp;0.298, p\u0026thinsp;=\u0026thinsp;0.002]. Similarly, the lower the patient self-care monitoring was the more strained were the caregivers [r = -0.224, p\u0026thinsp;=\u0026thinsp;0.025].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePredictors of Caregiver Strain\u003c/h2\u003e \u003cp\u003eDifferent variables were associated with caregiver strain as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. To explore relationships within the data more thoroughly, the mCSI was used as the outcome variable to create the best regression model using significant variables from the univariate analyses [please refer to Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e for Regression Analysis]. Predictors were retained in the regression model if they contributed significantly to the model or were conceptually relevant and did not negatively affect the variance.\u003c/p\u003e \u003cp\u003eA higher negative impact from caregiving [denoting high personal feeling of being stressed in caregiving], a lower physical and mental quality of life, and a lower caregiver perceived relationship quality explained about 63% of the variance in Caregiver Strain.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRegression Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted R2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnstandardized Beta\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandardized Beta\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.630\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e44.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.657\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelationship Quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.794\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-2.209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support - Negative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.960\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.601\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7.763\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical Quality of Life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-1.808\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental Quality of Life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-2.839\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e We evaluated caregiving strain among ICs of patients living with HF and identified its predictors through secondary analysis of a cross-sectional study that looked at dyadic determinants of self-care. To our knowledge, this is the first study to address perceived caregiving strain in HF patients in collectivist societies such as those in the MENA region.\u003c/p\u003e \u003cp\u003eResearch on self-care in patients living with cardiac problems has been growing internationally and in Lebanon and the MENA region. In one of the earlier studies on self-care in Lebanon, ICs of patients living with cardiac illness viewed caregiving as a moral and emotional duty to care for the family member stemming from obligation and responsibility towards their patients (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Despite this moral obligation, we highlighted moderate levels of caregiver strain among our sample of ICs. Moderate levels of caregiver strain were also reported earlier in a systematic review involving 12 papers with 4659 caregivers from eight Asian countries including one Arabic speaking country (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This same trend was seen in ICs of older adults with chronic illnesses living in Iran (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This similarity in strain severity could be due to cultural peculiarities and the complex medical profile of HF patients who have multimorbidity and complex self-care needs.\u003c/p\u003e \u003cp\u003e We also highlighted the unique roles women play in informal caregiving in collectivist societies like Lebanon. Women caregivers in collectivist societies see themselves in a position of responsibility towards the whole family (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This finding is confirmed in this study as over 85% of the ICs were women highlighting caregiving as an expected gender role for women in Lebanon. Other studies on older adults in Lebanon have had similar findings (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Although gender was not a significant predictor of caregiver strain, women caregivers were found to have higher caregiver strain than male caregivers, which could be due to the gender role in collectivist societies. This difference and a higher caregiver strain among women caregivers was seen in previous studies in the Lebanese setting (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). On the contrary, higher levels of strain were reported among male caregivers of Chinese chronically ill patients possibly explained by cultural norms and family structure in China (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eICs in this sample provided an average of 37.73\u0026thinsp;\u0026plusmn;\u0026thinsp;50.67 hours of caregiving per week which is equivalent to a full-time employment. More than a quarter of the ICs reported providing full care for their patient and highlighted that the care was done solely by them with minimal input from the patient; this underscores the high care dependency of patients living with HF. Most of the ICs in this sample were unemployed possibly because the majority are women, and this mirrors the high unemployment rates due to the financial conundrum facing Lebanon. Although not statistically significant, caregivers who were unemployed had higher caregiver strain than those who were employed. This could be because unemployment poses financial burdens and added caregiver strain and going to work may be seen as a respite for ICs. Income and current employment status of the members of the dyad did not have any significant impact on the strain level in this study; however, this was contradicted in a number of studies reporting financial strains and employment to be significantly associated with increased burden (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Financial strains were also associated with lower scores on the mental component of the quality of life of Chinese ICs (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHigher patient symptomatology was associated with lower caregiver strain in this sample. This contradicts findings of other studies that reported higher burden among ICs caring for patients with moderate to severe HF [New York Heart Association classes III and IV] compared with those caring for patients with mild HF (New York Heart Association classes I and II] (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). This could be explained by the notion that providing care to a person who is symptomatic and in need can be rewarding for a caregiver, as some studies have shown (\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and this can compensate the burden due to caregiving. Interestingly, we found that ICs providing full care to their patients reported significantly higher caregiver strain compared to those providing minimal or moderate care and being in a caregiver-oriented dyadic typology had the highest caregiver strain in this sample. This was not consistent with studies that highlighted that caregiver contributions to self-care maintenance and management were not significant predictors of caregiver burden (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePoor quality of the dyadic relationship as perceived by the IC was significantly associated with higher caregiver strain in this sample. Conceptually, relationship quality has been proposed to be a key factor in caregiver burden from caregiving, and caregiver depressive symptoms may significantly confound this relationship (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). This was confirmed in a study where relationship quality was positively associated with caregiver benefit and negatively associated with burden and depression (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Relationship quality and burden remained associated after controlling for depression. These findings further emphasize the critical role of perceived relationship quality in shaping caregiver strain among dyads living with HF. They highlight the need to move beyond individual-level assessments and incorporate relational evaluations into routine HF care. Systematic assessment of dyadic functioning may allow clinicians to identify caregivers at heightened risk for strain and to design interventions that strengthen relational resilience alongside symptom management.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrength and Limitations\u003c/h2\u003e \u003cp\u003e This secondary analysis suffers the limitations common to this type of analysis \u0026ndash; we were constrained by factors from the parent study such as cross-sectional design, convenience sampling, social desirability in self-report, and recruiting from both inpatient setting with greater patient needs and outpatient setting with lesser needs for caregiving. At the same time, this study has important strengths. To our knowledge, it is among the first in the MENA region to examine perceived caregiver strain in the context of HF while explicitly situating caregiving within a collectivist sociocultural framework. Although cross-sectional studies on caregiver burden have been conducted in other collectivist societies, such as China, and research on caregiver burden exists in countries like Saudi Arabia, prior work in the region has not clearly conceptualized or analytically linked caregiver strain to the underlying collectivist ethos in which caregiving is viewed as a familial and social obligation rather than an individual choice. By foregrounding this cultural lens, our study advances the discourse beyond prevalence estimates to a more contextualized understanding of strain within collectivist societies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, we found that different caregiver characteristics influence different dimensions of caregiver strain, and caregivers should be assessed for these potential determinants. HF nurses and physicians in the MENA region should start giving special attention to caregivers of HF patients particularly those who report feeling stressed in caregiving, have poorer quality of life and lower perceived relationship quality because they are more exposed to caregiver strain. Interventions to reduce HF caregiver strain should consider which dimensions of strain is affected in caregivers.\u003c/p\u003e \u003cp\u003eFinally, a very important finding in this study is that ICs have less strain when caring for the more functionally dependent or more symptomatic patients as this can compensate the burden due to caregiving. As such, healthcare providers can depend on ICs when patients need them most.\u003c/p\u003e \u003cp\u003eGovernments in the MENA region should recognize that caregiving is equivalent to a full-time employment and that more than a quarter of the ICs report that the care was done solely by them with minimal input from the patient underscoring the high care dependency of patients living with HF in this part of the world.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInformal Caregiver\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHF\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHeart Failure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMENA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMiddle East and North Africa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003emCSI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emodified Caregiver Strain Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCOPE\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarers of Older People in Europe Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u0026nbsp;\u003c/strong\u003eThis study\u0026nbsp;is in accordance with the Declaration of Helsinki and was approved by the American University of Beirut Institutional Review Board [Approval no. SBS-2018-0529] in December 2018. All participants signed an informed consent prior to the data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u003c/strong\u003e Not Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eNot Applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e \u003cem\u003eThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the\u0026nbsp;\u003c/em\u003e\u003cem\u003eUniversity Research Board \u003cem\u003eat the\u0026nbsp;\u003c/em\u003eAmerican University of Beirut.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions: AM\u003c/strong\u003e contributed to\u0026nbsp;Conceptualization, Funding Acquisition, Data Curation, Formal Analysis, Roles/Writing - Original Draft, and Writing - Review and Editing; \u003cstrong\u003eHD\u003c/strong\u003e contributed to\u0026nbsp;Writing - Original Draft; \u003cstrong\u003eHAH\u0026nbsp;\u003c/strong\u003eand\u003cstrong\u003e\u0026nbsp;HGB\u0026nbsp;\u003c/strong\u003econtributed to\u0026nbsp;Writing - Review and Editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eAuthors would like to acknowledge Mrs. Dayana ElChaar and Dr. Melissa Makhoul for their support throughout the data collection process as well as Coronary Care Unit Registered Nurses at the American University of Beirut who supported the tool translation and cultural validation process.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSchulz R, Sherwood PR. 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How Culture Shapes Informal Caregiver Motivations: A Meta-Ethnographic Review. Qual Health Res. 2022;32(10):1574\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin D, Liang D, Huang M, Xu X, Bai Y, Meng D. The dyadic effects of family resilience and social support on quality of life among older adults with chronic illness and their primary caregivers in multigenerational families in China: A cross-sectional study. Heliyon. 2024;10(5):e27351.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLipson JG, Meleis A. I. Issues in Health Care of Middle Eastern Patients. Western J Med. 1983;139:854\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlshammari B, Noble H, McAneney H, Alshammari F, O'Halloran P. Caregiver Burden in Informal Caregivers of Patients in Saudi Arabia Receiving Hemodialysis: A Mixed-Methods Study. Healthc (Basel). 2023;11(3):366.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDumit NY, Abboud S, Massouh A, Magilvy JK. Role of the Lebanese family caregivers in cardiac self-care: a collective approach. J Clin Nurs. 2015;24(21\u0026ndash;22):3318\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThornton M, Travis SS. Analysis of the reliability of the modified caregiver strain index. Journals Gerontol Ser B-Psychological Sci Social Sci. 2003;58(2):S127\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan WCH, Chan CLF, Suen M. Validation of the Chinese Version of the Modified Caregivers Strain Index among Hong Kong Caregivers: An Initiative of Medical Social Workers. Health Soc Work. 2013;38(4):214\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalducci C, Mnich E, McKee KJ, Lamura G, Beckmann A, Krevers B, et al. Negative impact and positive value in caregiving: validation of the COPE index in a six-country sample of carers. Gerontologist. 2008;48(3):276\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Shehri AH, Taha AZ, Bahnassy AA, Salah M. Health-related quality of life in type 2 diabetic patients. Ann Saudi Med. 2008;28(5):352\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuck HG, Kitko L, Hupcey JE. Dyadic heart failure care types: qualitative evidence for a novel typology. J Cardiovasc Nurs. 2013;28(6):E37\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTabachnick BG, Fidell LS. Using Multivariate Statistics. 6th ed. New Jersey: Pearson; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsac C, Lee P, Arulappan J. Older adults with chronic illness\u0026ndash;caregiver burden in the Asian context: a systematic review. Patient Educ Couns. 2021;104(12):2912\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSorayyanezhad A, Nikpeyma N, Nazari S, Sharifi F, Sarkhani N. The relationship of caregiver strain with resilience and hardiness in family caregivers of older adults with chronic disease: a cross-sectional study. BMC Nurs. 2022;21(1):184.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeoud J, Nehme C, Atallah R, Zablit C, Yeretzian J, Levesque L, et al. The health of family caregivers of older impaired persons in Lebanon: an interview survey. Int J Nurs Stud. 2007;44(2):259\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharbaji S, Ei Asmar K, McCall SJ, Saad GE, Chaaya M. Caregiver burden and mental health among informal caregivers of older adults in Lebanon. Discov Public Health. 2026;23(1):114.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie H, Cheng C, Tao Y, Zhang J, Robert D, Jia J, et al. Quality of life in Chinese family caregivers for elderly people with chronic diseases. Health Qual Life Outcomes. 2016;14(1):99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLahoz R, Proudfoot C, Fonseca AF, Loefroth E, Corda S, Jackson J, et al. Caregivers of Patients with Heart Failure: Burden and the Determinants of Health-Related Quality of Life. Patient Prefer Adherence. 2021;15:1153\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson EW, White KM. This is what family does: the family experience of caring for serious illness. Am J Hosp Palliat Med. 2018;35:348\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayes C, Bhandari N, Kathe N. Reliability and valid- ity of the medical outcomes study Short Form-12 version 2 (SF-12v2) in adults with non-cancer pain. Healthcare. 2017;5(22).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurante A, Greco A, Annoni AM, Steca P, Alvaro R, Vellone E. Determinants of caregiver burden in heart failure: does caregiver contribution to heart failure patient self-care increase caregiver burden? Eur J Cardiovasc Nurs. 2019;18(8):691\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrivedi RB, Piette J, Fihn SD, Edelman D. Examining the interrelatedness of patient and spousal stress in heart failure: conceptual model and pilot data. J Cardiovasc Nurs. 2012;27(1):24\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaunders MM. Factors associated with caregiver burden in heart failure family caregivers. West J Nurs Res. 2008;30(8):943\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLum HD, Lo D, Hooker S, Bekelman DB. Caregiving in heart failure: Relationship quality is associated with caregiver benefit finding and caregiver burden. Heart Lung. 2014;43(4):306\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dyads, Informal Caregivers, Perceived Caregiver Strain, Informal Caregivers, Collectivist Societies","lastPublishedDoi":"10.21203/rs.3.rs-8870946/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8870946/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInformal caregivers represent the backbone of community-based Heart Failure management, providing nearly 90% of long-term in-home care. Within the caregiving science framework, they function as primary care partners and essential contributors to dyadic illness management. However, the high care dependency associated with Heart Failure, coupled with limited formal system support, places these caregivers at elevated risk for caregiver burden, role strain, and adverse psychosocial outcomes. The aim of this seconday analysis is to identify predictors of caregiver strain among informal caregivers of patients living with Heart Failure in a collectivist society.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e108 patient caregiver who completed questionnaires on caregiver strain, social support, quality of life, caregiving context and needs, caregivers\u0026rsquo; appraisal of dyadic relationship quality, and dyadic typology. Bivariate analyses were conducted to examine associations between caregiver strain and relevant sociodemographic, clinical, and relational variables. Variables significant at the bivariate level were subsequently entered into a multivariable linear regression model to identify independent predictors of caregiver strain.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOn average 37.73\u0026thinsp;\u0026plusmn;\u0026thinsp;50.67 hours were dedicated for caregiving by informal caregivers. In this sample, decreased caregiver strain was associated with increased patient symptomatology while significant association was identified between increased caregiver strain and poor perceived dyadic relationship quality. A higher feeling of being stressed in caregiving, a lower mental quality of life, and a lower caregiver perceived relationship quality explained about 63% of the variance in Caregiver Strain.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFindings from this study underscore the central role of caregiver strain within the Heart Failure caregiving dyad and highlight the need for systematic assessment of caregiver burden in clinical practice. By proactively identifying caregiver strain and addressing modifiable psychosocial and relational determinants, healthcare professionals can enhance caregiving effectiveness, support adaptive dyadic functioning, and safeguard caregivers\u0026rsquo; psychological and physical well-being. Integrating caregiver-focused education on self-care, symptom management, structured discharge planning, and longitudinal follow-up into routine Heart Failure care may promote more sustainable informal caregiving in collectivist contexts.\u003c/p\u003e","manuscriptTitle":"Perceived Caregiver Strain in Carers of Patients Living with Heart Failure in Collectivist Societies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-26 15:52:18","doi":"10.21203/rs.3.rs-8870946/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-08T02:16:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223660677187495303865121043261413779481","date":"2026-03-30T05:48:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-25T04:37:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-23T09:25:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-19T12:00:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-19T11:57:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-02-13T10:41:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6f0936c4-d173-40f9-ab46-5a48ca9dadd0","owner":[],"postedDate":"March 26th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-26T15:52:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-26 15:52:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8870946","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8870946","identity":"rs-8870946","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}