Iran Journal of Nursing

Introduction
Spinal cord injury (SCI) causes psychological problems for the patient and family, in addition to physical complications. Due to long-term and sometimes permanent complications of this injury, patients often depend on caregivers for performing daily tasks, depending on the level of injury. The family caregivers of patients with SCI suffer from physical, psychological, social, and economic problems, which is called “care burden”. Continuous support for these caregivers can reduce their care burden on them. 
The continuous care model (CCM) for chronic coronary artery diseases developed by Ahmadi (2010) has four stages: familiarization, sensitization, control, and evaluation. It is an indigenous model designed to increase self-care ability, acceptance of the treatment process, and appropriate performance of patients with chronic diseases. This model focuses on the effective, interactive, and balanced role of the caregiver, patient, and family. In this model, the role of the nurse or caregiver is to identify the existing needs and problems, sensitize people to these problems, and try to solve them so that they have healthy behaviors and continuous care in a dynamic manner. This study aims to investigate the impact of the CCM on the care burden of the family caregivers of patients with SCI. 

Method 
This is a quasi-experimental study. The study population consists of the family caregivers of patients with SCI covered by the welfare organization in Kamyaran City in 2021. Of these, 96 samples were selected using a convenience sampling method. The inclusion criteria were duration of caregiving >6 months, age <70 years, and willingness to participate in the study. The exclusion criteria were lack of cooperation, death of the patient or caregiver, or change of caregiver during the study. After obtaining written informed consent from the participants, they were randomly divided into two groups of intervention (n=46) and control (n=46). During the study, two samples in the intervention group left the study. Therefore, the total number of participants was 94. The intervention group received CCM-based care, while the control received no intervention. They received the routine patient care program presented by the welfare organization.
They first completed the Zarit care burden interview (ZBI) instrument. Then, the intervention was provided at four stages of familiarization, sensitization, control, and evaluation, as a home-visiting program with the participation of the nurse, caregiver, patient, and family members for three months. In the familiarization phase (lasted three weeks), the patient, caregiver, and nurse first got to know each other, followed by evaluating the knowledge of the patient and caregiver about the disease, examining the knowledge of the caregiver regarding the care burden and its complications, recognizing and examining the facilities and limitations, measuring the patient’s expectations from the nurse/caregiver or vice versa, and needs assessment based on the evidence and statements of the caregivers. In the sensitization phase (lasted six weeks), the caregiver, patient, and the family members were involved in the implementation of the CCM. The caregivers attended skill training classes such as tailoring, aerobic exercise, and a weekly walking program. They also received medical, psychiatric, psychological, and nursing services and self-care education. The control stage aimed at continuing health behaviors to meet the needs of caregivers and reduce their problems. In each home visit, face-to-face meeting, and virtual communication, the caregivers or patients were asked about what they learned in the previous phase. The evaluation phase was done during a home visit. Each caregiver was evaluated theoretically and practically. 
Two weeks after the intervention, two groups completed the ZBI again. Independent t-test, Mann-Whitney U test, paired t-test, Wilcoxon test, one-way analysis of variance, Kruskal-Wallis test, and Pearson or Spearman correlation tests were used to analyze the research hypotheses in SPSS software, version 16.

Results
Based on the results of chi-square, independent t, Mann-Whitney U test, and Fisher’s exact test, the two groups were similar in terms of demographic variables (P>0.05). The independent t-test results showed no significant difference in the ZBI score at baseline between the control (51.91±7.95) and intervention (53.89±10.37) groups (P>0.05). However, after the intervention, the score in the intervention group (40.62±11.76) significantly decreased compared to the control group (51.33±9.01) (P<0.001). In addition, there was a significant difference between the pretest and posttest ZBI scores in the intervention group (P<0.001), but the difference was not significant in the control group.

Conclusion
The findings of the present study showed that the CCM-based intervention reduced the care burden of the family caregivers of patients with SCI. The CCM is an effective and useful model for reducing the burden of care for these caregivers due to its supportive and continuous nature. This intervention should be used in Iran; the health center managers should focus more on continuous communication with the SCI patients and their caregivers. The CCM can be used for the caregivers of patients with other chronic diseases.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethical committee of Tarbiat Modares University (Code: IR.MODARES.REC.1400.073). All ethical principles were considered in this study. The participants were informed about the study objectives and methods and were assured of the confidentiality of their information. They were free to leave the study at any time, and if desired, the research results would be available to them. 

Funding
This study was extracted from the master’s thesis of Ziba Sarchami at the Department of Nursing, School of Nursing and Midwifery, Tarbiat Modares University, Tehran, Iran. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 

Authors' contributions
Investigation: Ziba Sarchami and Hassan Navipour; Project administration, data analysis, editing & review: Ziba Sarchami; Conceptualization: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank and appreciate the officials of the welfare department in Kamyaran city and all the caregivers who participated in this research for their cooperation.

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