Introduction
Dementia is a syndrome that can be caused by various diseases that over time destroy nerve cells and damage the brain, typically leading to a decline in cognitive function (i.e. the ability to process thoughts) beyond the expected biological consequences of aging [1]. With the continuous development of the aging of the world population, the incidence rate of dementia is also increasing [2]. The number of patients with dementia (PwD) in China accounts for about 1/4 of the total number of PwD globally, ranking first in the world [3]. It is expected that by 2050, the global number of dementia cases will increase to 152 million. According to statistics, informal caregivers provide an average of 5 h of care and supervision per day for PwD. Informal caregivers are typically those who receive little or no training and support compared to formal caregivers [4], and are mostly composed of family members, friends, or community members without compensation [5]. Ample researches have confirmed that long-term care for PwD is a heavy burden for informal caregivers, which can seriously damage their physical and mental health, reduce the quality of care, and even terminate caregiving behaviors [5]. Dementia has physical, psychological, social and economic impacts, not only for PwD, but also for their carers, families and society at large [1].
Lazarus and Folkman’s Stress-Coping Model (SCM) suggests that stress is a product of the interaction between individuals and the environment [6]. Stressors can be various life events, such as caregiving activities. When stressors act on individuals, they may produce adaptive or maladaptive outcomes. The SCM is widely used to explain individuals’ coping processes when facing stressful environments [7, 8]. However, the applicability of the SCM to elderly PwD caregivers remains uncertain and requires further validation.
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For informal caregivers of PwD, the burden of dementia on the entire family is a stressor faced by caregivers. The stress outcomes that caregivers may experience when dealing with stress depend on their cognitive appraisal and coping strategies [6]. Cognitive appraisal is the cognitive judgment process of individuals if their surrounding environment has an impact on them, including the perception of stressors and the evaluation of their coping resources [6]. Self-efficacy, as a type of cognitive appraisal, is considered an individual’s expectation of whether he or she is able to accomplish a certain behavior in a specific environment, and it is a perception and evaluation of individual’s behavioral ability [9]. The higher the self-efficacy, the better the ability to complete care tasks, the more positive the evaluation of one’s own coping ability [10]. Individual responses to stress are largely influenced by cognitive appraisal, and positive cognitive appraisal can effectively resolve stress through positive coping strategies and emotions [11]. Coping strategies is a purposeful and flexible regulatory behavior that individuals make in response to environmental changes [12]. Individuals’ cognitive appraisal and coping strategies are a continuous process.
To a certain extent, coping strategies depend on an individual’s cognitive evaluation. Individual’s cognitive evaluation and coping behavior are sensitive to the coping resources they possess, the presence or absence of coping resources is an important factor in either hindering or facilitating an individual’s successful adaptation [6]. Lack of resources will lead to negative experiences, while sufficient resources will effective in relieving stress and increasing well-being [13]. Support from family and society is often considered a coping resource that individuals possess beyond themselves [11, 14]. Family serves as a major social support subsystem, and provides resources that influence the outcome of caregiver stress [15]. Good family function has a positive impact both on the physiology and psychology well-being of PwD and caregivers [16]. Similarly, social support, as an external protective resource also plays a crucial role in reducing the psychological pressure of caregivers [17].
In our study, we aimed to consider the burden of dementia on the entire family as a source of stress for caregivers, observing the continuous mediating effect of cognitive appraisal and coping strategies, as well as the moderating effect of resources on the stress outcomes. Although existing research has confirmed the mediating role of cognitive appraisal and coping strategies, these studies have not considered these two variables as sustained coping resources [7, 11]. Moreover, most studies only focus on the individual buffering or harmful effects of family function or social support, and some studies even report that the protective effects of these external resources are not significant, thus requiring further exploration [11, 14]. The outcome variables explored by stress coping theories are usually emotional and mental health [11]. Caregivers of elderly PwD may experience a series of negative psychological health conditions such as anxiety and depression when the care tasks they face exceed the stress they can bear. Previous studies on caregivers’ psychological conditions have focused more on depressive symptoms, anxiety has been understudied [18, 19]. Therefore, we chose the indicator of psychological distress, which refers to the unpleasant process caused by various factors (e.g., psychological, social, personal health, etc.), as manifested by physical discomfort and psychological pain, to thoroughly study the psychological condition of caregivers in coping with stress in terms of two dimensions: anxiety and depression [20].
The purpose of this study was to examine (1) whether SCM can effectively explain the relationship between family burden and psychological distress among informal caregivers of elderly PwD, (2) whether cognitive appraisal and coping strategies play a continuous mediating role between family burden and psychological distress, and (3) whether family function and social support, as a coping resources outside of caregivers themselves, can well moderate the relationship between coping strategies and psychological distress. To address these questions, a moderated mediation model was developed. This study was guided by the following hypotheses:
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Hypothesis(H)1:
Family burden positively correlates with psychological distress.
H2:
Self-efficacy and positive coping mediate the association between family burden and psychological distress.
H3:
Family function moderates the effect between the positive coping and psychological distress.
H4:
Social support moderates the effect between the positive coping and psychological distress.
The conceptual framework of this study is presented in Fig. 1
Fig. 1
Conceptual framework
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Methods
Study design and participants
We used a cross-sectional design. Objective sampling method was adopted to select PwD and their informal caregivers from June 2022 to June 2023 in memory clinics, neurology clinics and inpatient departments of three grade-A hospitals in Wuhan, Hubei Province, China. PwD were eligible to be included in this study if they ≥ 60 years, met the WHO International Classification of Diseases, 10th Revision (ICD-10) diagnostic criteria for dementia and lived at home with their family before admission (≥ 3 months) rather than nursing homes [21]. Informal caregivers were eligible to participate if they (1) ≥ 18 years; (2) length of care ≥ 3 months, ≥ 8 h peer a week, undertaking the main caregiving duties; (3) clear consciousness, normal intelligence, good communication skills and voluntary participation in this study and signing the informed consent form. Employed caregivers were excluded. G*Power 3.1.9.7. was used to calculate the sample size. The parameters were two-tailed, a medium effect size (f2 = 0.30), a power of 0.95, a statistical significance of 95% (α = 0.05) [22]. The minimum number of subjects was considered to be 134 but we recruited 193 subjects. Henseler et al. argued that the PLS-SEM allows the use of smaller and larger sample size [23].
Instrumentation
Demographic information
A self-designed questionnaire was used, PwD information included: age(years), gender, education level, marital status, numbers of children, type of medical expenses payment, Activity of daily living (ADL), Mini-Mental State Examination (MMSE), types of dementia, duration of illness (years); Caregiver information included: age, gender, education level, marital status, employment situation, monthly family income (yuan), domicile place, religious, relationship with PwD, whether to live with the PwD, average daily care duration (h), patient care duration (years).
Family burden scale of disease (FBS)
FBS was used to measure the burden of the patient’s illness on the family and its members. Its clinical application is relatively wide, with high reliability, validity, and stability [24]. It was developed by Indian scholars Pai and Kapur in 1981 [25], and the Chinese version was introduced by the Chinese University of Hong Kong in 2004 [26]. The scale has 24 items, including 6 dimensions, using a 3-point scale from 0 to 2, 0 = no effect, 1 = mild burden, 2 = severe burden. The higher the total score, the greater the family burden of the disease. The Cronbach’s α in this study was 0.920.
General self-efficacy scale (GSES)
The 10-item Chinese version of GSES has strong universality and was designed by Wang et al. [27, 28] to assess one’s ability to succeed in specific situations. The GSES consists of 4 factors: strategic, resilience, motivational, and executive efficacy. Participants rate each item on a 4-point Likert scale (ranging from 1 = not at all true to 4 = completely true), yielding a total score between 10 and 40. Higher scores indicate higher self-efficacy. The Cronbach’s α in this study was 0.941.
Simplified coping style questionnaire (SCSQ)
We utilized the Chinese version of the SCSQ to assess individuals’ coping style [29]. The SCSQ entries are straightforward, easy to interpret, and practical for clinical applications [30]. The scale comprises two dimensions: positive and negative coping, with 12 and 8 items, respectively, totaling 20 items. In this study, we focused solely on the positive coping dimension, which includes 12 items with a scoring range of 0–36 points (0 = never, 1 = rarely, 2 = often, 3 = always). A higher score indicates a greater likelihood of individuals adopting a positive coping style. The Cronbach’s α in this study was 0.859.
The family adaptation and cohesion evaluation scales II-CV (FACES II-CV)
FACES II-CV was used to assess family function and was translated and revised by Fei et al. [31]. The revised FACES II has good reliability and validity for use in China, making it a powerful measurement tool for scientific research [32]. It evaluates family function based on two aspects: adaptability (16 items) and cohesion (14 items). Items were rated on a 5-point scale (from never = 1 to always = 5), with a total score ranging from 0 to 120 points. A higher score indicates higher adaptability and cohesion. The Cronbach’s α in this study was 0.955.
Social support rating scale (SSRS)
The 10-item SSRS was developed to measure the levels of social support [33]. This scale consists of 10 items within 3 domains: subjective, objective, and the utilization of social support. The total score of SSRS ranges from 12 to 66 points. The higher the total score of social support, the more social support is received. SSRS has been widely used in China and has demonstrated good reliability and validity in practice [34]. The Cronbach’s α in this study was 0.825.
10-item kessler psychological distress scale (K10)
The K10 was developed by Kessler et al. [35] and evaluated by Zhou et al. [36] for the reliability and validity of the Chinese version. It is relatively convenient to operate and can more accurately reflect the degree of individual psychological distress. The results of cross-cultural debugging show that the scale is suitable for the Chinese population and is widely used in the evaluation of people’s mental health, with high stability [37]. We used it to indicate any nonspecific psychological distress experienced in the past 4 weeks prior to the interview. The total possible score of the K10 ranges from 10 (no distress) to 50 (severe distress), 10–15: individual is likely well; 16–21: mild mental disorder; 22–29: moderate mental disorder; 30–50: severe mental disorder. The higher the score, the more severe the psychological distress. The Cronbach’s α in this study was 0.930.
Procedure
Prior to the formal investigation, researches were uniformly trained. After obtaining informed consent, the investigators administered a face-to-face questionnaire survey on the participants, ensuring that the data were completely anonymous. The researchers helped those who could not fill out the questionnaire by themselves to complete the survey.
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Quality control
Before the start of the study, we determined the questionnaire items based on an extensive literature review and expert consultation. We conducted a pre-survey and promptly modified the questionnaire content according to the pre-survey results; Throughout the research process, we used a unified guiding expression, and the research subjects filled it out themselves. To avoid measurement bias by the researchers, we consistently used the same expression when answering questions. We utilized closed-ended questions to prevent reporting bias in the research subjects; During data analysis, a two-person input method was employed to ensure the accuracy of the data entry process.
Data analysis
Data analysis was conducted using SPSS 26.0 and SmartPLS 3.0. SPSS 26.0 was adopted to perform descriptive statistics to summarize the demographic background of the respondents and calculate the correlation between variables. The study model and related hypotheses were validated using SmartPLS, a Partial Least Square-Based Structural Equation Modeling (PLS-SEM) software. We opted for PLS-SEM for mediation effect analysis because it is more suitable for exploratory studies aimed at prediction than other methods. Moreover, when the structural model is intricate, involves a large number of constructs (5 or more), and the sample size is small, it still demonstrates high testing power [38].
Results
Samples characteristics
A total of 193 pairs of elderly PwD and caregivers were included in this study. The average age of the PwD was 75.23 years old (SD = 10.57), and the caregivers’ average age was 55.81 years old (SD = 13.09). The PwD were predominantly male (53.89%), while the caregivers were mostly female (65.80%). The majority of PwD were cared for by their children (57.51%). For detailed information, refer to Table 1.
Table 1
Demographics of informal caregivers and clinical characteristics of the PwD(193 pairs)
PwD | n (%) | Caregivers | n (%) |
|---|---|---|---|
Gender | Gender | ||
Male | 104(53.89) | Male | 66(34.20) |
Female | 89(46.11) | Female | 127(65.80) |
Education level | Education level | ||
Primary school or below | 113(58.55) | Primary school or below | 42 (21.76) |
Junior school | 64(33.16) | Junior school | 67(34.72) |
High school or above | 16(8.29) | High school or above | 84(43.52) |
Marital status | Marital status | ||
Single | 2(1.04) | Single | 11(5.70) |
Married | 121(62.69) | Married | 176(91.19) |
Divorced or Widowed | 70(36.27) | Divorced or Widowed | 6(3.11) |
Numbers of Children | Employment situation | ||
0 | 1(0.52) | Full-time job | 59(30.57) |
1 | 35(18.13) | Part-time job | 29(15.03) |
2 | 93(48.19) | Retire | 93(48.19) |
3 or more | 64(33.16) | No | 12(6.21) |
Type of medical expenses payment | Monthly family income (yuan) | ||
Medical insurance | 175(90.67) | ≤ 3000 | 47(24.35) |
own expense | 8(4.15) | 3000–5000 | 70(36.27) |
other | 10(5.18) | ≥ 5000 | 76(39.38) |
Activity of daily living, ADL | Domicile place | ||
Independent | 10(5.18) | Rural | 81(30.34) |
Moderate dependence | 77(39.90) | Urban | 186(69.66) |
Severe dependence | 65(33.68) | Religious | |
Total dependence | 41(21.24) | Yes | 30(15.54) |
Mini-Mental State Examination, MMSE | No | 163(84.46) | |
Mild | 28(14.51) | Relationship with PwD | |
Moderate | 80(41.45) | Spouse | 55(28.50) |
Severe | 85(44.04) | Child | 111(57.51) |
Types of dementia | relatives | 22(11.40) | |
Alzheimer’s disease (AD) | 93(48.19) | Other | 5(2.59) |
Vascular dementia (VaD) | 77(39.90) | Whether to live with the PwD | |
Mixed dementia (MD) | 16(8.29) | Yes | 125(64.77) |
Other | 7(3.62) | No | 68(35.23) |
Duration of illness(years) | Average daily care duration (h) | ||
≤ 1 1–2 | 64(33.16) 51(26.42) | ≤ 5 | 22 (11.40) |
2–5 | 45(23.32) | 5–8 | 37(19.17) |
5–10 | 18(9.33) | ≥ 8 | 134(69.43) |
≥ 10 | 15(7.77) | Patient care duration (years) | |
≤ 1 | 65(33.68) | ||
1–2 | 46(23.83) | ||
2–5 | 43(22.28) | ||
5–10 ≥ 10 | 24(12.44) 15(7.77) | ||
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Measurement model
Firstly, we evaluate the reliability and validity of the measurement model. We measured the ‘Cronbach’s alpha’ and ‘composite reliability (CR)’ of constructs for assessing ‘internal consistency’. All the values of ‘Cronbach’s alpha’ and CR are above the minimum acceptable value of 0.7 (Table 2). For the “convergent validity”, this study assessed Average Variance Extracted (AVE), which was required to be higher than 0.50 [39]. Four variables’ AVE values in Table 2 were higher than the 0.50, illustrating that the structure explains, on average, more than half of the variance of its associated indicators. However, family burden and social support were slightly below 0.50. Fornell and Larcker stated that if AVE was less than 0.5, but CR was higher than 0.6, the convergent validity of the construct was still adequate [38]. Additionally, we examined the Heterotrait-Monotrait Ratio (HTMT) to evaluate the discriminant validity. Henseler et al. believed that HTMT values below 0.90 are acceptable, and all structures included in this analysis have HTMT values below 0.90. A good value of discriminant validity was found using the measurement model (Table 3) [38].
Table 2
Construct reliability, validity and correlations
correlations | |||||||||
|---|---|---|---|---|---|---|---|---|---|
Construct | Cronbach’s alpha | CR | AVE | 1 | 2 | 3 | 4 | 5 | 6 |
1.Family burden | 0.92 | 0.925 | 0.402 | 1 | |||||
2.Self-efficacy | 0.941 | 0.941 | 0.680 | -0.763** | 1 | ||||
3.Positive coping | 0.859 | 0.859 | 0.505 | -0.714** | 0.831** | 1 | |||
4.Family function | 0.955 | 0.955 | 0.581 | -0.753** | 0.708** | 0.676** | 1 | ||
5.Social support | 0.825 | 0.825 | 0.494 | -0.617* | 0.748** | 0.757** | 0.619** | 1 | |
6.Psychological distress | 0.93 | 0.935 | 0.617 | 0.727** | -0.900** | -0.815** | -0.729** | -0.638** | 1 |
Table 3
Heterotrait – monotrait ratio (HTMT)
Construct | 1 | 2 | 3 | 4 | 5 | 6 |
|---|---|---|---|---|---|---|
1.Family burden | ||||||
2.Self-efficacy | 0.809 | |||||
3.Positive coping | 0.752 | 0.882 | ||||
4.Family function | 0.675 | 0.803 | 0.775 | |||
5.Social support | 0.727 | 0.818 | 0.818 | 0.781 | ||
6.Psychological distress | 0.822 | 0.841 | 0.760 | 0.843 | 0.721 |
Structural model
Further, we evaluated the structural model through path analysis and tested the hypotheses of the study. Firstly, we validated whether the observed variables satisfy the model estimation requirements. The results of the linearity analysis using VIF showed that all endogenous and exogenous combined constructs were below the threshold of 5, indicating the absence of collinearity [40]. Then, we obtained the β and corresponding t-values by using the “non-parametric” bootstrapping procedure. Finally, we reported the coefficient of determination (R2), effect size (f2) and Cross-validated Redundancy (Q2). The R2 revealed the prediction accuracy of the structural model, ranging from 0 to 1, with 0.25, 0.50, and 0.75 representing weak, medium, and strong prediction accuracy, respectively. f2 showed the strength of the respective variable to explain the endogenous latent variable, with f2 values of 0.02, 0.15, and 0.35 indicating small, medium, and large effects, respectively. Q2 represented the predictive relevance; the higher the value of Q2, the better the predictive accuracy of the model, generally > 0 means that the predictive relevance of the model is acceptable. The results of the structural model are presented in Table 4, and SEM is shown in Fig. 2. The results demonstrate that family burden positively correlates with psychological distress (β = 0.357, t = 5.149, P = 0.000, f2 = 0.212), supporting H1 (Table 4).
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Table 4
Results of path analysis and hypothesis testing
Hypothesesis | Path | β | P | t | CI(5%,95%) | f2 | R2 | Q2 | Results |
|---|---|---|---|---|---|---|---|---|---|
H1 | FB-> PD | 0.357 | 0.000 | 5.149 | (0.217,0.489) | 0.212 | 0.738 | 0.438 | Supported |
H2 | FB-> SE-> PC-> PD | 0.111 | 0.010 | 2.591 | (0.033,0.203) | Supported | |||
H3 | FFxPC-> PD | 0.072 | 0.210 | 1.253 | (-0.026,0.205) | 0.011 | Rejected | ||
H4 | SSxPC-> PD | 0.128 | 0.006 | 2.776 | (0.033,0.215) | 0.032 | Supported |
Fig. 2
Structural equation model.(*** P < 0.001;**P < 0.01)
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Moreover, we predicted the mediating role of self-efficacy and positive coping in the relationship between family burden and psychological distress. If both the lower and upper confidence intervals (CIs) do not include zero, the mediation role is significant based on the use of a 95% CI as evidence. In this regard, the pathway from family burden to psychological distress via self-efficacy and positive coping is significant (supporting H2) (β = 0.111, CI = 0.033 ~ 0.203) (Table 4). Additionally, we also assessed the variance accounted for (VAF) to evaluate the mediation analysis. The VAF value indicates that self-efficacy and positive coping partially mediate the relationship between family burden and psychological distress.
Additionally, we measured the moderator effect size using the “bias-corrected and accelerated” (BCa) bootstrapping technique with a resample of 5000. Table 4 showed that the interaction term (family function_positive coping) did not have a significant positive impact, but (Social support_positive coping) had a significant positive effect on psychological distress (β = 0.072, t = 1.253, p = 0.210, f2 = 0.011; β = 0.128, t = 2.776, p = 0.006, f2 = 0.032) with medium effect size, rejecting H3, and supporting H4. Then, we plotted a simple slope analysis to understand the interaction effect of (social support_positive coping) on psychological distress (Fig. 3).
Fig. 3
Simple slope analysis. Note SS: Social support; PC: Positive coping style
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Furthermore, we measured the Goodness-of-Fit Index (GFI), which is the geometric mean of the average communality and average R2 [41]. In our study, the GFI value was significantly higher than the cutoff value of 0.36 for a large effect size of R2, indicating that our model has a good model fit. Finally, utilized the Blindfolding function to obtain Q2 values, and all Q2 values were above 0, illustrating that the model strong good correlation (Table 5).
Table 5
Goodness-of-fit index (GFI)
Constructs | AVE | R2 |
|---|---|---|
Family burden | 0.402 | |
Family function | 0.581 | |
Social support | 0.494 | |
Self-efficacy | 0.680 | 0.582 |
Positive coping | 0.505 | 0.641 |
Psychological distress | 0.617 | 0.738 |
Average scores | 0.547 | 0.654 |
(\(\left(GFI=\sqrt {\overline{AVE}\times\overline{{R}^{2}}}\right)\)) | 0.598 |
Discussion
This study examined the relationship between family burden and psychological distress by the mediating role of self-efficacy and positive coping, as well as the moderating roles of family function and social support to demonstrate the applicability of the SCM in caregivers. The findings offer a practical foundation for implementing the SCM in informal caregivers of elderly PwD in China.
Firstly, we considered that family burden positively correlates with psychological distress, which is consistent with the Unsar and García-Albercas’ findings [42, 43]. Unsar found a significant positive correlation between caregiver burden and anxiety and depression. Moreover, the burden on caregivers increases with the duration of care, leading to a rising incidence of caregiver anxiety and depression [42]. García-Alberca also confirmed that due to the longer course of dementia, patients typically last 5–15 years or more from diagnosis to death [43]. Daily living and medical care for PwD becomes an essential and basic need, which leads to an increased burden on the caregiver’s family. Prolonged and heavy caregiving could easily cause the caregiver to suffer from negative emotions such as depression and anxiety [44].
Our research also found that self-efficacy and positive coping have a mediating effect on family burden and psychological distress. This result validates the applicability of SCM in informal caregivers of elderly PwD, confirming that cognitive appraisal and coping strategies are a continuous and dynamic process that is key to an individual’s ability to generate stress responses. Our research provides strong practical support for the SCM. In our study, self-efficacy stimulates caregivers to make positive appraisals and employ positive coping strategies to offset the negative impact of care burden on quality of life, thereby enabling them to maintain good physical and mental health to sustain long-term care activities [45]. In China, with the increasing emphasis on the development of elderly care, the State Council has proposed to build a diversified elderly care service system to effectively increase the capacity of family elderly care [46]. More than 90% of PwD are taken care of by family members at home, and over 50% of caregivers exhibit negative emotions such as anxiety and depression [4]. The health and living conditions of informal caregivers directly determine the quality of life and prognosis of PWD. The self-efficacy of informal caregivers, as an individual’s speculation and judgment of their ability to complete a certain behavior, directly affects the choice of coping strategies. Caregivers with high self-efficacy often face difficulties with a positive and wholehearted attitude, choosing proactive coping strategies and actively solving problems. Therefore, clinical nurses should pay attention to evaluating the self-efficacy and coping strategies of caregivers of PwD, and use methods such as health education, relaxation training, physical therapy, or motivational interviews and so on to eliminate or minimize the specific reasons for the decrease in both. This will promote caregivers to improve their self-efficacy level and adopt more proactive coping strategies, thereby improving their overall health status.
SCM suggests that the external resources obtained by individuals influence the outcome of stress coping through their interaction with stressors, but it is not yet clear which part of the external resources specifically act on [6]. So, our study attempts to consider family function and social support as important external resources individuals acquire and observe their role in the relationship between caregiver coping strategies and poor mental health. Our results demonstrated that social support positively moderated the relationship between positive coping and psychological distress. The buffering model in social support theory proposes that the perception of available support leads to an assessment of potentially threatening situations as less stressful [16]. Social support cushions the potential negative impact of stress events. When an individual experiences negative life events, social support will play a buffering role to prevent psychological disorders [47]. Lakey and Cohen et al. also argued that social support could reduce the impact of stressful events on mental health through the supportive actions of others [48]. Additionally, it could mitigate stress-related adverse emotions by triggering positive emotions such as happiness, hope, and optimism. Hence, in order to help informal caregivers of elderly PwD alleviate the negative psychological impact of long-term care burden, it is necessary to consider the protective role of social support.
Finally, the moderating effect of family function between positive coping and psychological distress was not significant. The possible reason might be that in China, influenced by traditional “filial piety” culture, there exists a moral norm that adult children have an obligation to take care of their elderly parents. Under the influence of this concept, most caregivers believe that taking care of elderly PwD is a necessary ‘task’ and it is difficult to gain positive experiences from it [49]. As for elderly PwD, receiving help from family members is also a “natural” thing; they have become accustomed to the influence of these resources on them. Therefore, the moderation effect of family function is not significant. Additionally, the scale we selected, as well as the existing scales for measuring family function, were mostly developed by some developed countries decades ago. Although they have been revised in cultural contexts, there are still certain cultural differences. Moreover, with the development of the times, people have gained a better understanding of marriage and family, such as the issue of only child marriage in China, the emergence of the “NEET (Not currently engaged in Employment, Education or Training)” and “DINK (Double Income No Kids)” ethnic groups, and so on [50]. Existing scales may not be applicable to families in the current Chinese cultural background, which may also affect the research results on the moderation role of family function in our study to a certain extent. Hence, it is necessary to develop the theory and scale of family functions that are in line with Chinese culture.
This study applied the SCM to provide new insights into enhancing the psychological well-being of elderly PwD caregivers. The results revealed that the family burden of caregivers significantly increased psychological distress. Self-efficacy and positive coping partially mediated the relationship between family burden and psychological distress, while social support moderated the effect of positive coping on psychological distress. We establish a theoretical foundation and offer novel perspectives for intervention strategies aimed at reducing the caregiving burden on caregivers of elderly PwD and improving their physical and mental health. Therefore, we believe that caregivers of PwD should approach caregiving events with a positive mindset, actively seek positive experiences during the caregiving process, and confront stressors proactively rather than avoiding them. For clinical nurses, it is essential to pay closer attention to the physiological and psychological conditions of caregivers, strengthen diverse cooperation in different environment, disciplines, and professions, promptly assess caregivers’ health status, provide appropriate advice to guide caregivers in changing their mindsets, and develop effective coping strategies for managing caregiving stress. From a societal perspective, caring for PwD is a demanding and enduring responsibility that drains caregivers’ time, energy, and finances, leading to family and societal conflicts. Providing caregivers with diverse social support resources and channels is crucial to alleviating their physical, psychological, financial, and other stressors. According to data from the WHO in 2021, formal agreements and joint plans for dementia care in China are not yet fully developed, and the availability of social and economic protections is insufficient [51]. This suggests that the government should plan, coordinate and integrate various available resources, improve the caregivers of PwD social support system, continuously explore and learn from other nursing care models, and establish a social service system for PwD that is suitable for China’s national conditions.
Limitation
Firstly, based on cross-sectional survey data, it is difficult to determine the causal relationship between the variables, and there might be selection bias, recall bias, and confounding factors, after which longitudinal researches can be expanded to better establish causal relationships; Secondly, in measuring the family resources for caregiver stress coping, we only considered family as one dimension of support. Future research could take into account the role of more dimensions of family in caregiver stress coping and explore other potential mediating and moderating variables that might effect the relationship between family burden and psychological distress; Then, we only studied in three hospitals in Wuhan, China, and the research results might have certain regional limitations. Future research could further explore in diverse geographical regions to validate and expand upon these findings; Finally, Lazarus also suggested that caregivers not only generate negative emotions during the caregiving process, but also have certain positive experiences. Future research could target caregivers’ positive emotional experiences for investigation.
Conclusion
The present study validated the applicability of the CAM among informal caregivers of elderly PwD, and confirmed the chain mediating effect of cognitive appraisal (self-efficacy) and coping strategies (positive coping) between stressors (family burden) and outcomes (psychological distress). To our knowledge, this is the first study to consider family function and social support as common external resources that caregivers receive from outside of themselves, and to observe their role between the positive coping and psychological distress. However, the effect of family function has not yet been confirmed. This study has made valuable contributions to understanding the psychological distress of informal caregivers of elderly PwD in China. Its insights are applicable to designing interventions that could significantly improve caregiver well-being, addressing a critical and under-researched area with practical implications for caregiver support and mental health interventions.
Acknowledgements
We would like to express our gratitude to all the nurses, patients, and their families who participated in the survey in this study.
Declarations
Ethics and approval and consent to participate
This study was approved by the Ethics Committee of Wuhan University of Science and Technology (Ethical Committee code: 2022105). After obtaining informed consent, the investigators administered a face-to-face questionnaire survey on the participants, ensuring that the data were completely confidential and strictly abide by the principles of being beneficial, respecting human dignity and fairness.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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