Impact of Post-Traumatic Stress Disorder among Home Care-givers of COVID-19 Patients Visiting Tertiary Care Hospitals of Peshawar

Impact of Post-Traumatic Stress Disorder among Home Care-givers of COVID-19 Patients Visiting Tertiary Care Hospitals of Peshawar | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Post-Traumatic Stress Disorder among Home Care-givers of COVID-19 Patients Visiting Tertiary Care Hospitals of Peshawar Bibi Nahida, Naveed Ullah, Dr Khalid Rehman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8915151/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The COVID-19 pandemic has exerted significant psychological distress on their patients but also on their family caregivers. Home caregivers to the infected people are especially exposed to stress related disorders because of the lasting exposure, the fear of transmission, and social isolation. There is, however, paucity in evidence on the aspects of post-traumatic stress disorder (PTSD) symptoms among low-income and middle-income countries (including Pakistan) home caregivers. Methods The study was a descriptive cross-sectional study that was conducted at a time interval of November 2023 to September 2024, on 384 home caregivers of patients with COVID-19 in tertiary care hospitals in Peshawar, Pakistan. Recruitment of participants was done through consecutive sampling. A structured questionnaire was used whereby the Impact of Event Scale-Revised (IES-R) was included to gather the data. Cross-tabulation and descriptive statistics analyses were conducted using SPSS version 25 and the level of significance was set to p < 0.05. Results A total of 384 respondents took part in the survey of which 348 responded to the survey and were used in final analysis. Most of the caregivers were found to have moderate to high PTSD symptoms. In general, 80.3% of the participants had a score that fell in the range of clinically significant psychological distress. Women caregivers had a high score in PTSD as compared to males (p = 0.015). Married participants had also more distress levels than unmarried caregivers. There were no major differences that were observed according to place of residence. Conclusion The home caregivers working with COVID-19 patients were under a significant psychological distress, and the prevalence of symptoms associated with PTSD was high. The female and married caregivers were at a disadvantage. These results provide a clear insight into the extreme necessity of specific mental health screening, psychosocial support initiatives, and gender-specific caregiver interventions during and after the occurrence of a public health emergency. COVID-19 PSTD Stress Pandemic Caregivers Psychological Data Analysis Figures Figure 1 INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges to global health systems and has profoundly affected the physical, social, and psychological well-being of individuals and communities ( 1 ). Beyond its immediate medical consequences, the pandemic has generated long-term psychological distress among affected populations. ( 2 ). A systematic review and meta-analysis revealed that 11% of healthcare workers experienced PTSD after the SARS outbreak, underscoring the frontline staff's long-term psychological vulnerability. More recent data also shows that the mental health burden endures for a long time after outbreaks. ( 3 ). Few research has looked at how the COVID-19 pandemic affected mental health in the early stages of the pandemic. However, a handful of studies that gathered information in the first half of 2020 did note that HCWs were suffering from considerable psychological impairment during the COVID-19 pandemic, such as sadness and anxiety ( 4 ). Besides the acute effects on health caused by COVID-19, this pandemic has also had long-term effects. Posttraumatic stress disorder (PTSD) was reported to be more prevalent among health care workers (HCWs) than in the general population during the SARS epidemic, according to studies on those who survived of prior coronavirus epidemics, such as the severe acute respiratory syndrome (SARS) epidemic ( 5 ). Because of their anxieties and embarrassment over letting strangers into their homes who could bring a virus, homecare may find it extra harder to seek assistance today. Although the rise of telehealth is offering an essential remedy, there are still significant gaps in internet availability and digital competence among substantial smaller populations of family caregivers, especially those who are elderly and in remote locations ( 6 ). Following infectious disease outbreaks, a sizable number of people have been shown to experience mental health issues, including recovered patients, victims' relatives, medical professionals, and members of the public. While most of these issues often go away after the pandemic, PTSD symptoms can linger for a longer time and cause serious grief and incapacity ( 7 ). According to surveys, almost everyone has gone through at least one traumatic event in their lifetime, and the type of trauma greatly affects the chance of developing PTSD ( 8 ). The spread of this lethal sickness has affected several connections and important specialists, largely the medical professionals who have immediate touch with the patients. Each nation and hospital Centre made extraordinary steps to be ready to handle the huge inflow of victims. ICUs (Intensive Care Units) had significant effects. In Pakistan, delaying and postpone a significant portion of surgical activities allowed for a two-fold increase in the number of ICU beds. Additionally, the available medical personnel may be beneficial for these extra ICU beds. For professionals to start working as soon as feasible, training must happen promptly. All these circumstances and adjustments in the life of a person may influence that person's psychological health. A horrific incident can cause post-traumatic stress disorder (PTSD), a mental health disease that can be brought on by experiencing it or seeing it. Flashbacks, nightmares, excruciating anxiety, and uncontrolled thoughts about the incident are just a few possible symptoms. In international lifespan surveys, the average rate of PTSD is 3.9 percent overall and 5.6 percent among those who have experienced trauma. In national surveys of the general adult population in the United States and Canada, the average lifetime incidence of PTSD is reported to vary from 6.1 to 9.2 percent, with one-year incidences of 3.5 to 4.7 percent ( 9 ) Many home-based caregivers have occupations that do not allow them to work remotely; as a result, they might have to remain working within of their homes and run the danger of infecting their families with viruses. Due to closing schools, some family caregivers may be forced to shoulder extra parenting and a homeschooling duty in addition to striving to complete their job and caregiving obligations at home. Need to pay close attention to the different vulnerabilities that the global health crisis introduces since they have the potential to negatively impact on caregiver’s psychological health. With COVID-19, caregivers must make an additional set of challenging healthcare choices that will probably exacerbate unpleasant self-questioning about if they are choosing the best course of action for the people, they are providing care for. MATERIAL AND METHODS Study design and Settings : A descriptive cross-sectional study was conducted between November 2023 and September 2024 among home caregivers of patients diagnosed with COVID-19. The study was carried out in three tertiary care hospitals in Peshawar, Khyber Pakhtunkhwa, Pakistan, which were designated centers for the management of COVID-19 cases during the study period. Sample Size and Sampling Technique: The study population comprised primary home caregivers of COVID-19 patients who had received treatment in specialized isolation units of the selected hospitals. Caregivers were recruited using a consecutive sampling technique. Participants were approached during hospital visits and follow-up encounters and were invited to participate voluntarily. A total of 384 caregivers were initially enrolled. After excluding incomplete questionnaires, data from 348 participants were included in the final analysis. Inclusion and Exclusion Criteria Caregivers aged 18 years or older who had provided home-based care to a confirmed COVID-19 patient for at least one hour per day were eligible for inclusion. Only first-degree relatives who lived with the patient before and after hospitalization were considered. Caregivers with a self-reported history of diagnosed psychiatric disorders, those who were seriously ill at the time of data collection, and individuals unwilling to provide informed consent were excluded from the study. Data Collection Instrument : Data were collected using a structured, self-administered questionnaire consisting of two sections. The first section assessed sociodemographic characteristics, including age, gender, marital status, educational level, and place of residence. The second section incorporated the Impact of Event Scale–Revised (IES-R), a validated 22-item instrument designed to measure post-traumatic stress symptoms related to traumatic events. Each item of the IES-R is scored on a five-point Likert scale ranging from 0 (not at all) to 4 (extremely), with higher scores indicating greater psychological distress. The scale evaluates three symptom domains: intrusion, avoidance, and hyperarousal. Data Collection Procedure After obtaining institutional permission, eligible participants were approached by trained research assistants. The objectives and procedures of the study were explained in detail, and written informed consent was obtained. Participants completed the questionnaire in a quiet setting within the hospital premises or during scheduled follow-up visits. Assistance was provided to participants with limited literacy when required. Ethical A pproval : Home caregivers completed a self-administered questionnaire to gather data. The Ethical Review Committee of the Institute of Public Health and Social Sciences at the Khyber Medical University in Peshawar, Pakistan conducted a review and approved the study protocol. This paper was carried out in compliance with the ethical principles of the institutional ethics committee, as well as those of the Declaration of Helsinki. All participants signed the informed consent written before data collection. Strict confidentiality and anonymity of study participants were treated during the study. All safeguards for data privacy and anonymity were appropriately considered. Data Analysis Data were entered and analyzed using Statistical Package for the Social Sciences (SPSS) version 25. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated for demographic and clinical variables. The total IES-R score was computed by summing individual item scores. Participants were categorized into levels of psychological distress based on established cut-off values. Cross-tabulation and chi-square tests were used to examine associations between PTSD symptoms and sociodemographic variables. A p-value of less than 0.05 was considered statistically significant. RESULTS A total of 384 caregivers were recruited for the study. After excluding incomplete questionnaires, data from 348 participants were included in the final analysis, yielding a response rate of 90.6%. Among the participants, 199 (57.2%) were female, 153 (44.0%) were male, and 55 (15.8%) did not report their gender. The mean age of participants ranged from 22 to 70 years, with the highest proportion falling within the 25–30-year age group. More than half of the respondents were married (188, 54.0%), while 160 (46.0%) were unmarried. Regarding educational status, 36 (10.3%) had completed matriculation, 78 (22.4%) had intermediate education, and 160 (46.0%) were graduates. In terms of residence, 195 (56.0%) participants resided in urban areas, whereas 153 (44.0%) were from rural regions. Table 1: showing the overall gender distribution in sample data: Gender Frequency (%) Male 153 (38 %) Female 199(49 %) Not specified 55(13 %) Marital Status Single 160(46 %) Married 188(54 %) Level of Education Matric 36(10.34 %) Intermediate 78(22.41 %) Graduate 160(45.97 %) Urban 195(56 %) Rural 153(44 %) The male correspondents' ages ranged from 22 to 70 years old. The highest density of correspondents falls in age between 25-30 years (around 53 individuals) for females, while male correspondents were 29 in same age group. Analysis of individual IES-R items showed that intrusive and hyperarousal symptoms were particularly prevalent among participants. Approximately 27.0% of caregivers reported experiencing reminders of the traumatic event “a little bit,” while 16.9% reported experiencing them “extremely.” Sleep-related disturbances were common, with 36.3% reporting moderate difficulty in staying asleep. Feelings of irritability and anger were reported at moderate to high levels by 63.7% of participants. More than half of the respondents (52.3%) reported feeling moderately watchful and on guard. Concentration difficulties were also prominent, with 38.2% of participants reporting extreme difficulty concentrating. Emotional numbness and avoidance behaviors were frequently reported, indicating persistent psychological distress. Table 2 Item-Level Responses on the IES-R Variables Not at all A little bit Moderately Quite a bit Extremely Mean (SD) 0 1 2 3 4 Any reminder brought back feelings about it 62 (17.5%) 96 (27 %) 82 (23.1%) 54 (15.2%) 60(16.9%) 1.87 (1.33) I had trouble staying asleep 45 (12.7) 83 (23.4) 129 (36.3) 66 (18.6) 31 (8.7) 1.87 (1.126) Other things kept making me think about it. 42 (11.8) 75 (21.1) 97 (27.3) 100 (28.2) 40 (11.3) 2.06 (1.192) felt irritable and angry 51 (14.4 %) 77 (21.7%) 92 (25.9%) 90 (25.4%) 44 (12.4%) 2.0 (1.245) I avoided letting myself get upset when I thought about it or was reminded of it 37 (10.4%) 75 (21.1%) 97 (27.3%) 75 (21.1%) 70 (19.7%) 2.19 (1.266) I thought about it when I didn't mean 59 (16.6%) 85 (23.9%) 110 (31%) 75 (21.1%) 25 (7%) 1.78 (1.165) I felt as if it hadn't happened or wasn't real. 42 (11.8%) 71 (20%) 113 (31.8%) 76 (21.4%) 52 (14.6%) 2.07 (1.215) I stayed away from reminders of it. 36 (10.1%) 81 (22.8%) 113 (31.8%) 71 (20%) 53 (14.9%) 2.07 (1.198) Pictures about it popped into my mind 32 (9%) 56 (15.8%) 109 (30.7%) 104 (29.3%) 53 (14.9%) 1.163) I was jumpy and easily startled. 39 (11%) 76 (21.4%) 118 (33.2%) 75 (21.1%) 46 (13%) 2.04 (1.179) I tried not to think about it. 45 (12.7%) 74 (20.8%) 99 (27.9%) 76 (21.4%) 60 (16.9%) 2.09 (1.267) I was aware that I still had a lot of feelings about it, but I didn't deal with them. 36 (10.1%) 64 (18%) 123 (34.6%) 94 (26.5%) 37 (10.4%) 2.09 (1.125) My feelings about it were kind of numb 34 (9.6%) 74 (20.8%) 115 (32.4%) 99 (27.9%) 32 (9%) 2.06 (1.111) I found myself acting or feeling like was back at that time. 42 (11.8%) 72 (20.3%) 98 (27.6%) 84 (23.7%) 57 (16.1%) 2.13 (1.254) I had trouble falling asleep. 46 (13%) 70(19.7%) 116 (32.7%) 82 (23.1%) 40(11.3%) 2.0 (1.185) I had waves of strong feelings about it. 48 (13.5%) 70 (19.7%) 89 (25.1%) 90 (25.4%) 57 (16.1%) 2.10 (1.277) I tried to remove it from my memory. 52 (14.6%) 51 (14.4%) 96 (27%) 83 (23.4%) 72 (20.3%) 2.20 (1.32) I had trouble concentrating 41 (11.5%) 80 (22.5%) 95 (26.8%) 91 (25.6%) 47 (13.2%) 2.06 (1.215) Reminders of it caused me to have physical reactions 45 (12.7%) 83 (23.4%) 106 (29.9%) 72 (20.3%) 48 (13.5%) 1.222) I had dreams about it. 52 (14.6%) 73 (20.6%) 110 (31%) 86 (24.2%) 33 (9.3%) 1.93 (1.187) I felt watchful and on-guard. 35 (9.9%) 70 (19.7%) 128 (36.1%) 90 (25.4%) 31 (8.7%) 2.03 (1.095) I tried not to talk about it 54 (15.2%) 57 (16.1%) 90 (25.4%) 78 (22%) 75 (21.1%) 2.181 (1.34) Assessment using the Impact of Event Scale–Revised (IES-R) revealed that the majority of caregivers experienced moderate to high levels of post-traumatic stress symptoms. The mean total IES-R score was 3.60 ± 0.87. Based on established cut-off scores, 24 participants (6.8%) were classified as having no PTSD symptoms, 22 (6.2%) had partial symptoms, 23 (6.5%) met the criteria for probable PTSD, and 285 (80.3%) demonstrated scores indicative of clinically significant psychological distress. Tables 3 Prevalence and Severity of PTSD Symptoms Frequency(%) Mean (SD) No PTSD 24(6.8%) 3.60 (0.87) Partial PTSD 22(6.2) Probable Diagnosis of PTSD 23(6.5) High enough to suppress your immune system 285(80.3) Cross-tabulation analysis demonstrated a statistically significant association between gender and PTSD severity (χ² test, p = 0.015). Female caregivers were more likely to exhibit higher levels of psychological distress compared with male caregivers. Marital status was also associated with PTSD symptoms, with married participants showing higher levels of distress than unmarried individuals (p = 0.073). No statistically significant associations were observed between PTSD severity and place of residence, educational level, or age group. Table 4 Association Between PTSD Symptoms and Sociodemographic Variables Gender No PTSD Partial PTSD Probable Diagnosis of PTSD suppress your immune system P-value Males 17 6 8 121 0.015 Females 7 16 15 164 Single 13 16 14 118 0.073 Married 11 6 9 166 DISCUSSION Overall, we discovered that individuals exhibited PTSD-like symptoms for hypothetical future scenarios, which calls into question the idea that traumatic stress is an issue that exclusively affects the past. Participants challenged the notion that people must encounter a direct, in-person incident to acquire PTSD-like symptoms by describing these emotions regardless of whether they had been personally exposed to COVID-19. This finding is consistent with previous studies that reported elevated psychological distress among individuals indirectly exposed to pandemics through caregiving, media coverage, and prolonged uncertainty. (2,5). These studies suggest that perceived threat and emotional burden may play a critical role in the development of trauma-related symptoms, even in the absence of direct infection. While in contrast fever cases (29.16%) have been detected among health care workers to have PTSD in India (10). This indicates that while caregivers in our study demonstrated higher PTSD prevalence, healthcare workers also faced substantial psychological consequences, though with slightly lower overall rates. In the current study a statistically significant difference has been found between demographics and PTSD. More females were found to have PTSD as compared to males (p= 0.015). Similarly, there was more prevalence of PTSD among married as compared to those who were single (p=0.07). However, there was no difference among the rural and urban people having PTSD. Similarly, in other studies the risk for females to have PTSD is twice as males during their lifetime. These results are in line with previous studies that found women are almost twice as likely as men to acquire PTSD, a difference that is thought to be caused by increased exposure to traumatic events and potential biological sensitivity. (11) Biological vulnerability, hormonal factors, and socially constructed caregiving roles may partly explain this disparity. In Pakistan, women are often primary caregivers, which may further increase their emotional burden during illness. Most of the respondents have moderate responses on IES-R scale, indicating persistent intrusive thoughts, sleep disturbance, and emotional distress, and their experience and feeling during the events. These results are in line with research on COVID-19 patients who also exhibited moderate levels of PTSD symptoms in the post-recovery phase. (12). Interestingly, 15.4% of participants screened positive for PTSD even when exposure did not fully meet the diagnostic criteria, indicating that PTSD symptoms may arise from subjective perceptions and emotional reactions to caregiving during the pandemic as well as direct exposure. These findings support the increasing evidence that emotional burden and perceived stress can be more powerful predictors of traumatic stress reactions than actual exposure levels.(7) Similar studies have demonstrated a strong correlation between family caregivers' occupation and mental health and their risk of developing PTSD, anxiety, and depression. Research done during COVID-19 also highlights that caregivers are more vulnerable psychologically than the general population, especially those who work in long-term or home-based settings (13). The assumption that traumatic events are frequently remembered with vivid sensory and perceptual features but are not well incorporated into autobiographical memory is supported by recent findings. Flashbacks and other fragmentary, intrusive memories are the outcome of this. PTSD-related memories are vivid but disjointed, which interferes with meaning-based processing and emotional control, according to a 2025 review of trauma memory research (14) . These models concentrate on PTSD developing for specific types of external events. As a result, they do not take into consideration symptoms brought on by expected occurrences, trauma that was experienced indirectly, or circumstances that did not fit Criterion A. Instead, our results are consistent with a pathogenic event memory model that takes into consideration traumatic stress because of upcoming or imagined occurrences. Caregiver presence has often been linked to improved patient outcomes, especially in chronic illness management. In our study, however, male caregivers reported lower overall mental health compared with females, despite having slightly lower levels of anxiety and depression. Notably, 16.8% of female participants reported PTSD symptoms, underscoring the gendered differences in psychological vulnerability during caregiving (5) A study argues that, based on experience and improved coping mechanisms, this trend is suggestive of stronger resilience among female home caregivers during the pandemic, however further study is needed to confirm this. Additionally, gender disparities were discovered by separate analysis of the supplemental data for male and female caregivers. It's interesting to note that male caregivers reported lower levels of anxiety and depressed symptoms in the study (15). In the survey neutrality was also captured in the assigned questionnaire, the highest recorded against the item no.5 i.e. letting oneself get upset from past events, which is around 4%. The feeling of numbness was characterized a little bit by around 44.8% of the overall surveyed sample. We discovered that during the COVID-19 pandemic, family caregivers positive and negative feelings about the epidemic interacted and coexisted with the psychological and practical difficulties associated with providing care. Strengths and limitations The main strength of this study is its systematic approach and focus on an underexplored population—home caregivers of COVID-19 patients. Studying has several limitations. First off, the outcomes of the bulk of the investigations, which were restricted to two general hospitals, and cannot be generalized. Given the coronavirus outbreak's fast evolution and the need for advice to help family caregivers in similar situations, our quick review avoided grey literature in favor of peer-reviewed primary data publications. It is important to remember that this review is not complete and that it could have overlooked pertinent pieces, such as those published in magazines written in languages other than English. The study's limitations include a limited sample from two hospitals, potentially affecting the generalizability of findings. These factors might have affected the extent to which the evidence was. Despite these limitations, the study offers insightful information about PTSD symptoms experienced by caregivers during the pandemic. CONCLUSION Regardless of direct exposure, the majority of home caregivers of COVID-19 patients experience PTSD-like symptoms, highlighting the significant psychological burden they face. These findings highlight the critical need for gender-sensitive methods, specialized mental health therapies, and increased understanding of the psychological vulnerabilities of caregivers. Despite being restricted to just two hospitals, the study offers data that can guide more comprehensive caregiver support plans during and after pandemics. Prioritizing caregiver mental health will be crucial for fostering resilience and maintaining high-quality patient care as healthcare systems continue to change. Recommendations 1-Mental Health Support Programs: Establish mental health support programs for home caregivers, especially those providing care to COVID-19 patients. These programs should focus on addressing PTSD-like symptoms and offer coping strategies. 2-Gender-Specific Interventions: Design interventions considering gender disparities in caregivers. Explore tailored approaches for both male and female caregivers, recognizing potential differences in resilience and stress response. 3-Educational Initiatives: Implement educational initiatives to increase awareness about the psychological impact of caregiving during pandemics. Target both formal and informal caregivers, providing resources for managing stress and promoting mental well-being. 4-Regular Screening for PTSD Symptoms: Introduce regular screening for PTSD symptoms in caregivers, even those indirectly exposed to COVID-19. Early identification and intervention can mitigate the long-term psychological effects. 5-Collaboration with Mental Health Professionals: Foster collaboration between healthcare facilities and mental health professionals to provide comprehensive support for caregivers. This includes integrating mental health services into routine care for COVID-19 patients. Consent for Publication: Not applicable. The manuscript does not contain any individual person’s identifiable data in any form. Declarations Consent for Publication: Not applicable. The manuscript does not contain any individual person’s identifiable data in any form. Consent to Partici pate Written informed consent was obtained from all participants prior to their inclusion in the study. Participation was voluntary, and participants were informed of their right to withdraw at any time without any consequences. Data Availability The datasets generated during and analyzed during the current study can be obtained from corresponding author upon reasonable request . Declaration of Conflict of Interest All authors have no conflict of interest. Funding There is no funding received for this study. Clinical Trial Number Not applicable. References Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579(7798):270–3. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912–20. 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Investigating predictors of post-traumatic stress disorder in patients with covid- 19 discharged from the hospital صیخرت 19 - دیووك هب لاتبم نارامی ب رد هحناس زا سپ سرتسا للاتخا هدننك ينیب شی پ لماوع يسررب ناتسرامیب زا هدش. 2023;9(2):171–86. Adanir H, Erdogan A. Evaluation of Coronavirus Disease 2019-Related Anxiety, Depression, and Post-Traumatic Stress Disorder in Liver Transplantation Recipients and Their Caregivers. Cerrahpasa Med J. 2023;47(2):229–34. Manzanero AL, Guarch-Rubio M, Vallet R, Vara A. On post-traumatic stress disorder and the accessibility of memories: traumatic memories in refugees and asylum seekers. Psychiatry, Psychol Law. 2025;1–14. Cohen JB, Hanff TC, William P, Sweitzer N, Rosado-Santander NR, Medina C, et al. Continuation versus discontinuation of renin–angiotensin system inhibitors in patients admitted to hospital with COVID-19: a prospective, randomised, open-label trial. Lancet Respir Med. 2021;9(3):275–84. 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Beyond its immediate medical consequences, the pandemic has generated long-term psychological distress among affected populations. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). A systematic review and meta-analysis revealed that 11% of healthcare workers experienced PTSD after the SARS outbreak, underscoring the frontline staff's long-term psychological vulnerability. More recent data also shows that the mental health burden endures for a long time after outbreaks. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Few research has looked at how the COVID-19 pandemic affected mental health in the early stages of the pandemic. However, a handful of studies that gathered information in the first half of 2020 did note that HCWs were suffering from considerable psychological impairment during the COVID-19 pandemic, such as sadness and anxiety (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Besides the acute effects on health caused by COVID-19, this pandemic has also had long-term effects. Posttraumatic stress disorder (PTSD) was reported to be more prevalent among health care workers (HCWs) than in the general population during the SARS epidemic, according to studies on those who survived of prior coronavirus epidemics, such as the severe acute respiratory syndrome (SARS) epidemic (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Because of their anxieties and embarrassment over letting strangers into their homes who could bring a virus, homecare may find it extra harder to seek assistance today. Although the rise of telehealth is offering an essential remedy, there are still significant gaps in internet availability and digital competence among substantial smaller populations of family caregivers, especially those who are elderly and in remote locations (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Following infectious disease outbreaks, a sizable number of people have been shown to experience mental health issues, including recovered patients, victims' relatives, medical professionals, and members of the public. While most of these issues often go away after the pandemic, PTSD symptoms can linger for a longer time and cause serious grief and incapacity (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). According to surveys, almost everyone has gone through at least one traumatic event in their lifetime, and the type of trauma greatly affects the chance of developing PTSD (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe spread of this lethal sickness has affected several connections and important specialists, largely the medical professionals who have immediate touch with the patients. Each nation and hospital Centre made extraordinary steps to be ready to handle the huge inflow of victims. ICUs (Intensive Care Units) had significant effects. In Pakistan, delaying and postpone a significant portion of surgical activities allowed for a two-fold increase in the number of ICU beds. Additionally, the available medical personnel may be beneficial for these extra ICU beds. For professionals to start working as soon as feasible, training must happen promptly. All these circumstances and adjustments in the life of a person may influence that person's psychological health.\u003c/p\u003e \u003cp\u003eA horrific incident can cause post-traumatic stress disorder (PTSD), a mental health disease that can be brought on by experiencing it or seeing it. Flashbacks, nightmares, excruciating anxiety, and uncontrolled thoughts about the incident are just a few possible symptoms. In international lifespan surveys, the average rate of PTSD is 3.9 percent overall and 5.6 percent among those who have experienced trauma. In national surveys of the general adult population in the United States and Canada, the average lifetime incidence of PTSD is reported to vary from 6.1 to 9.2 percent, with one-year incidences of 3.5 to 4.7 percent (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMany home-based caregivers have occupations that do not allow them to work remotely; as a result, they might have to remain working within of their homes and run the danger of infecting their families with viruses. Due to closing schools, some family caregivers may be forced to shoulder extra parenting and a homeschooling duty in addition to striving to complete their job and caregiving obligations at home.\u003c/p\u003e \u003cp\u003eNeed to pay close attention to the different vulnerabilities that the global health crisis introduces since they have the potential to negatively impact on caregiver\u0026rsquo;s psychological health. With COVID-19, caregivers must make an additional set of challenging healthcare choices that will probably exacerbate unpleasant self-questioning about if they are choosing the best course of action for the people, they are providing care for.\u003c/p\u003e"},{"header":"MATERIAL AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and Settings\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc170326090\"\u003eA descriptive cross-sectional study was conducted between November 2023 and September 2024 among home caregivers of patients diagnosed with COVID-19. The study was carried out in three tertiary care hospitals in Peshawar, Khyber Pakhtunkhwa, Pakistan, which were designated centers for the management of COVID-19 cases during the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size and Sampling Technique:\u003c/strong\u003e\u003cspan id=\"_Toc170326094\"\u003e\u0026nbsp;The study population comprised primary home caregivers of COVID-19 patients who had received treatment in specialized isolation units of the selected hospitals. Caregivers were recruited using a consecutive sampling technique. Participants were approached during hospital visits and follow-up encounters and were invited to participate voluntarily. A total of 384 caregivers were initially enrolled. After excluding incomplete questionnaires, data from 348 participants were included in the final analysis.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCaregivers aged 18 years or older who had provided home-based care to a confirmed COVID-19 patient for at least one hour per day were eligible for inclusion. Only first-degree relatives who lived with the patient before and after hospitalization were considered.\u003c/p\u003e\n\u003cp\u003eCaregivers with a self-reported history of diagnosed psychiatric disorders, those who were seriously ill at the time of data collection, and individuals unwilling to provide informed consent were excluded from the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Instrument\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eData were collected using a structured, self-administered questionnaire consisting of two sections. The first section assessed sociodemographic characteristics, including age, gender, marital status, educational level, and place of residence. The second section incorporated the Impact of Event Scale\u0026ndash;Revised (IES-R), a validated 22-item instrument designed to measure post-traumatic stress symptoms related to traumatic events.\u003c/p\u003e\n\u003cp\u003eEach item of the IES-R is scored on a five-point Likert scale ranging from 0 (not at all) to 4 (extremely), with higher scores indicating greater psychological distress. The scale evaluates three symptom domains: intrusion, avoidance, and hyperarousal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter obtaining institutional permission, eligible participants were approached by trained research assistants. The objectives and procedures of the study were explained in detail, and written informed consent was obtained. Participants completed the questionnaire in a quiet setting within the hospital premises or during scheduled follow-up visits. Assistance was provided to participants with limited literacy when required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical A\u003c/strong\u003e\u003cstrong\u003epproval\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Home caregivers completed a self-administered questionnaire to gather data. The Ethical Review Committee of the Institute of Public Health and Social Sciences at the Khyber Medical University in Peshawar, Pakistan conducted a review and approved the study protocol. This paper was carried out in compliance with the ethical principles of the institutional ethics committee, as well as those of the Declaration of Helsinki. All participants signed the informed consent written before data collection. Strict confidentiality and anonymity of study participants were treated during the study. All safeguards for data privacy and anonymity were appropriately considered.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData were entered and analyzed using Statistical Package for the Social Sciences (SPSS) version 25. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated for demographic and clinical variables.\u003c/p\u003e\n\u003cp\u003eThe total IES-R score was computed by summing individual item scores. Participants were categorized into levels of psychological distress based on established cut-off values. Cross-tabulation and chi-square tests were used to examine associations between PTSD symptoms and sociodemographic variables. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 384 caregivers were recruited for the study. After excluding incomplete questionnaires, data from 348 participants were included in the final analysis, yielding a response rate of 90.6%.\u003c/p\u003e\n\u003cp\u003eAmong the participants, 199 (57.2%) were female, 153 (44.0%) were male, and 55 (15.8%) did not report their gender. The mean age of participants ranged from 22 to 70 years, with the highest proportion falling within the 25\u0026ndash;30-year age group. More than half of the respondents were married (188, 54.0%), while 160 (46.0%) were unmarried.\u003c/p\u003e\n\u003cp\u003eRegarding educational status, 36 (10.3%) had completed matriculation, 78 (22.4%) had intermediate education, and 160 (46.0%) were graduates. In terms of residence, 195 (56.0%) participants resided in urban areas, whereas 153 (44.0%) were from rural regions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: showing the overall gender distribution in sample data:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"463\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u0026nbsp;\u003c/strong\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e153 (38 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e199(49 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e55(13 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e160(46 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e188(54 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of Education\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eMatric\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e36(10.34 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eIntermediate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e78(22.41 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eGraduate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e160(45.97 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e195(56 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e153(44 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;The male correspondents\u0026apos; ages ranged from 22 to 70 years old. The highest density of correspondents falls in age between 25-30 years (around 53 individuals) for females, while male correspondents were 29 in same age group.\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc170283762\"\u003eAnalysis of individual IES-R items showed that intrusive and hyperarousal symptoms were particularly prevalent among participants. Approximately 27.0% of caregivers reported experiencing reminders of the traumatic event \u0026ldquo;a little bit,\u0026rdquo; while 16.9% reported experiencing them \u0026ldquo;extremely.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSleep-related disturbances were common, with 36.3% reporting moderate difficulty in staying asleep. Feelings of irritability and anger were reported at moderate to high levels by 63.7% of participants. More than half of the respondents (52.3%) reported feeling moderately watchful and on guard.\u003c/p\u003e\n\u003cp\u003eConcentration difficulties were also prominent, with 38.2% of participants reporting extreme difficulty concentrating. Emotional numbness and avoidance behaviors were frequently reported, indicating persistent psychological distress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eItem-Level Responses on the IES-R\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"759\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Variables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot at all\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eA little bit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModerately\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuite a bit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExtremely\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col\u003e\n \u003cli\u003eAny reminder brought back feelings about it\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e62 (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e96 (27 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e82 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e54 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e60(16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e1.87 (1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"2\"\u003e\n \u003cli\u003eI had trouble staying asleep\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e45 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e83 (23.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e129 (36.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e66 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e31 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e1.87 (1.126)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"3\"\u003e\n \u003cli\u003eOther things kept making me think about it.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e42 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e75 (21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e97 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e100 (28.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e40 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.06 (1.192)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003col start=\"4\"\u003e\n \u003cli\u003efelt irritable and angry\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e51 (14.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e77 (21.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e92 (25.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e90 (25.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e44 (12.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2.0 (1.245)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"5\"\u003e\n \u003cli\u003eI avoided letting myself get upset when I thought about it or was reminded of it\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e37 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e75 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e97 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e75 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e70 (19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.19 (1.266)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"6\"\u003e\n \u003cli\u003eI thought about it when I didn\u0026apos;t mean\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e59 (16.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e85 (23.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e110 (31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e75 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e25 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e1.78 (1.165)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"7\"\u003e\n \u003cli\u003eI felt as if it hadn\u0026apos;t happened or wasn\u0026apos;t real.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e42 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e71 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e113 (31.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e76 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e52 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.07 (1.215)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"8\"\u003e\n \u003cli\u003eI stayed away from reminders of it.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e36 (10.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e81 (22.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e113 (31.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e71 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e53 (14.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.07 (1.198)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"9\"\u003e\n \u003cli\u003ePictures about it popped into my mind\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e32 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e56 (15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e109 (30.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e104 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e53 (14.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003col\u003e\n \u003cli\u003e1.163)\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"10\"\u003e\n \u003cli\u003eI was jumpy and easily startled.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e39 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e76 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e118 (33.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e75 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e46 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.04 (1.179)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"11\"\u003e\n \u003cli\u003eI tried not to think about it.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e45 (12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e74 (20.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e99 (27.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e76 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e60 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.09 (1.267)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"12\"\u003e\n \u003cli\u003eI was aware that I still had a lot of feelings about it, but I didn\u0026apos;t deal with them.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e36 (10.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e64 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e123 (34.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e94 (26.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e37 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.09 (1.125)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"13\"\u003e\n \u003cli\u003eMy feelings about it were kind of numb\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e34 (9.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e74 (20.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e115 (32.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e99 (27.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e32 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.06 (1.111)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"14\"\u003e\n \u003cli\u003eI found myself acting or feeling like was back at that time.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e42 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e72 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e98 (27.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e84 (23.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e57 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.13 (1.254)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003col start=\"15\"\u003e\n \u003cli\u003eI had trouble falling asleep.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e46 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e70(19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e116 (32.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e82 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e40(11.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2.0 (1.185)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"16\"\u003e\n \u003cli\u003eI had waves of strong feelings about it.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e48 (13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e70 (19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e89 (25.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e90 (25.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e57 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.10 (1.277)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"17\"\u003e\n \u003cli\u003eI tried to remove it from my memory.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e52 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e51 (14.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e96 (27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e83 (23.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e72 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.20 (1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"18\"\u003e\n \u003cli\u003eI had trouble concentrating\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e41 (11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e80 (22.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e95 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e91 (25.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e47 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.06 (1.215)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"19\"\u003e\n \u003cli\u003eReminders of it caused me to have physical reactions\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e45 (12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e83 (23.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e106 (29.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e72 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e48 (13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003col\u003e\n \u003cli\u003e1.222)\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003col start=\"20\"\u003e\n \u003cli\u003eI had dreams about it.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e52 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e73 (20.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e110 (31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e86 (24.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e33 (9.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1.93 (1.187)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"21\"\u003e\n \u003cli\u003eI felt watchful and on-guard.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e35 (9.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e70 (19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e128 (36.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e90 (25.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e31 (8.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.03 (1.095)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003col start=\"22\"\u003e\n \u003cli\u003eI tried not to talk about it\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e54 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e57 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e90 (25.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e78 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e75 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.181 (1.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Assessment using the Impact of Event Scale\u0026ndash;Revised (IES-R) revealed that the majority of caregivers experienced moderate to high levels of post-traumatic stress symptoms. The mean total IES-R score was 3.60 \u0026plusmn; 0.87.\u003c/p\u003e\n\u003cp\u003eBased on established cut-off scores, 24 participants (6.8%) were classified as having no PTSD symptoms, 22 (6.2%) had partial symptoms, 23 (6.5%) met the criteria for probable PTSD, and 285 (80.3%) demonstrated scores indicative of clinically significant psychological distress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Tables 3\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePrevalence and Severity of PTSD Symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eFrequency(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo PTSD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e24(6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.60 (0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePartial PTSD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e22(6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProbable Diagnosis of PTSD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e23(6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh enough to suppress your immune system\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e285(80.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp id=\"_Toc149482030\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eCross-tabulation analysis demonstrated a statistically significant association between gender and PTSD severity (\u0026chi;\u0026sup2; test, p = 0.015). Female caregivers were more likely to exhibit higher levels of psychological distress compared with male caregivers.\u003c/p\u003e\n\u003cp\u003eMarital status was also associated with PTSD symptoms, with married participants showing higher levels of distress than unmarried individuals (p = 0.073). No statistically significant associations were observed between PTSD severity and place of residence, educational level, or age group.\u003c/p\u003e\n\u003cp\u003e\u003cspan id=\"_Toc170283785\"\u003e\u003cstrong\u003e\u0026nbsp;Table 4\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAssociation Between PTSD Symptoms and Sociodemographic Variables\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"635\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo PTSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePartial PTSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProbable Diagnosis of PTSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003esuppress your immune system\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\u0026nbsp;\u0026nbsp;\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMales\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\u0026nbsp;\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemales\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\u0026nbsp;\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e164\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSingle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\u0026nbsp;\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\u0026nbsp;\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e166\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 36px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOverall, we discovered that individuals exhibited PTSD-like symptoms for hypothetical future scenarios, which calls into question the idea that traumatic stress is an issue that exclusively affects the past. Participants challenged the notion that people must encounter a direct, in-person incident to acquire PTSD-like symptoms by describing these emotions regardless of whether they had been personally exposed to COVID-19.\u003c/p\u003e\n\u003cp\u003eThis finding is consistent with previous studies that reported elevated psychological distress among individuals indirectly exposed to pandemics through caregiving, media coverage, and prolonged uncertainty.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(2,5).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThese studies suggest that perceived threat and emotional burden may play a critical role in the development of trauma-related symptoms, even in the absence of direct infection.\u003c/p\u003e\n\u003cp\u003eWhile in contrast fever cases (29.16%) have been detected among health care workers to have PTSD in India (10). This indicates that while caregivers in our study demonstrated higher PTSD prevalence, healthcare workers also faced substantial psychological consequences, though with slightly lower overall rates.\u003c/p\u003e\n\u003cp\u003eIn the current study a statistically significant difference has been found between demographics and PTSD. More females were found to have PTSD as compared to males (p= 0.015). Similarly, there was more prevalence of PTSD among married as compared to those who were single (p=0.07). However, there was no difference among the rural and urban people having PTSD. Similarly, in other studies the risk for females to have PTSD is twice as males during their lifetime. These results are in line with previous studies that found women are almost twice as likely as men to acquire PTSD, a difference that is thought to be caused by increased exposure to traumatic events and potential biological sensitivity. (11) Biological vulnerability, hormonal factors, and socially constructed caregiving roles may partly explain this disparity. In Pakistan, women are often primary caregivers, which may further increase their emotional burden during illness.\u003c/p\u003e\n\u003cp\u003eMost of the respondents have moderate responses on IES-R scale, indicating persistent intrusive thoughts, sleep disturbance, and emotional distress, and their experience and feeling during the events. These results are in line with research on COVID-19 patients who also exhibited moderate levels of PTSD symptoms in the post-recovery phase. (12).\u003c/p\u003e\n\u003cp\u003eInterestingly, 15.4% of participants screened positive for PTSD even when exposure did not fully meet the diagnostic criteria, indicating that PTSD symptoms may arise from subjective perceptions and emotional reactions to caregiving during the pandemic as well as direct exposure. These findings support the increasing evidence that emotional burden and perceived stress can be more powerful predictors of traumatic stress reactions than actual exposure levels.(7)\u003c/p\u003e\n\u003cp\u003eSimilar studies have demonstrated a strong correlation between family caregivers\u0026apos; occupation and mental health and their risk of developing PTSD, anxiety, and depression. Research done during COVID-19 also highlights that caregivers are more vulnerable psychologically than the general population, especially those who work in long-term or home-based settings (13).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe assumption that traumatic events are frequently remembered with vivid sensory and perceptual features but are not well incorporated into autobiographical memory is supported by recent findings. Flashbacks and other fragmentary, intrusive memories are the outcome of this. PTSD-related memories are vivid but disjointed, which interferes with meaning-based processing and emotional control, according to a 2025 review of trauma memory research (14)\u003cstrong\u003e.\u003c/strong\u003e These models concentrate on PTSD developing for specific types of external events.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs a result, they do not take into consideration symptoms brought on by expected occurrences, trauma that was experienced indirectly, or circumstances that did not fit Criterion A. Instead, our results are consistent with a pathogenic event memory model that takes into consideration traumatic stress because of upcoming or imagined occurrences.\u003c/p\u003e\n\u003cp\u003eCaregiver presence has often been linked to improved patient outcomes, especially in chronic illness management. In our study, however, male caregivers reported lower overall mental health compared with females, despite having slightly lower levels of anxiety and depression. Notably, 16.8% of female participants reported PTSD symptoms, underscoring the gendered differences in psychological vulnerability during caregiving (5)\u003c/p\u003e\n\u003cp\u003eA study argues that, based on experience and improved coping mechanisms, this trend is suggestive of stronger resilience among female home caregivers during the pandemic, however further study is needed to confirm this. Additionally, gender disparities were discovered by separate analysis of the supplemental data for male and female caregivers. It\u0026apos;s interesting to note that male caregivers reported lower levels of anxiety and depressed symptoms in the study (15).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In the survey neutrality was also captured in the assigned questionnaire, the highest recorded against the item no.5 i.e. letting oneself get upset from past events, which is around 4%. \u0026nbsp;The feeling of numbness was characterized a little bit by around 44.8% of the overall surveyed sample. We discovered that during the COVID-19 pandemic, family caregivers positive and negative feelings about the epidemic interacted and coexisted with the psychological and practical difficulties associated with providing care.\u003c/p\u003e\n\u003cp id=\"_Toc170326099\"\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main strength of this study is its systematic approach and focus on an underexplored population\u0026mdash;home caregivers of COVID-19 patients. Studying has several limitations. First off, the outcomes of the bulk of the investigations, which were restricted to two general hospitals, and cannot be generalized. Given the coronavirus outbreak\u0026apos;s fast evolution and the need for advice to help family caregivers in similar situations, our quick review avoided grey literature in favor of peer-reviewed primary data publications. It is important to remember that this review is not complete and that it could have overlooked pertinent pieces, such as those published in magazines written in languages other than English.\u003c/p\u003e\n\u003cp\u003eThe study\u0026apos;s limitations include a limited sample from two hospitals, potentially affecting the generalizability of findings. These factors might have affected the extent to which the evidence was. Despite these limitations, the study offers insightful information about PTSD symptoms experienced by caregivers during the pandemic.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eRegardless of direct exposure, the majority of home caregivers of COVID-19 patients experience PTSD-like symptoms, highlighting the significant psychological burden they face. These findings highlight the critical need for gender-sensitive methods, specialized mental health therapies, and increased understanding of the psychological vulnerabilities of caregivers. Despite being restricted to just two hospitals, the study offers data that can guide more comprehensive caregiver support plans during and after pandemics. Prioritizing caregiver mental health will be crucial for fostering resilience and maintaining high-quality patient care as healthcare systems continue to change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1-Mental Health Support Programs:\u0026nbsp;\u003c/strong\u003eEstablish mental health support programs for home caregivers, especially those providing care to COVID-19 patients. These programs should focus on addressing PTSD-like symptoms and offer coping strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2-Gender-Specific Interventions:\u0026nbsp;\u003c/strong\u003eDesign interventions considering gender disparities in caregivers. Explore tailored approaches for both male and female caregivers, recognizing potential differences in resilience and stress response.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3-Educational Initiatives:\u0026nbsp;\u003c/strong\u003eImplement educational initiatives to increase awareness about the psychological impact of caregiving during pandemics. Target both formal and informal caregivers, providing resources for managing stress and promoting mental well-being.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4-Regular Screening for PTSD Symptoms:\u0026nbsp;\u003c/strong\u003eIntroduce regular screening for PTSD symptoms in caregivers, even those indirectly exposed to COVID-19. Early identification and intervention can mitigate the long-term psychological effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5-Collaboration with Mental Health Professionals:\u0026nbsp;\u003c/strong\u003eFoster collaboration between healthcare facilities and mental health professionals to provide comprehensive support for caregivers. This includes integrating mental health services into routine care for COVID-19 patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable. The manuscript does not contain any individual person\u0026rsquo;s identifiable data in any form.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable. The manuscript does not contain any individual person\u0026rsquo;s identifiable data in any form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to \u003cstrong\u003ePartici\u003c/strong\u003epate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants prior to their inclusion in the study. Participation was voluntary, and participants were informed of their right to withdraw at any time without any consequences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and analyzed during the current study can be obtained from corresponding author upon reasonable request\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no funding received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579(7798):270\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChau SWH, Wong OWH, Ramakrishnan R, Chan SSM, Wong EKY, Li PYT, et al. History for some or lesson for all? A systematic review and meta-analysis on the immediate and long-term mental health impact of the 2002\u0026ndash;2003 Severe Acute Respiratory Syndrome (SARS) outbreak. BMC Public Health. 2021;21(1):670.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWasim T, e Raana G, Bushra N, Riaz A. Effect of COVID-19 pandemic on mental wellbeing of healthcare workers in tertiary care hospital. Ann King Edw Med Univ. 2020;26(Special Issue):140\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndhavarapu S, Yardi I, Bzhilyanskaya V, Lurie T, Bhinder M, Patel P, et al. Post-traumatic stress in healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Psychiatry Res. 2022;317:114890.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKent EE, Ornstein KA, Dionne-Odom JN. The family caregiving crisis meets an actual pandemic. J Pain Symptom Manage. 2020;60(1):e66\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiao S, Luo D, Xiao Y. Survivors of COVID-19 are at high risk of posttraumatic stress disorder. Glob Heal Res policy. 2020;5(1):29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKessler RC, Aguilar-Gaxiola S, Alonso J, Benjet C, Bromet EJ, Cardoso G, et al. Trauma and PTSD in the WHO world mental health surveys. Eur J Psychotraumatol. 2017;8(sup5):1353383.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBisson KH. The effect of anxiety and depression on college students\u0026rsquo; academic performance. Exploring social support as a moderator; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsiri EJ, Dawria A, Nr BR, Muthugounder K, Zahrani YI, Mm BK et al. Comprehensive mental health implications of the recent pandemic in Southern Capital of Kingdom of Saudi Arabia: a community-based cross-sectional study. Psychol Health Med. 2025;1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKessler RC, Aguilar-gaxiola S, Alonso J, Benjet C, Bromet EJ, Cardoso G et al. Trauma and PTSD in the WHO World Mental Health Surveys. 2000;8066.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlipour Z, Nasrabadi T, Fattahmoghaddm L. Investigating predictors of post-traumatic stress disorder in patients with covid- 19 discharged from the hospital صیخرت 19 - دیووك هب لاتبم نارامی ب رد هحناس زا سپ سرتسا للاتخا هدننك ينیب شی پ لماوع يسررب ناتسرامیب زا هدش. 2023;9(2):171\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdanir H, Erdogan A. Evaluation of Coronavirus Disease 2019-Related Anxiety, Depression, and Post-Traumatic Stress Disorder in Liver Transplantation Recipients and Their Caregivers. Cerrahpasa Med J. 2023;47(2):229\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManzanero AL, Guarch-Rubio M, Vallet R, Vara A. On post-traumatic stress disorder and the accessibility of memories: traumatic memories in refugees and asylum seekers. Psychiatry, Psychol Law. 2025;1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen JB, Hanff TC, William P, Sweitzer N, Rosado-Santander NR, Medina C, et al. Continuation versus discontinuation of renin\u0026ndash;angiotensin system inhibitors in patients admitted to hospital with COVID-19: a prospective, randomised, open-label trial. Lancet Respir Med. 2021;9(3):275\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, PSTD, Stress, Pandemic, Caregivers, Psychological, Data, Analysis","lastPublishedDoi":"10.21203/rs.3.rs-8915151/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8915151/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe COVID-19 pandemic has exerted significant psychological distress on their patients but also on their family caregivers. Home caregivers to the infected people are especially exposed to stress related disorders because of the lasting exposure, the fear of transmission, and social isolation. There is, however, paucity in evidence on the aspects of post-traumatic stress disorder (PTSD) symptoms among low-income and middle-income countries (including Pakistan) home caregivers.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study was a descriptive cross-sectional study that was conducted at a time interval of November 2023 to September 2024, on 384 home caregivers of patients with COVID-19 in tertiary care hospitals in Peshawar, Pakistan. Recruitment of participants was done through consecutive sampling. A structured questionnaire was used whereby the Impact of Event Scale-Revised (IES-R) was included to gather the data. Cross-tabulation and descriptive statistics analyses were conducted using SPSS version 25 and the level of significance was set to p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 384 respondents took part in the survey of which 348 responded to the survey and were used in final analysis. Most of the caregivers were found to have moderate to high PTSD symptoms. In general, 80.3% of the participants had a score that fell in the range of clinically significant psychological distress. Women caregivers had a high score in PTSD as compared to males (p\u0026thinsp;=\u0026thinsp;0.015). Married participants had also more distress levels than unmarried caregivers. There were no major differences that were observed according to place of residence.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe home caregivers working with COVID-19 patients were under a significant psychological distress, and the prevalence of symptoms associated with PTSD was high. The female and married caregivers were at a disadvantage. These results provide a clear insight into the extreme necessity of specific mental health screening, psychosocial support initiatives, and gender-specific caregiver interventions during and after the occurrence of a public health emergency.\u003c/p\u003e","manuscriptTitle":"Impact of Post-Traumatic Stress Disorder among Home Care-givers of COVID-19 Patients Visiting Tertiary Care Hospitals of Peshawar","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-16 09:45:11","doi":"10.21203/rs.3.rs-8915151/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3ef56b50-7d3e-4f89-a829-3c1118655239","owner":[],"postedDate":"March 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T05:56:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-16 09:45:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8915151","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8915151","identity":"rs-8915151","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}