We identified the experiences of caregivers of stroke families during the COVID-19 pandemic, and these experiences were categorized into 6 themes: difficulty of care services, workload and additional caregiving tensions, threatened relationships between caregivers and stroke survivors, threats to caregivers' physical health. and psychological well-being, and the need to continue in a nurturing role [5]. One of the impacts of the COVID-19 pandemic on caregivers of mental disorders is the increased physical burden. Closure of rehabilitation and child care centers in Hong Kong. means that people with mental disorders are no longer able to receive therapy, resulting in a decrease in their function and an increase in dependence on caregivers [4]. This situation is exacerbated by social isolation and the act of working from home, as participants have to provide longer care for their family members with reduced informal and formal support. hours of care are known to be generally higher for single caregivers and those living with care recipients, therefore making them more susceptible to burnout from trying to meet work and increasing demands for care simultaneously in their homes and jobs during the pandemic [2]. Support service retirement also leaves participants without the opportunity to take a break from their piled up parenting duties, because they reported poorer physical health and fatigue when caring for people with mental disorders during the COVID-19 pandemic [8].
In addition, because people with mental disorders and people with multiple comorbidities are more susceptible to COVID-19 infection, caregivers feel obligated to be involved in Hygiene practices such as disinfecting the environment more often add to the burden of their caregiving duties. Participants also experienced psychological improvement and emotional burden during the pandemic [3]. While many caregivers of mental disorders are already experiencing psychological stress in connection with their extraordinary caregiver role, the uncertainty surrounding the COVID-19 pandemic has increased the suffering of participants, placing them at higher risk for anxiety and depression. Participants reported similar concerns about infection and transmission of COVID-19 with previous studies, as and concerns over unemployment, reduced income, and increased spending on hygiene products [9]. Studies show that social support can reduce the psychological distress and risk of patient abuse and act as a buffer against physical and mental illness [10]. While participants in this study previously had the opportunity to take a break from parenting duties and relieve stress by meeting up with family and friends, social distancing measures have isolated participants and limited the support they receive from their social support network, contributing to stress higher [11].
In this study, the alarming situation of increasing the risk and frequency of harassment is revealed. Social isolation, increased patient dependence, and time demands during a pandemic have been shown to increase patients' susceptibility to abuse from caregivers, which is similar to the accounts of participants in this study [12],[13]. Economic pressures and forced closeness with family members during quarantine can also lead to an increased risk of aggression and domestic violence [14].
Our findings further suggest that ill-treatment of people with mental disorders has preceded, and that current parenting difficulties may have exacerbated the situation [15]. Despite the shocking difficulties, the caregivers expressed their commitment to continuing the role of care for their mentally ill patients, as a way to repay the care they had received themselves from the survivors [16]. This is similar to the findings of previous studies, where caregivers maintained a nurturing role despite deteriorating health. Indonesia's traditional culture in the future emphasizes collective interests and values of filial piety committed to the family, and plays a key role in making decisions to provide care for family members [17],[18]. Quitting the parenting role would thus be seen as a departure from the expectations of the spouse [19].
Coping strategy is defined as a certain process accompanied by an effort in order to constantly change the cognitive and/or behavioral domains to manage and control external and internal demands and pressures that are predicted to burden and exceed the abilities and resilience of the individual concerned [20]. The results of this study indicate that the coping strategies used by caregivers are adaptive. The results of this study indicate that there are adaptive coping strategies used by caregivers when finding obstacles in caring for clients with mental disorders. Caregivers try to make peace with the situation when they have difficulty in providing care to clients with mental disorders [21]. This is done so that caregivers do not feel stressed and burdened with the work they are doing. This is in line with Fitriani's research which states that caregivers' perceptions of their burdens can also affect various aspects of daily life which in turn can affect the quality of life [22].
Deliberations and discussions are constructive activities carried out by caregivers as a form of coping strategies for caregivers. Deliberations are usually carried out by the caregivers of the halfway house directly face to face or through the WhatsApp group application. Deliberations and discussions conducted by caregivers are positive things that must be carried out so that they do not become a burden on the caregiver in caring for clients with mental disorders which then affect the caregiver's quality of life. The next adaptive coping strategy is praying by saying istighfar, Al Fatihah, dhikr, and taking lessons from events that have occurred. This is in line with research by Alfiandi et al (2018) which states that religious coping affects a person's cognitive patterns to find solutions to difficult situations they face. Some caregivers have basic education in Islamic boarding schools so praying is one of the adaptive coping methods they do when facing difficulties in caring for clients with mental disorders. Participants in this study mentioned adaptive coping strategies by remembering positive things. Remembering the advice of the kyai at the Islamic boarding school, remembering the nurse's oath that was once uttered, intending to do work for the sake of Allah SWT, remembering the patient's development, self-reflection, and returning the problem to God Almighty. This is in line with the results of Dewi's research (2018) which identified a spiritual coping strategy by submitting and returning all the problems she experienced to God in accordance with the Book of Al-Quran Surah Yusuf verse 86.
The results of this study identify the existence of an adaptive coping strategy by seeking support. Caregiver will tell the problems and difficulties during treatment to a person who is considered capable of providing solutions and support. In this way, it is hoped that the problem will be resolved soon and not burden the caregiver [23]. This is in line with Ribe's (2018) statement which states that seeking social support for caregivers with mental disorders can reduce the risk of mental health problems and reduce the level of perceived burden [24].
The results of this study indicate that there are difficulties in the communication aspect felt by the caregiver. Yusuf (2019) explains that severe mental disorders are disturbances in thoughts, behavior and feelings that are manifested in the form of a set of symptoms and or significant behavioral changes, and can cause obstacles in carrying out human functions. Damage to social interactions experienced by schizophrenic patients is a problem due to positive and negative symptoms that must be immediately addressed with therapeutic communication so that self-isolation does not occur [25], [26]. In patients with mental disorders experience emotional disturbances that are shown through affect and mood. Affect is an external expression of one's emotions that can be seen from one's face [27].