Iran Journal of Nursing

Background & Aims: Advanced cancer is accompanied by physical, mental, and social complications in the patients. During the diagnosis and treatment processes, the necessary care is provided to the patient by formal caregivers for only a short period at the hospital; in other cases, the care is provided by informal caregivers. Informal caregivers are untrained individuals who are not paid for care provision, delivering care to their family members and close relatives. Under such circumstances, if the caregiver is not able to manage the caretaking time and their personal time, they will become prone to caregiver burden. Caregiver burden has a covert and personal nature, encompassing components such as time-related, evolutionary, physical, social, and emotional caregiver burden. The concept has external and internal dimensions; the external dimension of caregiver burden consists of the factors that are related to the patient, such as attention to the patients’ needs, allocating time to the patients, and the provided services for the recovery of the patients. Internal caregiver burden involves personal beliefs, angers, internal emotions, and the individual’s sense of importance toward the role of the caregiver. Meanwhile, coping strategies are the internal factors used by caregivers in the face of life tensions. In this regard, the role of religion as a strategy for coping with stress is considered as a form of defensive mechanism in a positive view (benevolent religious reappraisal, reappraisal of God's power, seeking spiritual support, collaborative religious coping, religious purification, religious redemption, religious helping, religious focus, spiritual connection, and seeking support from clergies) and a negative view (reappraisal of the punishing God, active/passive deference, self-directing religious coping, demonic reappraisal, spiritual discontent, and interpersonal religious discontent). Despite the importance of coping strategies and role of religion as an index that has been constantly emphasized in facing difficulties and adversities, it remains unclear in the literature whether religious coping could predict the caregiver burden of the caregivers of advanced cancer patients. Although extensive research has been conducted in this regard, further investigations should be focused on end-stage cancer patients and their caregivers. The present study aimed to predict the burden toleration among end-stage cancer patient caregivers based on their religious coping styles.
Materials & Methods: This cross-sectional, correlational study was conducted on the caregivers of end-stage cancer patients referring to the palliative care center of Firoozgar Hospital in Tehran, Iran during April-September 2017. In total, 154 individuals were selected via convenience sampling based on Tabachnick and Fidell sample size estimation method. The inclusion criteria were the minimum caregiving period of one month, disease course and treatment (end-stage patients requiring a main caregiver for full-time care), basic literacy (ability to read and write), age of 15-75 years, Iranian nationality, and willingness to participate in the research. The exclusion criterion was the diagnosis of psychotic disorders in the patients affecting the interview process and validity of responses. Data were collected using the caregiver burden inventory by Guest and Novak and the religious coping questionnaire (RCOPE) by Pargament with 14 items. Data analysis was performed in SPSS version 16 using Pearson’s correlation-coefficient and multiple regression analysis simultaneously.
Results: Out of 146 participants, 71 (48.6%) were male and 75 (51.4%) were female within the age range of 15-72 years. No significant association was observed between the positive religious coping style and caregiver burden, while the negative religious coping style was positively and significantly correlated with the caregiver burden, with the correlation level of 34%. Furthermore, the negative religious coping style (t=4.444; β=0.352) could significantly predict the caregiver burden, while the positive religious coping (t=0.438; β=0.035) could not significantly explain the caregiver burden.
Conclusion: According to the results, the positive religious coping style and caregiver burden had no significant correlation, while the association between negative religious coping style and caregiver burden was positive and significant. Therefore, using the negative religious coping styles could reduce mental health and increase the caregiver burden. In fact, as a dimension of spirituality and a coping style, religion could result in the reduction of tensions, and the World Health Organization (WHO) has also acknowledged spirituality as a fundamental factor to enhance mental health. On the other hand, the positive religious coping style could not predict the caregiver burden in this study. Long-term and extensive care provided to end-stage cancer patients by the caregivers may reduce the effectiveness of coping strategies (e.g., positive coping styles) in the reduction of the caregiver burden due to the prolonged disease course and treatment process. Our findings also indicated that the negative religious coping style exerted a negative impact on the burden tolerance of the caregivers of the end-stage cancer patients, exposing these individuals to a higher sense of burden and reduced quality of life. As such, training on coping skills with a focus on improving positive religious coping strategies in the caregivers of cancer patients since the initial stages of the disease could be an effective step toward reducing the caregiver burden incurred upon these caregivers during the treatment process. In conclusion, it is recommended that the results of this study be incorporated into the psychological services provided to the caregivers of end-stage cancer patients in order to decrease their burden.

Background & Aims: Multiple sclerosis (MS) is a disease that evolves into a chronic progressive phase and leads to a loss of muscular ability following the attack of the nervous system by the immune system. MS incidence has significantly increased in Iran and the world, and its disabling and progressive nature has affected various aspects of the life of patients and their caregivers. In fact, caregivers face the process of death, pain, and fear of mortality of patients during the care process, which may affect their quality of life. Therefore, given the direct impact of the caregivers’ quality of life on patients’ quality of life, more support of caregivers is of utmost importance. Since the care of patients might cause death anxiety and decrease the quality of life of caregivers, the present study aimed to determine the relationship between death anxiety and the quality of life of caregivers of MS patients.
Materials & Methods: This descriptive and correlational study was performed on caregivers of MS patients who referred to Iran MS society in 2018. In total, 200 individuals were selected by convenience sampling after determining the sample size based on 95% confidence interval, 80% test power, and 0.2 correlation coefficient between death anxiety and quality of life of MS patients. The research was approved by the ethics committee of the Iran University of Medical Sciences (IR.IUMS.REC.1397.357). Data were collected using a demographic characteristics questionnaire for caregivers of MS patients (age, gender, level of education, marital status, economic status, occupational status, relationship with the patient, duration of care, and being responsible for care alone), the 36-item short-form health survey (SF-36), and Templer’s death anxiety scale. The latter instrument encompassed 15 items and was scored in a range of 0-15. In this regard, a score higher than eight was indicative of high death anxiety in the participants, whereas scores below seven showed low death anxiety. On the other hand, SF36 had eight dimensions of general health, physical performance, role limitations due to physical issues, role limitations due to emotional reasons, physical pain, social performance, joy, and psychological health. In the mentioned questionnaire, the lowest and highest scores were zero (worst case scenario) and 100 (best case scenario), respectively. In the end, higher scores demonstrated a better quality of life. Data analysis was performed n SPSS version 16 using descriptive (frequency, frequency percentage, mean and standard deviation) and inferential (analysis of variance, independent t-test, Scheffe’s test, and Pearson’s correlation coefficient) statistics.
Results: In this study, the mean age of the participants was 40.39±11.75 years. The majority of the participants were male (58.5%) and married (64.4%). In terms of relationships with patients, 40% of the subjects were spouses of the patients, and 54.5% of them took care of the patients alone. The mean duration of patient care was 8.7±5.9, and most caregivers had a diploma degree (36.2%). Regarding residential status, 58.3% of the subjects had personal homes, and 44.2% of the participants had government jobs and a moderate economic status. In addition, about half of the people (50.8%) had social security insurance, and 54.5% of caregivers took care of the patients alone. According to the results, the mean death anxiety and quality of life scores of caregivers were estimated at 5.92±3.82 and 55.42±14.82, respectively. Moreover, 143 subjects (71.5%) received a low death anxiety score (in the range of zero-seven) while 57 of them (28.5%) a high score (above eight) in this respect. In the study of caregivers' quality of life, the highest and lowest mean and standard deviation were obtained in terms of physical performance and role limitations due to emotional reasons, respectively. The results showed a moderate quality of life in caregivers, and a significant, reverse correlation between death anxiety and quality of life (r=0.42) (P<0.05). In addition, there was a significant association between death anxiety and the variables of relationship with the patient (P=0.001), duration of care (P=0.036), occupational status (P=0.021), and type of insurance (P=0.006). Furthermore, a significant relationship was found between quality of life and the variables of age (P=0.032), level of education (P<0.001), income level (P<0.001), occupational status (P<0.001) and insurance (P<0.001).
Conclusion: According to the results of the study, the majority of caregivers had low death anxiety. In addition, the mean score of death anxiety was estimated at 5.92 (out of 15), which demonstrated low death anxiety in these individuals. The results were indicative of a reverse correlation between death anxiety and quality of life and its dimensions. In other words, an increase in death anxiety led to a decrease in quality of life and its dimensions. Given the significant correlation between death anxiety and quality of life, it is recommended that more support be provided by healthcare providers to eliminate problems and decrease death anxiety in caregivers, especially those taking care of MS patients. Given the progressive nature of MS and its psychological outcomes, caregivers of these patients need ongoing psychological training to help them care for patients more effectively. Therefore, it is suggested that programs be designed to help caregivers and improve their quality of life in line with focusing on themselves and their needs. It is also recommended that more attention be paid to the importance of care and caregivers in the field of nursing management and continuous nursing education. It is also important to focus on the problems and disabilities of patients and their caregivers. For further research, it is suggested that the quality of life of caregivers be compared with the quality of life of patients and death anxiety in caregivers with death anxiety in patients.

Background & Aims: Schizophrenia is a severe psychological disorder that adversely affects the life quality of patients and their caregivers. In addition, life quality is a multidimensional and important index in determining the impact of the disease on the patient (18) and is assessed from two objective and mental aspects. It is the family of these patients who always incur the burden of support and care. Not only families must provide preliminary care (personal care and financial support) for patients, but also, they should adjust to the symptoms of the disease and accept and manage them. the Schizophrenia Caregiver Quality of Life Questionnaire encompasses significant experiences of Schizophrenia caregivers and is completely different from the conventional general quality of life questionnaires. The present study aimed to evaluate the psychometric properties of the Farsi version of the schizophrenia caregiver quality of life questionnaire (S-CGQoL).
Materials & Methods: This psychological study was conducted on all the caregivers of schizophrenia patients in Isfahan, Iran in 2018. Caregivers of schizophrenia patients were selected via continuous sampling from three mental hospitals and three nursery centers during three months and were asked to fill the S-CGQoL by Richieri et al., which was translated in the present study, and the World Health Organization Quality of Life Questionnaire (WHOQOL) (Skevington et al.). The items of this tool are scored based on a five-point Likert scale from never (score=1), to rarely (score=2), sometimes (score=3), often (score=4) and always (score=5). The S-CGQoL includes 25 items and evaluates seven dimensions of psychological and physical well-being (five items), psychological burden and daily life (seven items), relationships with spouse (three items), relationships with the psychiatric team (three items), relationships with family (two items), relationships with friends (two items) and material burden (three items). The total score is obtained from the sum of these questions, and higher scores in this questionnaire mean a higher quality of life. The tool was translated into Farsi by the translation-retranslation method. In addition, the retest reliability of the instrument was assessed by asking 40 previous participants to refill the questionnaires after two weeks. Overall, 13 out of 40 individuals returned questionnaires and 27 tools were excluded due to being incomplete. The inclusion criteria were: 1) having a family member diagnosed with schizophrenia based on DSM.5, 2) being the main caregiver of a person with schizophrenia based on interviews and being the closest relative of the patient, and 3) giving full consent to participate in the research. On the other hand, the exclusion criterion was incomplete questionnaires. Reliability was assessed by the Cronbach’s alpha method and split-half test. Following that, 200 questionnaires were distributed, 155 of which were returned. Data analysis was performed in SPSS version 24 and Amos version 21 using psychometric indexes such as confirmatory factor analysis (CFA), correlation coefficient and Cronbach’s alpha.
Results: The results of the CFA indicated significant correlations between the factorial load of all the items in the S-CGQoL with the related factor (P<0. 05) with relatively appropriate efficiency indices. Moreover, the results of internal reliability indicated the Cronbach’s alpha range of 0. 54-0. 92 in various sub-indices of the questionnaire. The results of the retest reliability showed that Pearson’s correlation coefficients for all the sub-indices of the S-CGQoL were significant in the two performed stages (P<0. 05), with the overall correlation coefficient of 0.96. In addition, the results of concurrent validity of the sub-indices of the SCGQoL with WHOQOL with the correlation-coefficient was significant (P<0.05) with a correlation coefficient of -0.56, which means that there was a strong and reverse correlation between the two instruments. According to the retest correlation coefficient results, there was a significant correlation between the scores of the first and second implementations of the S-CGQoL (P<0.01). Furthermore, the reliability of the entire S-CGQoL was approved at a Cronbach’s alpha of 0.92 and split-half of 0.78. 
Conclusion: According to the results, the Farsi version of the S-CGQoL had proper validity and reliability and could be used for the caregivers of patients with schizophrenia in the healthcare centers in Iran. Based on our findings, the overall score of the instrument with subscales of psychological and physical well-being, psychological burden and daily life, relationships with spouse, relationships with the psychiatric team, relationships with family, relationships with friends, and material burden had a favorable fit, and the questions were able to properly fit the factors related to themselves. According to the CFA and internal consistency of the S-CGQoL, the Farsi version of the instrument had construct validity and significant fit. It is suggested that the retest reliability of the tool be assessed at intervals longer than two weeks.

Background & Aims The family caregivers of stroke patients experience a high care burden that has negative effects on their lives. Resilience is a factor that seems to be able to help them adapt to these conditions. The present study aims to determine the role of resilience in predicting the care burden of family caregivers of stroke patients.
Materials & Methods In this descriptive-correlational study with a cross-sectional design, 194 family caregivers of stroke patients in Besat Hospital in Hamedan, Iran, in 2023 participated. The patients had moderate disability (A score of 61-90 based on the Barthel index). Participants were selected by a convenience sampling method. Data collection tools included a demographic form, Novak and Guest’s care burden inventory, and the Connor-Davidson resilience scale. Data analysis was done in SPSS software, version 25 using descriptive statistics, Pearson correlation test, and linear regression analysis.  
Results The age of caregivers was 42.53 years; 52% were male and 26.8% had a high school diploma. The mean scores of care burden and resilience were 86.35±13.09 and 42.56±10.38, respectively. The relationship between care burden and resilience was inverse and significant (P<0.05, r=-0.185). Resilience was found to be the predictor of care burden (β=-0.233). 
Conclusion Given that resilience is one of the effective factors in reducing the care burden of the family caregivers of stroke patients, it is recommended that health care providers, by identifying effective strategies, help caregivers of these patients to strengthen their resilience to reduce their care burden and help them in caring for their patients.