Family caregivers burden and quality of life among gastric cancer patients: The mediating role of psychological resilience based on Lazarus's transactional model

doi:10.21203/rs.3.rs-5212109/v1

Background

Currently, the incidence of gastric cancer in China is increasing, and with prolonged survival times, the nursing tasks and responsibilities that family caregivers need to undertake are becoming increasingly significant. The level of care provided by this group has a crucial impact on patients’ health-related outcomes. Therefore, decreasing caregivers’ life burden and improving their quality of life is vital for promoting patient recovery.

Purpose

The aim of this study was to investigate the effect of caregiver burden on the quality of life of patients with gastric cancer, and to explore the mediating role of psychological resilience in this relationship.

Methods

Data collection was conducted in the gastrointestinal surgery ward of a Grade III A hospital. 189 family caregivers of gastric cancer patients were surveyed using scales measuring caregiver burden, psychological resilience, and quality of life. Structural equation modeling was employed to validate the research hypotheses proposed, based on Lazarus’s transactional model.

Results

Caregiver burden was negatively correlated with psychological resilience and positively correlated with quality of life (p < .01). Psychological resilience plays a partial mediating role between caregiver burden and quality of life.

Conclusion

Caregiver burden is the key to predicting and reducing the quality of life of caregivers of gastric cancer patients. Psychological resilience is an intervention mechanism that explains how caregiver burden reduces caregiver quality of life in patients with gastric cancer.

caregiver burden

psychological resilience

quality of life

gastric cancer patients

Lazarus's transactional model

Gastric cancer ranks as the fifth most prevalent cancer and stands as the third leading cause of cancer mortality worldwide^[1], and it is noted that over 50% of new cases emerge in developing nations, including China.^[2]. As treatment concepts and methods progress, there has been an enhancement in survival times, both for the overall population and for patients stratified by nonmetastatic and metastatic disease status^[3]. The role of family caregivers is increasingly significant, with evidence suggesting that over time, as gastric cancer detection and treatment continue to advance, and the recurrence rate of cancer decreases in the first 5 years following diagnosis, the benefits are not age-restricted, with approximately two-thirds of cancer patients surviving for at least 5 years following their initial diagnosis.^{[4, 5]}. Moreover, previous studies have demonstrated that the association between the health status of caregivers (physical and mental) and the outcomes of patients’ diseases^[6]. Therefore, family caregivers play a critical roles in the management and support of gastric cancer patients. Nonetheless, the data on the challenges they face in caregiving remain scarce^[7].

Family caregivers, comprising partners, relatives, or friends who deliver care for dedicating significant periods, ranging from months to years. In light of the deeply ingrained Confucian values of “filial piety” (Xiao) and “face” (Mianzi), which are conservatively and widely held in China, family members are customarily anticipated to assume the responsibility of caring for individuals with cancer^[8]. This care involoves a diverse array of tasks that are physically, socially, emotionally, and financially burdensome possession^[9]. Meanwhile, their own social, cognitive, and psychological needs often remain unmet^[10]. Current research has found a considerable prevalence of depression among family caregivers of patients with advanced cancer^[11]. Moreover, for gastric cancer patients and caregivers, it should not be overlooked that complex problems faced by them include nutritional challenges (weight loss, malnutrition, malabsorption, nausea, vomiting, anorexia, dysphagia ), surgery, chemotherapy and radiotherapy^[12]. Consequently, the responsibilities and burdens shouldered by family caregivers of gastric cancer patients are particularly significant, and more worthy of research and attention.

Caregiver burden refers to the extent to which caregivers perceive their emotional or physical health, social life and financial status due to caring for their relatives^{[13, 14]}. Many studies also divide it into four aspects, including physical fatigue, psychological and emotional guilt, economic strain and social isolation or helplessness^[15]. Prior evidence has demonstrated that excessive caregiving responsibilities may cause a substantial caregiving burden, which can adversely impact the well-being and quality of life of caregivers. Prolonged stress may further diminish their ability to cope effectively with the challenges^[16]. More importantly, deterioration in the health of the family caregiver may also limit his/her ability to contribute with help in the patient’s recovery^[17]. Current research thus has a growing interest in exploring resolution how to reduce the burden on family caregivers.

Quality of life has become established as a significant concept and target for research and practice in the fields of health and medicine^[18]. It also refers to the perception that each individual has their own position in the context of the culture and value system, and this is closely related to this person’s goals, expectations, life standards, and concerns^[19]. Prior study has showed that family caregivers would encounter more than 200 problems and difficulties and these will lead to a diminished quality of life of the caregivers^[20]. More importantly, lower levels of quality of life could decrease patients' survival^[21]. However, it is less clear whether quality of life of family caregivers of patients with gastric cancer could be lowered by the caregivers burden. So the first purpose of study was to explore the relationship between the quality of life and burden of family caregivers of patients with gastric cancer.

Furthermore, we endeavored to explore the underlying mechanisms by which caregivers burden contributes to the quality of life of patients with gastric cancer. Psychological resilience is considered as a dynamic process or complex function of numerous individual and social-environmental factors which allows an individual to maintain good psychological health despite significant adversity^[22]. Family resilience plays an important role in promoting positive adaptation in the face of adversity in families of cancer patients and family caregivers^[23]. Past studies have found that caregiver burden is negatively related to rsilience, and resilience can form support networks to foster an environment conducive to patient and caregiver well-being, thereby has a positive relation with quality of life^{[24, 25]}. Accordingly, based on Lazarus’s transactional model of stress, we propose the hypothesis that caregiver burden, psychological resilience, and quality of life are correlated, with psychological resilience potentially serving as an intervening mechanism between caregiver burden and quality of life. Lazarus’s transactional model of stress^[26] encompasses three components: stress, cognitive appraisal, and coping, emphasizing the impact of cognitive appraisal and coping on individual outcomes in stressful environments. In our study, caring for gastric cancer patients is a highly complex and challenging task for caregivers, which can be regarded as a source of stress. Psychological resilience is considered as the caregivers’ cognitive appraisal of the existing stress. Meanwhile, the quality of life of family caregivers is perceived as their coping response to individual outcomes. Therefore, we propose a research hypothesis model suggesting that increased caregivers burden predicts lower psychological resilience, which in turn leads to a decline in quality of life. Psychological resilience acts as a mediating effect between caregiver burden and quality of life of family caregivers of patients with gastric cancer (Fig. 1). As such, this study aims to elucidate the reasons for the decline in quality of life from the perspective of caregiver burden and to explore the mechanisms underlying this process. Consequently, corresponding intervention measures could be proposed to enhance the quality of life of family caregivers of gastric cancer patients, thereby improving the rate of survival of gastric cancer patients.

2.1 Family caregivers burden and quality of life

Family caregivers of cancer patients are required to undertake a variety of tasks, including comprehensive cancer care, emotional and mental health support, daily activities, and interpersonal relationships and these responsibilities are significantly associated with caregiver burden^[27]. These burdens induce profound physical, psychological, social, and spiritual changes in the lives of family caregivers^[28]. The burden on family caregivers of cancer patients primarily comprises five core dimensions: physiological burden, social burden, psychological burden, financial burden, and disease perception burden^[29].

First, caring for cancer patients often leads to physical symptoms in caregivers, most commonly pain and fatigue, which disrupt daily life, impact health. Second, these discomfort symptoms could result in negative psychological emotions such as anxiety and depression^[30]. Finally, the quality of life of family caregivers of gastric cancer is diminished from both physiological and psychological perspectives^[31]. Here, we argue that reducing the burden on caregivers of cancer patients can enhance their quality of life. Thus, based on these arguments, our first hypothesis is:

Hypothesis 1

Family caregivers burden of patients with gastric cancer is negatively and directly related to quality of life.

2.2 Psychological resilience as a mediating variable

Psychological resilience, the ability to adaptively rebound from stress, is associated with creativity, optimism and eudaimonic traits^[32]. As cancer patients approach the end of life and require medical decisions to be made on their behalf, especially if the patients are unable to make decisions for themselves, the risk to the mental health of caregivers may further escalate. Cancer family caregivers, while enduring high levels of objective caregiving tasks and psychological challenges, also need to contend with emotional and physical stress. Previous studies have shown that resilience is one of the key factors in these situations^[33]. However, existing research has insufficiently investigated and explored the psychological resilience of family caregivers of gastric cancer patients. The substantial burden and lower quality of life for these caregivers may potentially impact the treatment and care outcomes for gastric cancer patients. Therefore, studying the predictors and consequences of psychological resilience among family caregivers of gastric cancer patients is of significant importance.

In recent years, scholars and researchers have conducted multi-dimensional investigations on the mental resilience of family caregivers of patients with cancer. The results indicate that the psychological resilience of family caregivers of cancer patients is significantly correlated with the burden^{[34, 35]}. Caregivers with lower psychological resilience may attempt to control their emotions by avoiding negative events, memories, and pain, adopting passive coping strategies, and increasing self-depletion, thereby exacerbating their burden^[36]. When caregiving becomes a structured necessity or its intensity increases, it can have negative impacts on both patients and caregivers, leading to an imbalance between the burden and the capacity to bear it. This imbalance can result in multidimensional biopsychosocial reactions, which may diminish psychological resilience^[37].

Higher psychological resilience can contribute to improving quality of life. Psychological resilience is a critical component of quality of life during stages such as diagnosis, treatment, survival, and palliative care, and is an important feature for promoting positive social and mental health, as well as a significant way to enhance quality of life^[38]. Family caregivers of cancer patients often experience poor quality of life, which is a multidimensional construct encompassing physical, emotional, social, financial, and spiritual well-being. Particularly, caregivers of patients with advanced cancer may have poor mental health conditions, including depression and anxiety, as well as physical symptoms such as fatigue, sleep disorders, loss of appetite, and pain^[39]. Due to the fact that the current formal healthcare system cannot meet all the needs of cancer care, family caregivers become an essential asset in supporting patients throughout the cancer survival period or during palliative care^[40]. Therefore, exploring the factors that influence their quality of life is of great significance for improving the physical and mental health of family caregivers and enhancing the treatment outcomes for gastric cancer patients.

Therefore, we expect that psychological resilience would play a mediating role in the relationship between the burden of family caregivers of gastric cancer patients and their quality of life. Good psychological resilience is beneficial in reducing their burden. As the burden in terms of physical, psychological, social, economic, and disease perception aspects is alleviated, it will help to enhance the quality of life. In summary, we propose that:

Hypothesis 2

Psychological resilience is a mediating factor in the relationship between the burden of family caregivers of gastric cancer patients and their quality of life.

3.1 Participants and data collection

The participants were family caregivers of patients diagnosed with gastric cancer at the Department of Gastrointestinal Surgery, the First Affiliated Hospital of Air Force Medical University in Shaanxi, China. With the assistance of surgeons and nurses, a convenience sampling method was employed to survey the family caregivers of gastric cancer patients from March to July 2023. The inclusion criteria were as follows: ① the care recipient was a patient with gastric cancer; ② the caregiver was primarily responsible for the care of the gastric cancer patient; ③ the caregiver’s age was ≥ 18 years; ④ the caregiver agreed to participate in the study after being informed of the study details. The exclusion criteria included: ① individuals with mental illness; ② those receiving payment for their caregiving role; ③ caregivers who refused to participate in the study. According to Kendall’s rough method for determining sample size, the sample size should be 5 to 10 times the number of items in the research variables. The Quality of Life in Life Threatening Illness - Family Carer Version (QOLLTI-F) used in this study contains a total of 16 items. Considering a 20% attrition rate, the minimum sample size calculation yields 96 to 192 cases. This study included a total of 189 research subjects.

Following the acquisition of informed consent from the study participants, data collection was carried out during the discharge process. A standardized questionnaire and guide were employed to elaborate on the study’s objectives, content, and method of completion. The purpose and significance of the study were reiterated on the cover of the questionnaire. Participants were informed that they could withdraw from the study at their own discretion without the need to provide any reason. Any queries raised by participants were addressed, and the questionnaires were collected on-site promptly, with a completion time limit of 30 minutes. A total of 195 questionnaires were distributed, of which 189 were validly returned, resulting in an effective response rate of 95.45%.

3.2 Measures

3.2.1 Family caregivers burden

Family caregivers burden was measured using Caregiver Burden Scale for Cancer Patients (CBS-CP), which was developed by Chinese scholar Li^[41]. The questionnaire consists of 29 items, divided into five dimensions: physiological burden (9 items), social burden (6 items), psychological burden (6 items), financial burden (5 items), and disease perception burden (3 items). Example item is “Caring for the patient has affected my sleep”. Excluding two items for overall evaluation of the burden, the 29 remaining items are scored as follows: Never (0 points), Sometimes (1 point), Often (2 points), Frequently (3 points), and Always (4 points). Higher scores indicate greater burden for family caregivers, with a score below 29 considered as no burden, 29–58 as mild burden, 58–87 as moderate burden, and over 87 as severe burden. The Cronbach's α coefficients for the total CBS-CP scale and its five dimensions range from 0.70 to 0.96, with test-retest reliability (after an interval of 10 days) of ≥ 0.87.

3.2.2 Psychological resilience

Psychological resilience was measured using Connor-Davidson Resilience Scale (CD-RISC), which was developed by Kathryn M. Connor M.D. and translated by Yu and Zhang^{[42, 43]}. The scale is used to measure the level of psychological resilience over the past one month. It consists of 25 items, divided into three dimensions: strength (13 items), tenacity (8 items), and optimism (4 items). Example item is “I am adaptable to change”. The Likert 5-point scoring method is employed, with scores ranging from 0 to 4 indicating “completely incorrect,” “rarely correct,” “sometimes correct,” “mostly correct,” and “completely correct,” respectively. The total score ranges from 0 to 100, with higher scores indicating higher levels of psychological resilience. In the general population in China, the Cronbach's α coefficient for this scale is 0.82 to 0.91.

3.2.3 Quality of life

Quality of life was measured using Quality of Life in Life Threatening Illness–Family Carer Version (QOLLTI-F), which was developed by Cohen^[44]. The scale is used to assess the quality of life of the primary family caregivers of home-based or hospitalized patients. It consists of 16 items across three dimensions: carer’s self-feelings (6 items), carer’s stress (5 items), carer’s outlooks (5 items)^[45]. Example items are “I feel that I don’t get enough sleep” and “My relationship with my family is not as harmonious as it used to be”. Scored on a scale of 0 to 4, with 0 indicating “strongly disagree” and 4 indicating “strongly agree,” the total score ranges from 0 to 64. Higher scores indicate better quality of life. Structural validity testing revealed that all items in the scale could predict 55% of the total variance in the scale’s overall score and the scores of its individual dimensions. The test-retest reliability of the total scale and its dimensions ranged from 0.50 to 0.80.

3.3 Statistical analysis

First, we used SPSS 27.0 version for descriptive statistical analysis of each socio-demographic characteristics and scale score, and Pearson correlation coefficient was used to test the correlation among caregiver burden, mental resilience, and quality of life. In addition, depending on the type of variable, we compared the quality of life of different sociodemographic subgroups using an independent t-test or ANOVA. Then, using AMOS 25.0 version, structural equation model (SEM) was used to analyze the mediating role of mental resilience between caregiver burden and quality of life in gastric cancer patients. Structural equation model is a statistical method to analyze the relationship between variables based on the covariance matrix of variables. It is generally composed of measurement equation and structural equation^{[46, 47]}.

To validate the effectiveness of the model, we utilized the following indices: Chi-square test (χ²), Comparative Fit Index (CFI), Goodness of Fit Index (GFI), Tucker-Lewis Index (TLI), and Root Mean Square Error of Approximation (RMSEA). The model was considered to have a superior fit when the χ² test was not statistically significant, both CFI and TLI were greater than 0.90, RMSEA was less than 0.08, and the Standardized Root Mean Square Residual (SRMR) was less than 0.06^[48].

4.1 Socio-demographic characteristics and comparison of quality of life

With the assistance of surgeons and nurses, 189 out of 195 respondents completed our survey. Six caregivers conducted incomplete surveys, resulting in an effective response rate of 95.45%. The sociodemographic characteristics of family caregivers of gastric cancer patients are presented in Table 1.

Table 1

Social-demographic characteristics of the participants and the comparison of quality of life (N = 189).
Variable	N(%)	Mean (SD)	t/F	p
Age(yrs)
< 45	96(50.79)	34.37 ± 7.60	0.58	0.56
45 ~ 60	60(31.75)	34.65 ± 7.66
≥ 60	33(17.46)	32.97 ± 6.61
Gender
Male	119(62.96)	34.09 ± 7.63	0.08	0.78
Female	70(37.04)	34.41 ± 7.17	0.08	0.78
Educational attainment
Junior high school and below Junior High School Junior High School or Below	50(26.45)	32.84 ± 7.66	1.24	0.29
High school and technical secondary school	62(32.81)	34.42 ± 8.43
High school and technical secondary school	77(40.74)	34.94 ± 6.35
Marital status
Unmarried	15(7.94)	34.48 ± 7.24	1.44	0.24
Married	173(91.53)	34.48 ± 7.24
Divorced	1(0.53)	28.00 ± 0.00
Religious belief
Yes	11(5.82)	32.82 ± 8.52	0.41	0.52
No	178(94.18)	34.30 ± 7.39	0.41	0.52
Chronic disease
Yes	29(15.34)	33.76 ± 7.15	0.13	0.72
No	160(84.66)	34.29 ± 7.52	0.13	0.72
Sleep status
Good	104(55.02)	33.43 ± 7.25	1.75	0.18
Fair	75(39.68)	34.88 ± 7.87
Poor	10(5.30)	37.30 ± 5.10
Occupation
Government organs and public institutions	36(19.05)	34.31 ± 7.39	0.12	0.99
Teachers and staff	14(7.41)	34.64 ± 4.89
Medical professionals	5(2.64)	36.20 ± 6.02
Workers	27(14.29)	33.93 ± 9.02
Farmers	27(14.29)	34.52 ± 8.46
Self-employed	27(14.29)	33.52 ± 7.57
Others	53(28.03)	34.19 ± 6.99
Current employment status
Employed	88(46.56)	34.74 ± 7.48	0.83	0.37
Not employed	101(53.44)	33.75 ± 7.42	0.83	0.37
Relationship with the Patient
Spouse	59(31.22)	34.07 ± 6.55	0.34	0.85
Children	87(46.03)	34.43 ± 7.81
Parent	29(15.34)	33.59 ± 6.59
Sibling	8(4.23)	36.50 ± 7.96
Others	6(3.18)	32.50 ± 13.71
Time of disease diagnosis (m)
< 1	64(33.86)	32.91 ± 6.56	1.53	0.22
1 ~ 6	89(47.09)	34.99 ± 8.44
≥ 6	36(19.05)	34.61 ± 6.03
Average daily caregiving duration(h)
< 10	100(47.09)	34.27 ± 7.87	0.01	0.91
≥ 10	89(52.91)	34.15 ± 6.98	0.01	0.91
Presence of similar caregiving experience
Yes	57(30.16)	33.77 ± 7.19	0.28	0.60
No	132(69.84)	34.40 ± 7.57	0.28	0.60
Patient’s self-care ability Patient’s Daily Self-Care Ability Patient’s Daily Self-Care Ability
Basic self-care	148(78.31)	33.43 ± 7.32	4.30	0.02**
Partial self-care	37(19.58)	36.68 ± 6.79
Inability	4(2.11)	40.25 ± 12.01
Monthly household income(RMB)
< 5000	83(43.92)	34.92 ± 7.69	3.69	0.01**
5000 ~ 10000	81(42.86)	33.86 ± 7.37
10000 ~ 30000	21(11.11)	34.95 ± 5.29
≥ 30000	4(2.11)	22.75 ± 4.86
Form of medical expense payment
Social medical insurance	157(83.07)	33.96 ± 7.35	4.60	0.01**
Public funding	3(1.59)	24.00 ± 7.55
Self-payment	29(15.34)	36.62 ± 7.06

We performed independent t-tests or ANOVA to compare quality of life across different socio-demographic subgroups (Table 1). In terms of quality of life, significant differences were observed in the patient’s self-care ability (p = 0.015), monthly household income (p = 0.013), and form of medical expense payment (p = 0.011), whereas no statistically significant differences were found in the quality of life scores of family caregivers for the other variables.

4.2 Descriptive statistics of caregivers burden, psychological resilience and quality of life

Table 2 shows the descriptive statistics of the all measures scale. The family caregivers’ burden of patients with gastric cancer score was (61.03 ± 20.95), psychological resilience score was (85.80 ± 20.71) and quality of life score was (30.41 ± 10.70) which demonstate the family caregivers of gastric cancer patients have a medium level of burden (a medium level is the score range from 58 to 87), a high leverl of psychological resilence and a low level of quality of life. The quality of life scores for family caregivers of gastric cancer patients are the lowest, which will be the most important point we need to pay attention to in our following research. Our study aims to help them improve their quality of life by identify the factors and mechanisms.

Table 2

Descriptive statistics and internal consistency of all measures used in the current study
		Mean	SD	Min.	Max.	Cronbach’s ɑ	Items
1	Physiological burden	17.90	6.48	9	36	.76	9
2	Social burden	13.61	5.67	6	24	.75	6
3	Psychological burden	9.98	3.92	6	24	.79	6
4	Financial burden	11.82	5.91	5	20	.76	5
5	Disease perception burden	7.70	3.20	3	12	.80	3
6	Caregivers burden	61.03	20.95	29	97	.87	29
7	Strength	44.80	11.84	13	42	.70	13
8	Tenacity	28.58	6.84	8	32	.79	8
9	Optimism	12.42	3.31	4	16	.88	4
10	Psychological resilience	85.80	20.71	25	100	.80	25
11	Carer’s self-feelings	11.77	4.32	6	24	.80	6
12	Carer’s stress	10.15	4.11	5	20	.81	5
13	Carer’s outlooks	8.49	3.12	5	18	.85	5
14	Quality of life	30.41	10.70	16	61	.91	16

The possible score range for all measure terms is 0–4, N = 189.

4.3 Correlational analysis of caregivers burden, psychological resilience and quality of life

Table 3 presents the Pearson correlation coefficients between the caregivers burden, psychological resilience, and quality of life of family caregivers of gastric cancer patients in the current study. The results showed that caregivers burden and its five dimensions are significant negatively correlated with (r=-.52, p < .01; r=-.47, p < .01; r=-.46, p < .01; r=-.41, p < .01; r=-.44, p < .01; r=-.33, p < .01) and psychological resilience and its three dimensions are significant positively correlated with the quality of life(r = .31, p < .01; r = .29, p < .01; r = .28, p < .01; r = .31, p < .01). Moreover, caregivers burden had a significant negative correlation with psychological resilience (r=-.25, p < .01). Therefore, in order to improve the quality of life of family caregivers of gastric cancer patients, it is necessary to reduce their caregiver burden and improve psychological resilience, because they are closely interrelated.

Table 3

Correlations among study variables
	1	2	3	4	5	6	7	8	9	10	11	12	13
1
2	.66^**
3	.69^**	.71^**
4	.51^**	.76^**	.53^**
5	.53^**	.58^**	.52^**	.51^**
6	.84^**	.91^**	.82^**	.82^**	.72^**
7	−.18^**	−.18^**	−.25^**	−.19^**	−.11^**	−.22^**
8	−.21^**	−.20^**	−.26^**	−.18^**	−.06^**	−.22^**	.85^**
9	−.25^**	−.23^**	−.29^**	−.26^**	−.08^**	−.28^**	.73^**	.80^**
10	−.21^**	−.20^**	−.27^**	−.21^**	−.10^**	−.25^**	.97^**	.94^**	.84^**
11	−.46^**	−.48^**	−.40^**	−.45^**	−.34^**	−.53^**	.25^**	.21^**	.24^**	.25^**
12	−.41^**	−.41^**	−.35^**	−.40^**	−.27^**	−.46^**	.21^**	.22^**	.26^**	.24^**	.80^**
13	−.42^**	−.39^**	−.39^**	−.28^**	−.29^**	−.46^**	.37^**	.36^**	.38^**	.39^**	.76^**	.79^**
14	−.47^**	−.46^**	−.41^**	−.44^**	−.33^**	−.52^**	.29^**	.28^**	.31^**	.31^**	.93^**	.94^**	.90^**

N = 189, ^**p < .01. 1 = Physiological burden, 2 = Social burden, 3 = Psychological burden, 4 = Financial burden, 5 = Disease perception burden, 6 = Caregivers burden, 7 = Strength, 8 = Tenacity, 9 = Optimism, 10 = Psychological resilience, 11 = Carer’s self-feelings, 12 = Carer’s stress, 13 = Carer’s outlooks, 14 = Quality of life.

4.4 Testing the research hypotheses

Firstly, the research hypotheses were validated by assessing the fit of the measurement model which includes three dimensions (caregiver burden, psychological resilience, and quality of life) using confirmatory factor analysis. The confirmatory factor analysis indicated that the three-factor model exhibited a satisfactory fit to the data: χ² = 65.449, df = 39, χ²/df = 1.678, CFI = 0.982, TLI = 0.974, RMSEA = 0.060, 90% CI: 0.021–0.207, SRMR = 0.048 (p < .01).

Secondly, we tested whether family caregiver burden has a negative impact on quality of life by verifying whether the direct effect model is significant, as posited in hypothesis 1. The results indicated that the direct effects model fit the data well: χ2 = 33.129, df = 18, χ2/df = 1.841, CFI = 0.984, TLI = 0.976, RMSEA = 0.067, 90%CI: 0.357–0.569, SRMR = 0.042 (p < .01). Figure 2 depicts the direct model, showing a negative correlation between caregiver burden and quality of life (β=-.55, p < .01). Simultaneously, we used 2000 bootstrapping resamples method to validate the 95% CI of the total impact of caregiver burden on quality of life. Table 4 shows that the 95% CI of the total impact is (-0.40, -0.69), and 55% of the variance in quality of life can be explained by caregiver burden.

Finally, we tested whether psychological resilience is a mediating factor in the relationship between the burden of family caregivers of gastric cancer patients and their quality of life by verifying whether the mediating effect model is significant, as posited in hypothesis 2. The results indicated that the indirect effects model fit the data well: χ² = 65.449, df = 39, χ²/df = 1.678, CFI = 0.982, TLI = 0.974, RMSEA = 0.060, 90% CI: 0.021–0.207, SRMR = 0.048 (p < .01). Figure 3 depicts the indirect model, showing a negative correlation between psychological resilience and caregiver burden (β=-.27, p < .01), which positively associated with quality of life (β = .19, p < .01). Furthermore, caregiver burden was still significantly associated with quality of life even after inclusion of psychological resilience (β=-.51, p < .01), suggesting that psychological resilience played a partially mediating role. In addition, we used 2000 bootstrapping resamples method to validate the 95% CI of the indirect impact of caregiver burden on quality of life through psychological resilience. Table 4 shows that the 95% CI of the mediating impact is (-0.01, -0.11), and 75% of the variance in quality of life can be explained by caregiver burden and psychological resilience, and the indirect effect accounts for 9.09% of the total impact of caregivers burden on quality of life (total effect = -0.55, indirect effect = -0.05).

This indicates that family caregiver burden is a significant predictor of quality of life, and enhancing psychological resilience can further improve quality of life. Psychological resilience plays a substantial partial mediating role between caregiver burden and quality of life. Consequently, efforts to alleviate caregiver burden should be accompanied by strategies to promote psychological resilience.

Table 4

Confidence interval of mediating effect value in chain mediated model (2000 bootstrap samples)
Model path	Estimate	95%CI
Model path	Estimate	LLCI	ULCI
CB→QOL	−0.55	−0.40	−0.69
CB→PR→QOL	−0.05	−0.01	−0.11

The quality of life for family caregivers of gastric cancer patients in the current study was significantly lower than that reported in previous research^[49–51]. Firstly, the discrepancy may be attributable to the inclusion of various types of tumors, such as lung cancer, esophageal cancer, breast cancer, and colorectal cancer, in some studies^[52]. Studies that include tumors with higher survival rate tend to report relatively higher quality of life among caregivers^[53]. In contrast, in our study exclusively focuses on primary family caregivers of gastric cancer patients, who have an average five-year survival rate of 44.5% in China^[54]. This lower survival rate may have a significant impact on the caregivers’ quality of life^[55]. Simultaneously, the varying degrees of uncertainty associated with different diseases and patients have a negative correlation with the quality of life of caregivers^[56]. Additionally, the comprehensive medical insurance and economic support systems in Western developed countries, which are generally more robust than those in developing countries, also constitute a significant reason for the lower quality of life levels observed in the current study^[31]. This is consistent with the results of this study, in our study, household income and medical payment methods have significant differences in quality of life. Finally, due to the traditional Chinese value of filial piety, caregivers feel the need to be personally involved in all aspects of care. This excessive psychological and physical burden resulting from such cultural expectations contributes to a decline in their quality of life. Among the family caregivers’ quality of life, the “carer’s outlook” dimension scored the lowest. This domain encompasses not only an assessment of the caregivers’ role and personal values regarding nursing but also involves professional nursing care^[45]. The caregiver role substantially exhausts their time and energy, as well as their capacity for control. Role overburden specifically capitalizes on the caregivers’ perception of being overwhelmed with more tasks than they can manage, resulting in a profound sense of internal fatigue^[57]. Simultaneously, family caregivers of cancer patients exhibit a low level of health literacy^[58]. Health literacy is primarily reflected in six aspects: accessing information, understanding information, the relationship with the care recipient, the relationship with healthcare providers, managing care, and challenges with support systems^[59]. These caregivers face daily challenges, which can diminish their sense of self-efficacy and, consequently, lower their quality of life^[60].

The results of this study show that the burden of family caregivers of gastric cancer patients can negatively predict the quality of life. In other words, we conclude that caregivers with lower burdens have a higher quality of life, this is consistent with findings from previous studies^{[61, 62]}. This is because when the burden is reduced, caregivers can allocate more time, energy, and financial resources autonomously, thereby enhancing their relationships, religious beliefs, social participation, and the ability to engage in daily life activities, which in turn strengthens their sense of self-identity^[63]. On the other hand, the improvement of life quality will form a positive feedback to reduce the psychological distress of caregivers, thus reducing the burden of caregivers^[64]. This constitutes a virtuous cycle. The concept of quality of life (QOL) is a multifaceted and dynamic construct that has evolved over time. The World Health Organization (WHO) provides a widely recognized definition of QOL, describing it as an individual’s perception of their position in life in the context of the culture and value system they belong to, as well as in relation to their personal goals, expectations, and concerns^[65]. Gastric cancer patients undergo multiple rounds of chemotherapy, radiotherapy, or neoadjuvant therapy, which prolongs hospitalization and significantly disrupts the normal life of caregivers^[31]. In our study, the patients’ dependence level was significantly correlated with the quality of life of caregivers. Therefore, according to the different self-care ability of patients in different periods, medical staff provide different psychosocial interventions, such as mindfulness, acceptance and commitment therapy, etc., to reduce the burden of caregivers^[66]. Concurrently, research indicates that enhancing caregiver training to promptly identify side effects and adverse events during cancer treatment, and developing novel dyadic family interventions that consider family and social integration, can also improve quality of life^{[67, 68]}.

The results of this study indicate that psychological resilience plays a mediating role between caregiver burden and quality of life. When the caregiver burden is reduced, the psychological resilience to overcome the disease is increased, and it is easier to obtain a sense of satisfaction and self-worth from the role of caregiver, so as to obtain a higher quality of life. Increased caregiver burden results in higher levels of psychological distress and stress, including anxiety and depression, leading to lower psychological resilience^[52]. In contrast, caregivers with high psychological resilience may possess good tolerance for negative emotions, strong self-reflection abilities, and a high sense of responsibility, all of which can facilitate better coping with psychological distress^[69]. Atsushi et al. found that although stress can increase the risk of mental disorders, thereby adversely affecting quality of life, enhancing psychological resilience can improve both health and quality of life, with a positive correlation observed between the two, which is consistent with our research finding^[70]. Therefore, psychological resilience plays a beneficial mediating role between caregiver burden and quality of life. Hence, it is essential not only to focus on caregiver burden but also to attend to their level of psychological resilience. Health policymakers should gain a better understanding of resource allocation to develop comprehensive and targeted health intervention programs for both caregivers and patients^[71]. Additionally, reducing out-of-pocket expenses for gastric cancer patients during treatment and increasing the proportion of medical insurance coverage should be considered^[72]. Meanwhile, allowing caregivers to actively participate in the formulation of strategies for disease recovery, establishing multiple access to information, as well as sound follow-up cycles and systems, improve mental resilience and thus improve quality of life^[73].

Family caregivers play a crucial role in the treatment cycle of chronic oncological diseases. They not only provide care for the patients’ daily activities but also often significantly influence the patients’ rehabilitation outcomes^[6]. Consequently, alleviating their burden and enhancing their quality of life becomes particularly important. Currently, family caregiver burden in cancer patients remains high, and targeted interventions are needed to reduce the adverse health outcomes associated with caregiver burden^[74]. Healthcare professionals need to consider how to enhance the level of health education and training for family caregivers to promote health-related outcomes in gastric cancer patients. Therefore, it is necessary to understand the burden and psychological resilience of family caregivers, providing references for policymakers and healthcare professionals to improve the quality of life of patients and family caregivers, and to facilitate disease recovery.

We acknowledge that the study has several limitations. First of all, this study was only conducted for patients with gastric cancer, and its applicability to other populations needs to be further verified. In addition, the results in this study are self-reported questionnaires and lack objective evaluation indicators. Although it can be interpreted as the evaluation of quality of life is the individual's self-perception in the culture and value system. Therefore, in the next study, the sample size should be expanded and carried out in different populations. At the same time, the method of randomized control study was adopted to explore the intervention measures.

Acknowledgements

We extend our gratitude to the all nurses and family caregivers involved for their support and cooperation.

Conflict of interest

No

Funding

The authors declare that no funds, grants, or other support was received during the preparation of this manuscript.

Ethics approval and consent to participate

Ethical clearance was obtained from the ethical committee of the Xijing Hospital , Air Force Military Medical University, China (reference NO.KY-20212024-C-1). This study was conducted in accordance with the ethical guidelines described in the Declaration of Helsinki. Prior to the survey, the research objectives were explained to the participants, and their oral and written informed consent was obtained. All data collected in this study were anonymized and used exclusively for the purposes of this research.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Author contributions statement

Conception of the study: Mengjia Luo, Hongjuan Lang, Yanran Dai; Literature review and design of trial: Mengjia Luo, Jv Lu, Yifan Jing; Data analysis and Statistics: Mengjia Luo, Chao Wu; Manuscript editing and review: Mengjia Luo, Hongjuan Lang, Gang Ji; The final version of the manuscript has been approved by all authors.

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No competing interests reported.

Family caregivers burden and quality of life among gastric cancer patients: The mediating role of psychological resilience based on Lazarus's transactional model

Status:

Version 1

Abstract

Background

Purpose

Methods

Results

Conclusion

Figures

1 INTRODUCTION

2 LITERATURE REVIEW AND HYPOTHESES

2.1 Family caregivers burden and quality of life

2.2 Psychological resilience as a mediating variable

3 METHODS

3.1 Participants and data collection

3.2 Measures

3.2.1 Family caregivers burden

3.2.2 Psychological resilience

3.2.3 Quality of life

3.3 Statistical analysis

4 Results

4.1 Socio-demographic characteristics and comparison of quality of life

4.2 Descriptive statistics of caregivers burden, psychological resilience and quality of life

4.3 Correlational analysis of caregivers burden, psychological resilience and quality of life

4.4 Testing the research hypotheses

5 Discussion

6 Conclusion

7 Limitations

Declarations

Author contributions statement

References

Additional Declarations

Status:

Version 1