Background
Globally, Dementia is the primary cause of disability in adults over 65 [1]. China has the largest percentage of people with dementia (PwD) around the world, comprising approximately 25% of the total worldwide [2]. Studies have reported the socioeconomic disparities in the risk of dementia in China [3]. Compared to the urban population, dementia was substantially more prevalent in rural individuals [4, 5]. However, the dementia care system in China is still imperfect, especially in rural areas [2]. In addition, under the influence of traditional filial piety culture, people believe that it is the responsibility of the family to care for the elderly, which is more deep-rooted in rural areas [6, 7]. Therefore, the vast majority of PwD are cared for by family members [8]. Under this context, the crucial role of family caregivers becomes apparent. Dementia is a disease that causes patients to gradually lose the ability to do daily activities, which requires caregivers to invest much time, energy, and financial support [8]. With the progression of dementia, dementia patients need full-time care ultimately, which limits the personal life of family caregivers, negatively impacts caregivers’ physical and psychological well-being, and leads to worse quality of life (QoL), especially in rural areas [9, 10]. Besides, A qualitative study pointed out that caregivers’ perception of their QoL was related to the quality of care provided to loved ones with dementia [11]. Therefore, understanding the QoL of caregivers is of great significance to patients and caregivers. However, nowadays, the study regarding the QoL of PwD family caregivers is concentrated in high-income nations and regions like the United States and Europe, and there is still a lack of relevant research in middle- and low-income countries and areas [12]. To guide the development and implementation of policy, treatment, care, and support to improve this significant outcome, it is critical to further identify the QoL and its influencing factors of PwD family caregivers in economically underdeveloped areas such as rural China.
Caregiver burden negatively influences QoL
The initial definition of the term caregiver burden was “the extent to which caregivers perceived their emotional or physical health, social life, and financial status as suffering as a result of caring for their relative” [13]. Due to the characteristics of dementia, caregivers need to continuously care for elderly dementia patients 24 hours a day and cope with their mental and behavioral symptoms. Throughout this ongoing caregiving, many family caregivers experience a lot of strain and burden resulting from this rigorous activity of caregiving, which has a negative impact on their physical, psychological, and QOL. It is estimated that 20–50% of family caregivers experience depression due to heavy care burden, which is 2 to 3 times higher than the general population [14]. Long-term effects of poor psychological and physical health are triggered by caregiver distress and burden. Research on caregivers indicates that caregiving has been associated with more psychological complaints and a lower QOL, both physically and mentally [15, 16]. However, few researches have studied the underlying mechanisms in the relationship between caregiver burden and QoL among PwD family caregivers. Therefore, in this study, we have focused on exploring whether this relationship still holds among Chinese rural PwD family caregivers and analyze how caregiver burden influences QoL among them. Study hypothesis 1 is that caregiver burden is directly predicted by the QoL of family caregivers of PwD.
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Social support as a mediator
Social support refers to the adequacy and quality of support/assistance potentially provided by an individual’s relationships (e.g., family, friends, and significant others) in times of need. A study on the QoL of caregivers of PwD in Thailand showed that perceived social support had a positive correlation with the QoL of family caregivers [10]. Several systematic reviews and meta-analyses also show that receiving social support may be an essential factor in enhancing the QoL of family caregivers [12, 17]. Additionally, different authors have claimed that social support, as a positive external resource, may promote family caregivers to be more successful in providing care for PwD, thereby reducing the risk of burden and negative health outcomes [18, 19]. In other words, caregiver burden may be influenced by the availability of family and social support; caregivers with an extensive social support network were less burdened. Meanwhile, studies have shown that the heavier the caregiver burden is, the worse the QoL of family caregivers of PwD [20]. Thus, it is obvious that there is a strong correlation between caregiver burden, social support, and QoL.
In addition, the stress process model developed by Pearlin et al. [21] states that caregivers’ burden and health outcomes are a complex process that involves numerous interconnected factors, including the stressors they are exposed to and the resources they have access to. Following this model, social support could be viewed as a significant mediating variable to reduce the negative consequences of stress/burden on the QoL of caregivers. Although researchers have investigated pairwise associations among caregiver burden, social support, and QoL but have not clarified relationships between the three of them, especially among rural dementia caregivers. Considering the tremendous stress that rural family caregivers of PwD suffer during care, it is necessary to further explore the association between caregiver burden, social support, and QoL of family caregivers of PwD according to the stress process theory to provide a theoretical basis for further intervention research. Therefore, hypothesis 2 of this study is that perceived social support could play a mediating role between caregiver burden and QoL among family caregivers of PwD.
Theoretical modeling
According to the theoretical model, we developed a hypothetical model for this investigation (Fig. 1.). Therefore, the aim of this research was to identify the QoL of family caregivers of PwD and to investigate the mediating role of social support between caregiver burden and QoL in rural China under the guidance of the stress process model.
Fig. 1
Theoretical model and hypothesis
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Materials and methods
Design
A cross-sectional design was used in the present study.
Sample
Family caregivers of PwD provide care for patients treated in the neurology department, brain hospital, and geriatrics hospital in Changsha City were recruited from May 12, 2022, to March 31, 2023. Inclusion criteria for participants were: (1) dementia diagnosis of the care recipient; (2) the registered permanent residence of the care recipient in rural areas; (3) main care tasks being performed by the primary family caregiver; (4) having cared for patients for no less than six months; (5) regular writing, reading, comprehension, and expression abilities and ability to communicate in Mandarin; (6) participation in this research is voluntary and a signed informed consent form is required. Exclusion criteria were: (1) Family hired professional care workers; (2) Those with severe cognitive impairment, mental disorders, severe visual or hearing impairment, and unable to communicate; (3) Currently participating in similar programs as family caregivers.
The sample size in this study was based on the primary outcome QoL of family caregivers with dementia. Power Analysis & Sample Size Software (PASS) was used for calculation. The mean score of QoL in Alzheimer’s disease (QoL–AD) in the previous dementia caregiver study was 30.05, and the standard deviation was 6.05 [22]. By running this mean and standard deviation in PASS software, it could be concluded that the sample content of 141 cases can produce a satisfactory bilateral 95% confidence interval (CI). Of the 173 caregivers who responded, 150 completed the survey. Finally, 150 family caregivers were enrolled in the present study with a valid response rate (86.71%). The distance from the mean of QoL–AD was controlled at 29.05–31.05, equivalent to a gap of 1 when the standard deviation was 6.05.
Date collection
Only caregivers were investigated using structured questionnaires detailed below, and information about PwD was collected from caregivers. Before the interview, participants were given a written and verbal explanation about the study including the benefits and risks. Then participants provided written consent. Every participant was interviewed personally to avoid any inconvenience and to assure confidentiality. Structured questionnaires were self-administered, the investigator supervised and assisted caregivers to completed questionnaires. The medical records and diagnosis certificates of PwD were also reviewed before the investigation.
Measures
Demographics and relevant information
A demographic information questionnaire was applied to obtain data on the demographics of the caregivers and PwD including age, gender, marital status, and level of education. Additionally, caregivers indicated their relationship to the patient, whether they lived with the patient, duration of caring in years, working conditions, household monthly income, perceived health status, and whether there are acute and chronic diseases now.
QoL in Alzheimer’s disease (QoL–AD)
The QoL–AD is a self-report assessment scale with 13 items, which evaluates physical health, energy, mood, living situation, memory, family, marriage, friends, chores, fun, money, self, and life as a whole [23]. There are four points for each item poor, fair, and good to excellent. The overall score ranging from 13 to 52 is calculated by summing the scores of the 13 items with higher scores indicating greater QoL [23]. This scale was also widely used in the measurement of QoL of dementia caregivers [12]. The Cronbach’s alpha for the family caregiver version is 0.87 and was 0.72 in this study. Family caregivers completed the caregiver version of the QoL-AD scale to evaluate caregiver-related QoL in the present study [24].
Caregiver burden inventory (CBI)
The CBI is a 24-item scale with five dimensions: time dependence, developmental, physical, social, and emotional burden [24]. Except for the physical burden, which comprises four items, each dimension has five. Each item is scored from 0 (not at all descriptive) to 4 (very descriptive), with a total score range of 0 to 96. Score ranges are 0–32 as mild, 33–64 as moderate, and 65–96 as severe. The Cronbach’s alpha for the whole scale ranges from 0.73 to 0.86 [25]. The Chinese version of the CBI used in this study has demonstrated good reliability in measuring the caregiver burden in the Chinese population with Cronbach’s alpha from 0.79 to 0.93 [26]. In our study, the Cronbach’s alpha was 0.80.
Multidimensional scale of perceived social support (MSPSS)
The 12-item MSPSS is designed to measure social support from three dimensions: friends, family, and significant others [27]. The Cronbach’s alpha of the original overall scale was 0.88 [28]. Each subscale has four items. Respondents choose whether they agree with each statement on a 7-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree.” The total score ranges from 12 to 84, with higher scores indicating more social support [29]. We used the Chinese version of MSPSS, and the reliability Cronbach alpha was 0.93 [28]. The Cronbach’s alpha in this study was 0.91.
Ethical considerations
The Ethics Committee of Xiang Ya Nursing School of Central South University approved this study (NO. E2021143). Written informed consent was obtained from all subjects or their assigned surrogate decision-makers. All participants’ information, including the questionnaires and scales, was confidential.
Data analysis
Data were analyzed using IBM SPSS Statistics 25.0 and SPSS PROCESS Procedure Version 3.3 (Model 4). First, we test the normality of the distribution of continuous variables. Besides descriptive statistics, independent samples t-tests and analysis of variance (ANOVA) were used to analyze the caregivers’ and PwD’ demographic related to caregivers’ QoL. We adopted Pearson correlations to analyze the association between QoL, caregiver burden, and social support. The statistical significance was set at P ≤ 0.05. Common method bias was tested by the Harman single factor test, and the total variance extracted from the first factor was less than 50% to indicate the absence of common method bias. There were 15 factors with eigenvalues greater than 1, and the first factor accounted for 16.47%, which was lower than the recommended threshold of 50%. Then we used SPSS PROCESS Procedure Version 3.3 (Model 4) to test the mediating role of social support between caregiver burden and QoL through establishing a mediating model by utilizing a bootstrap sample of 5000. When the 95% CI did not include zero, mediation effects were regarded as significant.
Results
Demographic characteristics and univariate analysis
Table 1 shows the demographic characteristics of family caregivers and PwD and their relationships with QoL. The family caregivers had a mean age of 52.43 ± 13.82 years and more than half were female (56.7%). The vast majority (89.3%) of participants had a spouse. The mean age of rural PwD was 71.63 ± 8.60. There were significant differences between in work and out of work (t = 3.756, P < 0.001), lived with the patient and not lived with (t = 3.024, P = 0.003), and male and female of PwD (t =-2.354, P = 0.020) in family caregiver’ QoL by using the independent samples t-test analysis. One-way ANOVA indicated that family caregiver’s age (F = 11.343, P < 0.001), perceived health status (F = 3.430, P = 0.010), presence of acute and chronic diseases (F = 3.819, P = 0.011), duration of caring in years (F = 5.682, P = 0.001) and age of PwD (F = 4.033, P = 0.009) had significant differences in the family caregiver’ QoL.
Table 1
Comparisons of QoL among different demographic characteristics (N = 150, % or Mean ± SD)
Variable | n (%) | t/F | P | Variable | n (%) | t/F | P |
|---|---|---|---|---|---|---|---|
Age | 52.43 ± 13.82 | F = 11.343 | < 0.001 | Relationship with patients | F = 2.238 | 0.054 | |
<35 | 13(8.7) | Spouse | 39(26.0) | ||||
35–44 | 36(24) | Son | 39(26.0) | ||||
45–54 | 41(27.3) | Daughter-in-law | 16(10.7) | ||||
55–64 | 31(20.7) | Daughter | 50(33.3) | ||||
≥ 65 | 29(19.3) | Brothers and sisters | 3(2.0) | ||||
Gender | t = 0.671 | 0.503 | Others | 3(2.0) | |||
Male | 65(43.3) | Household monthly income | F = 1.701 | 0.186 | |||
Female | 85(56.7) | Less than 1000 yuan | 5(3.3) | ||||
Marital status | t=-0.448 | 0.655 | 1000–1999 yuan | 67(44.7) | |||
With spouse | 134(89.3) | More than 2000 yuan | 78(52) | ||||
Without spouse | 16(10.7) | Duration of caring in years | 3.43 ± 2.328 | F = 5.682 | 0.001 | ||
Education level | F = 1.133 | 0.346 | ≤ 2 | 65(43.3) | |||
Primary school and below | 39(26.0) | 2.1–5 | 51(34.0) | ||||
Junior school | 41(27.3) | 5.1–7 | 19(12.7) | ||||
High/Specialized Secondary school | 41(27.3) | >7 | 15(10.0) | ||||
Junior college or above | 29(19.3) | Lived with the patient | t = 3.024 | 0.003 | |||
Working condition | t = 3.756 | < 0.001 | No | 40(26.7) | |||
In work | 77(51.3) | Yes | 110(73.3) | ||||
Out of work | 73(48.7) | Age of PwD | 71.63 ± 8.60 | F = 4.033 | 0.009 | ||
Perceived health status | F = 3.430 | 0.010 | < 65 | 35(23.3) | |||
Very bad | 9(6.0) | 65–74 | 59(39.3) | ||||
Poor | 36(24.0) | 75–84 | 43(28.7) | ||||
Average | 76(50.7) | ≥ 85 | 13(8.7) | ||||
Good | 25(16.7) | Gender of PwD | t =-2.354 | 0.020 | |||
Very good | 4(2.7) | Male | 69(46) | ||||
Acute and chronic diseases | F = 3.819 | 0.011 | Female | 81(54) | |||
No | 76(50.7) | Education level of PwD | F = 0.704 | 0.621 | |||
One piece | 51(34.0) | Primary school and below | 86(57.3) | ||||
Two pieces | 18(12.0) | Junior school | 48(32.0) | ||||
Three pieces or above | 5(3.3) | High/Specialized Secondary school | 10(6.7) | ||||
Junior college or above | 6(4.0) |
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Descriptive statistics and correlations of QoL, caregiver burden, and social support
Of 150 PwD family caregivers, the total score of QoL was 29.01 ± 4.06, the total score of social support was 52.10 ± 7.95, and the total score of caregiver burden was 52.85 ± 9.39. The caregiver burden mostly attained a moderate level (92.7%), whereas social support achieved a low to medium level (86.7%) (Table 2). Pearson’s correlations analysis showed that caregiver burden has a negative correlation with social support and QoL. Additionally, social support has a positive association with the QoL of family caregivers.
Table 2
Descriptive statistics and correlation of variables (N = 150, % or Mean ± SD)
Variable | n (%) or Mean ± SD | QoL | Caregiver burden | Social support |
|---|---|---|---|---|
QoL | 29.01 ± 4.06 | 1 | ||
Caregiver burden | 52.85 ± 9.39 | -0.295** | 1 | |
Low level | 2(1.3) | |||
Medium level | 139(92.7) | |||
High level | 9(6.0) | |||
Social support | 52.10 ± 7.95 | 0.348** | -0.242** | 1 |
Low level | 7(4.7) | |||
Medium level | 123(82.0) | |||
High level | 20(13.3) |
Test of hypothetical model
SPSS PROCESS Procedure model 4 was adapted to test the hypothesized interrelationships among the three study variables. Demographic factors that were statistically significant in the univariate analysis were selected as control variables including family caregiver’s age, working condition, perceived health status, presence of acute and chronic diseases, lived with the patient or not, duration of caring in years, age of PwD and gender of PwD. Results of regression analysis in Table 3 show that caregiver burden was negatively associated with social support (β=-0.179, 95%CI: -0.324, -0.035, P = 0.015) and QoL (β= -0.069, 95%CI: -0.136, -0.001, P = 0.047). Meanwhile, social support was positively associated with QoL (β = 0.135, 95%CI: 0.059, 0.212, P < 0.001). The detailed pathway is shown in Fig. 2.
Table 3
Regression analysis of variables in mediation model
Predictor Variable | Model 1(Dependent Variable: social support) | Model 2 (Dependent Variable: QoL) | ||||
|---|---|---|---|---|---|---|
β | t | 95%CI | β | t | 95%CI | |
Social support | / | / | 0.135 | 3.488*** | 0.059, 0.212 | |
Caregiver burden | -0.179* | -2.455 | -0.324, -0.035 | -0.069 | -2.007* | -0.136, -0.001 |
Family caregiver’s age | -0.145 | -1.839 | -0.302, 0.011 | -0.054 | -1.474 | -0.127, 0.019 |
Working condition | 1.453 | 0.762 | -2.315, 5.221 | -0.119 | -0.136 | -1.850, 1.613 |
Perceived health status | -0.993 | -1.035 | -2.888, 0.903 | 0.334 | 0.756 | -0.539, 1.206 |
Acute and chronic diseases | -1.869 | -1.781 | -3.943, 0.205 | -0.075 | -0.153 | -1.036, 0.887 |
Lived with the patient | 1.789 | 1.131 | -1.340, 4.918 | -1.470 | -2.017 * | -2.912, -0.029 |
Duration of caring in years | -0.628 | -2.125* | -1.211, -0.044 | -0.008 | -0.056 | -0.280, 0.2644 |
Age of PwD | -1.059 | -0.824 | -3.597, 1.480 | 1.300 | 2.203* | 0.133, 2.468 |
Gender of PwD | 0.120 | 1.383 | -0.052, 0.292 | -0.012 | -0.288 | -0.091, 0.068 |
R2 | 0.144 | / | 0.314 | / | ||
F | 2.609** | / | 6.368*** | / | ||
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The results of the Bootstrap test (Table 4) showed that social support could play a mediating effect between caregiver burden and QoL. The total effect was − 0.093 (95%CI: -0.162, -0.024), the direct effect was 0.069 (95%CI: -0.136, -0.001), and the indirect effect was − 0.024 (95%CI: -0.055, -0.002), accounting for 25.8% of the total. As demonstrated below, the caregiver burden was both directly and indirectly related to QoL through the mediating role of social support. Thus, the final findings confirmed all of the hypotheses.
Table 4
The total, direct, and indirect effect of caregiver burden on QoL
Result Variables | β | Boot SE | BootLLCI | BootULCI |
|---|---|---|---|---|
Total effect | -0.093 | 0.035 | -0.162 | -0.024 |
Direct effect | -0.069 | 0.034 | -0.136 | -0.001 |
Indirect effect | -0.024 | 0.014 | -0.055 | -0.002 |
Fig. 2
The pathway of the final model. a: Caregiver burden→ Social support; b: Social support → Quality of life; c: Total effect of caregiver burden → quality of life; c’: Direct effect of caregiver burden → quality of life
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Discussion
Our investigation evaluated the QoL among family caregivers of PwD in rural Hunan province, China. According to this research, the QoL among PwD family caregivers in rural China is worse than that reported from France ( 32.7 ± 4.9) [20] and Singapore (30.4 ± 5.3) [30], and still worse than results from a central region of China research(30.05 ± 6.05) [31]. Reasons for this discrepancy may be, compared with urban areas or developed countries, rural areas have a limited standard of living and less social attention [17]. In addition, results of the univariate analysis showed that the caregiver’s age, working condition, perceived health status, number of acute and chronic diseases, lived with the patient, years have lived with patients, and duration of caring in years are significant demographic factors that strongly affect the QoL of dementia caregivers. What is more, demographic factors of PwD including age, gender, duration of illness, and self-care situation, are significantly associated with QoL of dementia caregivers. It is consistent with narrative synthesized results reported by Farina in their systematic review [17]. In another meta-analysis [12] socio-demographic factors, including the caregiver’s age and PwD’s self-care situation, have no significant effect size. However, almost all of the included studies came from developed countries. In rural regions or developing countries, the impact of socio-demographic factors on dementia caregivers may differ, and we need more studies in rural areas or developing countries to identify their influence further.
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In the present study, we found that 98.7% of dementia caregivers have a moderate to high caregiver burden in rural China. When comparing with scores of the CBI, the caregiver burden level in our study is higher than in developed regions [32] or countries [33] and other developing countries, such as Iran [22] and Turkey [9]. Different socioeconomic and cultural levels and healthcare policies can contribute to this difference [34]. When compared with domestic cities, the caregiver burden level in our study is higher than in Guangzhou city [35] (40.43 ± 20.05) but lower than in Shanghai city (65.92 ± 16.74) [36]. The possible reasons include the disparity between economic development and medical care and the use of different sample sources. The findings of correlation analysis showed a negative relationship between caregiver burden and QoL. In line with previous research [9, 37], a higher caregiver burden among PwD family caregivers was associated with a greater chance of a worse QoL. Therefore, to improve the QoL of dementia family caregivers, efforts are still needed to reduce the dementia family caregiver burden.
Results also revealed that the mean social support score in this study was 52.10 ± 7.949, and the majority (82%) of family caregivers experience moderate social support from their family members, friends, and significant others. This is similar to the results reported by the other two studies [38, 39]. As China is a country that attaches great importance to filial piety and harmonious relations, family caregivers can obtain financial, emotional, and other support from family members and others. However, many caregivers cared for the sick almost all day long. Social activities were severely limited. In addition, the affiliate stigma of dementia caregivers made them reluctant to seek help from others[40]. It is difficult for them to proactively obtain effective support. Our result further evidences this view that only 13.3% of caregivers in this study had high social support. Correlation analysis revealed that lower caregiver burden was significant with higher social support. Our final model and previous studies have proven this result [18]. Besides, our findings revealed that social support was positively connected with the QoL of family caregivers of PwD. Therefore, we need to improve caregivers’ social support level to reduce their caregiver burden, enhance their QoL, and finally ameliorate the quality of care for people with dementia.
Our study found that social support has a mediation effect between caregiver burden and QoL, which piqued our curiosity. Through the mediating effect of social support, the model showed that caregiver burden has a direct effect on QoL in addition to having an indirect effect on the QoL of family caregivers of PwD. This conclusion suggests that social support could be a necessary way to reduce caregiver burden and improve the QoL in dementia caregivers and that this mediating pathway should inspire relevant interventions. Currently, the distribution of medical service resources in urban and rural areas is unbalanced in China. Under the guidance of national policies to further improve the medical and health service system [41], the allocation of medical resources should be tilted to rural and remote areas. The capacity building of clinical specialties such as psychiatry and geriatrics should be strengthened in county-level hospitals by increasing the proportion of experts in county-level hospitals, to improve the old-age care system, and build a formal social support network for dementia caregivers in rural areas. The recently published list of National Essential Services for the Aged has included family aged care support services [42]. Therefore, rural-community daycare services can be established to solve the problem of no one to take care of at home, and combine the elderly service institutions with rural family care to decrease the care burden of rural family caregivers. Meanwhile, considering caregiver time and transportation costs, using mobile applications to provide telemedicine care service suggestions is also a feasible measure to increase support for rural family caregivers of PwD. In addition, the government or other charities can directly provide some financial support to rural family caregivers with poor economic conditions. With the progress of dementia, family caregivers will devote more and more time and energy to providing care for patients, and the increasing burden of caregivers is inevitable. Social support, both formal and informal, from the outside can help them relieve the stress of caring activities, thus reducing the impact of care burden on caregivers’ physical and mental health, improving their QoL, and further ensuring the quality of care for dementia patients.
Limitations and future directions
This study adds to the understanding of caregiver burden, social support, and QoL of family caregivers of PwD in rural China, but there still are some limitations. First, the cross-sectional design places major limitations in making any definitive inferences. Therefore, future studies ought to take into account a longitudinal design to further understand the causal and temporal associations between these variables. Secondly, due to this study only using self-report questionnaires to obtain data, memory distortion, social expectations, and recall bias may influence the accuracy of the findings. It is possible to enhance the reliability of the results obtained from subsequent studies by adopting a methodology that combines self-reports with objective indicators. Thirdly, although this study is among the first to investigate the correlation between social support, caregiver burden, and QoL of PwD family caregivers in one model in rural Hunan, our findings could not apply to other areas. Multi-center collaborative research should be carried out in the future. Finally, additional variables that may also affect the QoL of family caregivers have not been taken into consideration, such as caregiver depression, neuropsychiatric symptoms of PwD, etc. Future studies should explore more aspects that could affect the QoL of PwD family caregivers should be investigated in future research.
Conclusions
Overall, the QoL of PwD family caregivers in rural Hunan Province is not optimistic. High caregiver burden and inadequate social support are predictors of poor QoL in dementia caregivers. In addition, the caregiving burden could not only have a direct significant effect on the QoL of family caregivers of PwD, but also have an indirect significant effect through the mediating effect of social support. Therefore, social support is essential to improve the QoL of family caregivers of PwD. Moreover, rural family caregivers of PwD should attract the attention of policymakers. It is significant to provide rural family caregivers of PwD with adequate social support to lessen their burden and enhance their QoL.
Acknowledgements
Not applicable.
Declarations
Ethics approval and consent to participate
This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics committee of Xiang Ya Nursing School of Central South University (NO. E2021143). Informed consent was obtained from all individual participants included in this study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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