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Research Article

Mental health status of caregivers of cancer patients attending a tertiary care hospital in Bhubaneswar, Odisha

[version 1; peer review: awaiting peer review]
PUBLISHED 21 Nov 2024
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This article is included in the Kalinga Institute of Industrial Technology (KIIT) collection.

Abstract

Background

The global prevalence of cancer is rapidly increasing, and patients often require ancillary non-clinical care during treatment. Caregivers, in turn, experience several mental health challenges as they fulfil their responsibilities. This study sought to estimate the prevalence of depression, anxiety, and stress among caregivers of cancer patients at a tertiary care hospital in Bhubaneswar; and explore the psychosocial factors contributing to their mental health.

Methods

For objective 1, a cross-sectional study design was employed to collect data from 230 caregivers accompanying cancer patients who attended a tertiary care hospital in Bhubaneswar, Odisha during February-April 2024. A licensed version of Hospital Anxiety and Depression Scale (HADS) was used to evaluate the levels of anxiety and depression, while the Perceived Stress Scale (PSS) was used to assess stress. For objective 2, ten in-depth interviews were conducted with caregivers, then recorded, transcribed and translated for thematic analysis.

Results

The prevalence of anxiety, depression and perceived stress among caregivers was found to be 45.2%, 43.4% and 44.8%, respectively. ‘Being the sole caregiver’ was identified as a significant predictor of caregivers’ mental health, affecting levels of depression, stress, and anxiety. Further, qualitative analysis identified factors like social support, financial hardships, emotional toll, personal wellbeing, communication with healthcare provider and transportation as key contributors to caregivers’ mental health decline.

Conclusion

Caregivers of cancer patients face significant mental health challenges that need focused attention. Integrating informal social networks, counselling services, creating support groups and offering financial assistance into cancer care programs can help address their needs.

Keywords

prevalence, stress, depression, anxiety, caregiver, cancer patient, Odisha

Introduction

Chronic health conditions and non-communicable diseases are the most pressing challenges of twenty-first century, which increase costs and negatively affect patients and communities worldwide.1 Annually, over 50 million people die from cancer, with 80% of these deaths occurring in low- and middle-income countries.2 According to the Global Cancer Observatory (GLOBOCAN), cancer cases in India are projected to rise to 2.08 million by 2040, accounting for a rise of 57.5% from 2020.3

Cancer and its therapies have a number of side effects that might lower a patient’s quality of life and necessitate long-term care.4 With the increasing incidence of new cancer diagnoses, the number of people taking up roles as cancer caregivers has increased considerably in the recent years.5 This condition not only impacts an individual’s emotional and physical well-being but also the family and caregivers’ ability to operate.6 A significant number of caregivers are usually the family members of cancer patients, acting as an “invisible” workforce that provides essential support and care. Their work is often unpaid, unpredictable and physically, emotionally, socially, and financially taxing.7 Caregivers are expected to be the primary source of support, but the strain of a loved one with a life-threatening illness often disrupts their routine, leaving them with a little time for their personal life. Additionally, because the need for care often strikes suddenly and without warning the caregivers lack sufficient prior guidance and preparation.8 This often leads to physical illness, reduced participation in health-promoting activities, disruptions to paid employment, and increased anxiety and feelings of hopelessness among caregivers.9

Mental illnesses are a significant public health issue and a major contributor to the global disease burden.10 These conditions, if not identified and treated promptly, can develop into serious pathologies.11 Current literature indicates that taking on caregiving responsibilities impacts caregivers’ psychological well-being, leading to stress, worry, anxiety, sadness, loneliness, and rage.12,13 Recent studies show that most caregivers suffer from one or more mental health problems.1317

Studies have found that various factors can contribute to the burden faced by cancer caregivers. However, there is limited data on the levels of anxiety, stress, and depression among caregivers of cancer patients, particularly regarding the contributing factors of these outcomes in low-and middle-income countries. Most previous mental health research in Bhubaneswar has focussed on patients themselves, highlighting the importance of this study. This paper aims to a) assess the prevalence of depression, anxiety, and stress among caregivers of cancer patients at a tertiary care hospital in Bhubaneswar; and b) explore the psychosocial factors contributing to the mental health challenges faced by these caregivers.

Methods

Study design

This was a cross-sectional study in which we employed a mixed-methods approach for data collection. The technique of triangulating two sets of findings can improve comprehension and increase the reliability of conclusions. Data collection was undertaken during February-April 2024 at a tertiary cancer care hospital in Bhubaneswar, Odisha.

Sampling

From the four tertiary cancer care hospitals in Bhubaneswar city, we purposively selected one, reaching out to all clinically diagnosed cancer patients attending outpatient services or admitted between February and April 2024. Caregivers above the age of 18, directly related to the cancer patient, who had provided care at least for 3 months and consented to participate, were included in the study. The final sample consisted of 230 caregivers. Additionally, ten caregivers were selected through purposive sampling for conducting in-depth interviews.

Data collection

Quantitative data collection

A semi-structured interview schedule was developed, comprising of two sections: a) socio-demographic details; and b) standardized tools to assess anxiety, depression, and stress. Questions for anxiety, depression and stress were adapted from two questionnaires namely, the Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS). HADS is a widely recognized self-report tool for emotional distress, commonly used in oncology and other somatic disease settings.18 It consists of 14-items with seven questions related to depression and seven related to anxiety, each valued from 0 to 3. Therefore, the overall score varied from 0 to 21 for each category. Caregivers responded through a 4-point scale (from 0 to 3) referring to their explicit experiences within the past week. An analysis of the two subscales revealed that total scores of 0-7 indicate a normal case, 8-10 a borderline case, and 11-21 an abnormal case.19 The 10-item Perceived Stress Scale is a self-reported tool used to measure psychological stress experienced over the past 30 days.20 The scale consists of four positive items (items 4, 5, 7 and 8) that measure an individual’s ability to manage current stressors (also known as positive stress, perceived efficacy or perceived control) and six negative items (items 1, 2, 3, 6, 9 and 10) that evaluate feelings of lack of control and negative reactions (negative stress, perceived helplessness or perceived stress).21 Responses are rated on a 5-point Likert scale, from (never) to 4 (very often). The four affirmative answers are reverse-coded, with higher scores corresponding to more stress. Scores of 0-13 indicate low stress, 14-26 suggest moderate stress, and 27-40 representing high perceived stress. The total PSS-10 score ranges from 0 to 40.22

Qualitative data collection

Ten in-depth interviews (IDI) were conducted to explore the factors contributing to mental health challenges among caregivers of cancer patients in a tertiary care hospital of Bhubaneswar. A tailor-made interview guide was meticulously developed, translated into local language, field-tested and contextualised before use. Each interview lasted for about 30-40 minutes. The questions included information regarding personal background, emotional impact, social support, impact on personal life, communication with healthcare providers, financial constraints and supportive services.

Data analysis

The quantitative data collected was entered into Excel sheet and analysed by using R 4.2.2 software.23 It’s an open-access software for statistical analysis and data visualization. HADS and PSS score distributions were used to determine the prevalence of stress, anxiety and depression among caregivers. Descriptive statistics were presented as mean ± standard deviation (SD) and frequency (%), as applicable. Pearsons’s chi-squared test and regression analysis were performed to examine associations between socio-demographic factors and caregivers’ psychological distress. For qualitative data, translations and verbatim transcriptions were imported into Atlas.ti 8 for analysis. Thematic framework analysis was employed involving steps such as data familiarization, coding and thematic grouping for interpretation of results.24

Results

Quantitative findings

Sociodemographic characteristics

Among the 230 study participants, 54.7% were aged 18-29 years, 24.3% were 30-39 years, 14.3% were 40-49 years and 6.5% were over 50 years. The majority were female respondents (53.5%) with males comprising 46.5%. 2.17% of the respondents had no education, 6.9% had primary level of education, 13.04% had secondary education, 57.3% were graduates, and 20.4% had post-graduate degrees. Employment status showed that 66% were employed, 31.4% were unemployed and 3.6% were retired. Duration of accompaniment was 6-12 months for 77.4% of participants, 13-24 months for 21.7%, and over 24 months for 0.86%. Caregiving status revealed that 41.7% were the sole caregivers of their patient, while 58.3% were not. Additionally, 45.6% families had insurance coverage, 54.3% did not, and 57.3% had a Biju Swasthya Kalyan Yojana (BSKY) health card, while 42.7% did not ( Table 1).

Table 1. Socio-demographic characteristics of study participants (N=230).

VariablesFrequency Percentage (%)
Age18-2912654.7
30-395624.3
40-493314.3
≥50156.5
GenderMale10746.5
Female12353.4
ReligionHindu20287.8
Muslim166.9
Christian52.1
Sikh73.1
Educational statusNo education52.17
Primary (1-5)166.9
Secondary (6-10)3013.04
Graduation13257.3
Post-graduation and above4720.4
Marital statusSingle11650.4
Married10846.9
Divorced20.8
Widowed41.7
Employment statusEmployed15266
Unemployed7231.3
Retired62.6
Monthly family income<25000146.08
≥25000-500006729.1
50000-750008536.9
75000 & above6427.8
Duration of accompaniment (in months)6-12 months17877.4
13-24 months5021.7
≥24 months20.86
Insurance coverageYes10545.6
No12554.3
BSKY coverageYes13257.3
No9842.6
Number of members0-518078.2
6-104419.1
11-1562.6
Only caregiverYes9641.7
No13458.3

Prevalence of anxiety, depression and stress

Among 230 participants, 126 (54.7%) had normal anxiety levels, 47 (20.4%) had borderline abnormal levels, and 57 (24.7%) had abnormal anxiety levels. For the ease of analysis, those with borderline abnormal and abnormal levels were considered as “CASE” OR “Anxious” resulting in an overall anxiety prevalence of 45.2%. For depression, 130 (56.5%) participants were at a normal level, 48 (20.8%) had borderline abnormal levels, and 52 (22.6%) had abnormal levels. Participants with borderline abnormal and abnormal levels were considered as “CASE” OR “Depressed”, leading to an overall depression prevalence of 43.4%. Likewise, for stress 127 (55.2%) participants reported low stress, 98 (42.6%) reported moderate stress, and 5 participants reported high perceived stress. Those with moderate and high perceived stress were categorized as “Stressed” resulting in an overall prevalence of moderate to high perceived stress at 44.8% translating to 103 participants, as shown in Table 2.

Table 2. Mental health status of study participants.

Mental health statusFrequency (N)Percentage (%) Mental health statusFrequency (N)Percentage (%)
Hospital anxiety and depression scale (HADS) Level of anxietyNormal (0-7)12654.7Not anxious (<8)12654.8
Borderline Abnormal (8-10)4720.4Anxious (≥ 8)10445.2
Abnormal (11-21)5724.7
Hospital anxiety and depression scale (HADS) Level of depressionNormal (0-7)13056.5Not depressed (<8)13056.6
Borderline Abnormal (8-10)4820.8Depressed (≥ 8)10043.4
Abnormal (11-21)5222.6
Perceived stress scale (PSS) Level of stressLow stress (0-13)12755.2Minimally stressed (<14)12755.2
Moderate stress (14-26)9842.6Stressed (≥ 14)10344.8
High perceived stress (27-40)52.2

Association of anxiety, depression and stress with socio-demographic factors

As shown in Table 3, with a p-value < 0.05 indicating statistical significance, age, gender, religion, caregiver status, insurance coverage, and duration of accompaniment were all significantly associated with anxiety, depression and stress. For instance, females showed higher anxiety levels than males (p < 0.001), while being the only caregiver was strongly associated with elevated anxiety levels (p < 0.001). BSKY insurance coverage was significantly associated with lower anxiety (p = 0.002).

Table 3. Association of anxiety, depression and stress with socio-demographic factors.

Variables Anxious (%) Not anxious (%) p valueDepressed (%)Not depressed (%) p value Minimally stressed (%) Stressed (%) p value
Age Group18-2968 (54.0%)58 (55.8%)0.07871 (54.6%)55 (55.0%)0.32969 (54.3%)57 (55.3%)0.003
30-3925 (19.8%)31 (29.8%)29 (22.3%)27 (27.0%)23 (18.1%)33 (32.0%)
40-4924 (19.0%)9 (8.7%)23 (17.7%)10 (10.0%)27 (21.3%)6 (5.8%)
≥509 (7.1%)6 (5.8%)7 (5.4%)8 (8.0%)8 (6.3%)7 (6.8%)
GenderFemale54 (42.9%)69 (66.3%)< 0.001 70 (53.8%)53 (53.0%)0.89968 (53.5%)55 (53.4%)0.982
Male72 (57.1%)35 (33.7%)60 (46.2%)47 (47.0%)59 (46.5%)48 (46.6%)
ReligionChristian4 (3.2%)1 (1.0%)0.044 4 (3.1%)1 (1.0%)0.2473 (2.4%)2 (1.9%)0.057
Hindu105 (83.3%)97 (93.3%)110 (84.6%)92 (92.0%)106 (83.5%)96 (93.2%)
Muslim10 (7.9%)6 (5.8%)10 (7.7%)6 (6.0%)11 (8.7%)5 (4.9%)
Sikh7 (5.6%)0 (0.0%)6 (4.6%)1 (1.0%)7 (5.5%)0 (0.0%)
Educational statusGraduation74 (58.7%)58 (55.8%)0.14973 (56.2%)59 (59.0%)0.84879 (62.2%)53 (51.5%)0.282
No-education 1 (0.8%)4 (3.8%)4 (3.1%)1 (1.0%)2 (1.6%)3 (2.9%)
Post-graduation 23 (18.3%)24 (23.1%)26 (20.0%)21 (21.0%)20 (15.7%)27 (26.2%)
Primary7 (5.6%)9 (8.7%)9 (6.9%)7 (7.0%)10 (7.9%)6 (5.8%)
Secondary21 (16.7%)9 (8.7%)18 (13.8%)12 (12.0%)16 (12.6%)14 (13.6%)
Marital statusDivorced2 (1.6%)0 (0.0%)0.4772 (1.5%)0 (0.0%)0.1651 (0.8%)1 (1.0%)0.890
Married57 (45.2%)51 (49.0%)62 (47.7%)46 (46.0%)57 (44.9%)51 (49.5%)
Single64 (50.8%)52 (50.0%)62 (47.7%)54 (54.0%)67 (52.8%)49 (47.6%)
Widowed3 (2.4%)1 (1.0%)4 (3.1%)0 (0.0%)2 (1.6%)2 (1.9%)
Employment statusEmployed89 (70.6%)63 (60.6%)0.17090 (69.2%)62 (62.0%)0.51688 (69.3%)64 (62.1%)0.363
Retired4 (3.2%)2 (1.9%)3 (2.3%)3 (3.0%)2 (1.6%)4 (3.9%)
Unemployed33 (26.2%)39 (37.5%)37 (28.5%)35 (35.0%)37 (29.1%)35 (34.0%)
Monthly family income<2500010 (7.9%)4 (3.8%)0.12710 (7.7%)4 (4.0%)0.4966 (4.7%)8 (7.8%)0.217
>=25000-5000034 (27.0%)33 (31.7%)34 (26.2%)33 (33.0%)32 (25.2%)35 (34.0%)
50000-7500041 (32.5%)44 (42.3%)48 (36.9%)37 (37.0%)48 (37.8%)37 (35.9%)
75000 & above41 (32.5%)23 (22.1%)38 (29.2%)26 (26.0%)41 (32.3%)23 (22.3%)
Duration of Accompaniment (in months)6-12 months91 (72.2%)87 (83.7%)0.10592 (70.8%)86 (86.0%)0.019 92 (72.4%)86 (83.5%)0.121
13-24 months34 (27.0%)16 (15.4%)37 (28.5%)13 (13.0%)34 (26.8%)16 (15.5%)
>=24 months1 (0.8%)1 (1.0%)1 (0.8%)1 (1.0%)1 (0.8%)1 (1.0%)
Insurance coverageNo71 (56.3%)54 (51.9%)0.50270 (53.8%)55 (55.0%)0.86272 (56.7%)53 (51.5%)0.428
Yes55 (43.7%)50 (48.1%)60 (46.2%)45 (45.0%)55 (43.3%)50 (48.5%)
BSKY coverageNo65 (51.6%)33 (31.7%)0.002 62 (47.7%)36 (36.0%)0.07561 (48.0%)37 (35.9%)0.065
Yes61 (48.4%)71 (68.3%)68 (52.3%)64 (64.0%)66 (52.0%)66 (64.1%)
Number of members0-595 (75.4%)85 (81.7%)0.273101 (77.7%)79 (79.0%)0.39993 (73.2%)87 (84.5%)0.088
6-1026 (20.6%)18 (17.3%)24 (18.5%)20 (20.0%)29 (22.8%)15 (14.6%)
11-155 (4.0%)1 (1.0%)5 (3.8%)1 (1.0%)5 (3.9%)1 (1.0%)
Only caregiverNo106 (84.1%)28 (26.9%)< 0.001 96 (73.8%)38 (38.0%)< 0.001 91 (71.7%)43 (41.7%)< 0.001
Yes20 (15.9%)76 (73.1%)34 (26.2%)62 (62.0%)36 (28.3%)60 (58.3%)

For depression, the duration of accompaniment (time as a caregiver) was significantly associated with depression (p = 0.019), particularly among those who had been caregiving for 6-12 months. Being the only caregiver was also strongly associated with higher depression (p < 0.001). Age was significantly associated with stress levels (p = 0.003), and again being the sole caregiver was strongly associated to higher stress (p < 0.001).

There were no significant associations between mental health status and marital status, education level, employment status, economic status, insurance coverage, or number of household members. Although these findings were not statistically significant at the conventional level, they suggest potential trends that should be explored further ( Table 3).

A stepwise logistic regression model was performed to identify factors contributing to caregiver stress, anxiety and depression. The analysis revealed that among the basic characteristics gender, religion, BSKY coverage, and being the only caregiver were significant predictors of anxiety. For depression, the significant predictors were duration of accompaniment and being the only caregiver. For stress, being younger and being the only caregiver were significant predictors. However, further Regression analysis indicated that all the other variables lost significance and showed no association, except for being the only caregiver, which remained a significant predictor of caregivers’ psychological distress ( Table 4).

Table 4. Predictors of depression, anxiety and stress among caregivers (N = 230).

Variablesp-value Odds Ratio95%CI
Lower Upper
Depression
Only care giver< 0.001 1.5270.9732.10
Stress
Only caregiver< 0.001 1.2600.71721.818
Anxiety
Only caregiver< 0.001 2.6662.04033.333

Qualitative findings

In-depth interviews were conducted with ten caregivers aged 29-62 years, with an equal number of males and females. Most had completed undergraduate or postgraduate education, while two had no formal education. Six were employed, while the others were either unemployed, retired, or had left their jobs for caregiving. The analysis of data extracted from the interviews revealed emergence of the following themes, highlighting key aspects of their experiences and perspectives.

Impact of care-giving on personal life and well-being

Many participants reported that caregiving significantly impacted their personal lives and well-being. They often neglected their own needs, feeling overwhelmed by the demands of caregiving. This dependency placed a heavy psychological strain on them. For some, particularly those who were the sole caregivers, it was emotionally draining, leaving them frequently exhausted and stressed. A few of the participants mentioned experiencing changes in their own health or well-being due to care-giving.

“It has strained my personal life, relationships, work, and daily activities up to some extent.” (49 years old, Female)

“It did affect my work, I had to leave my job during her surgery, because I had to take care of her and also do the household works.” (29 years old, Female, Employed)

“It’s hard when I am sick and I have to travel with him for this treatment.” (56 years old, Male)

Shifting of roles

The level of responsibility among participants varied, with some bearing more duties than others, depending on the patient’s condition and the number of people involved in their care. Caregiving included various tasks such as attending doctor’s appointments, managing medications, overseeing diet, and handling the patient’s daily activities. Additionally, as this shift in responsibility sometimes occurred suddenly, many respondents found it exceptionally stressful and demanding to manage these responsibilities.

“My mother used to manage all household works and home duties, but she is not capable of doing those jobs now, so I have to do it which is extremely stressful for me.” (29 years old, Female)

“During and after surgery it was very stressful for me, he was totally dependent on me for his day-to-day activities, I had to cook separately for him.” (32 years old, Female)

Emotional turmoil

For most participants, caring for a cancer patient had a profound emotional impact. Witnessing a loved one’s suffering brought intense grief, fear, and frustration along with overwhelming responsibilities and uncertainties of their situation. However, there were also moments of hope and gratitude for the time spent together. This daily struggle between feeling powerless and finding the strength to help provided a sense of purpose and fulfilment amidst the emotional turmoil. For a few, the diagnosis felt like the end of life as they knew it, making the experience particularly stressful and challenging.

“Obviously you will never be in be peace by knowing that your close one is suffering with something like that, I was emotionally dragged.” (62 years old, Male)

“My wife is suffering from breast cancer; we had thought of getting our younger son married last year but now will do only after she gets better.” (62 years old, Male)

Support from family and friends

Some participants in our study expressed gratitude for the support they received from family and friends. They appreciated various forms of assistance, including financial help, as well as emotional support, understanding, motivation, and encouragement. Practical aid, such as neighbours helping with chores and providing guidance on treatment options, was also highly appreciated. Despite the challenges of caregiving, the presence of a supportive network made it easier for participants to manage their daily responsibilities.

“Friend and neighbours helped us; they say kind words regarding his recovery which gives me hopes. My relatives and neighbours are calling me and asking me about his conditions, some of the relatives are also helping us financially.” (52 years old, Female)

“Friends and family provided unwavering emotional support, the neighbour around us offering meals, practical help, and kind words.” (29 years old, Female)

While many participants expressed gratitude for the support they received from friends and family, some felt disappointed and helpless due to the lack of support. These individuals faced significant difficulties and had to cope with the situation entirely on their own, managing all caregiving responsibilities without assistance. This lack of support exacerbated the emotional and practical challenges they encountered, highlighting the disparities in caregiving experiences.

“Once I had no money to bring him to hospital and some of my friends ignored me so that they won’t have to pay.” (56 years old, Male)

“As I am the only caregiver, I had to take him to the hospital alone, I had to always keep eyes on him that too alone, that’s when I felt unsupported.” (39 years old, Female)

Financial hardships

A few participants with low incomes faced significant financial hardships, struggling to afford prescriptions, medical supplies, and treatment co-pays. They often had to choose between paying for healthcare and other essential expenses like rent or groceries. However, they did receive some assistance through BSKY health cards. Among middle-income caregivers, most had health insurance, but out-of-pocket costs such as deductibles and co-pays still strained their budgets. Additionally, taking leave from work to care for their loved ones resulted in a loss of income, further adding to their financial stress.

“We are very much dependent on his income, because he is suffering from cancer and not able to go work, we are facing a lot of problems.” (52 years old, Female)

“We have BSKY card, so treatment is going through that money only, but yes we are having financial crisis at home because he is the earning man and not able to go to work now.” (52 years old, Female)

“As his business slowed down after he got cancer, requiring constant adjustments and sacrifices of other needs.” (39 years old, Female)

Communication with healthcare providers

Many participants initially faced challenges in understanding where to seek medical care and how to navigate the healthcare system, but over time, their communication with healthcare providers improved. A few participants, struggled to comprehend medical terminology and navigate the complex healthcare system. This lack of understanding ultimately caused confusion about caregiving among caregivers. Some participants, valued open communication with their team of doctors and actively sought updates on treatment plans and prognoses.

“Earlier I faced difficulties in where to show, whom to show, how to show, but now I know most of things, and staffs here are good.” (62 years old, Male)

“Sometimes, it’s very problematic to understand those complex words said by doctors.” (39 years old, Female)

“I maintain open lines of communication, actively participating in discussions about my son’s treatment plan, asking questions about everything.” (52 years old, Female)

Discussion

The mental health of cancer caregivers has a significant impact on both their quality of life and caregiving abilities. However, there is limited research on the prevalence of anxiety, depression and stress among caregivers of cancer patients at a tertiary care hospital in Bhubaneswar, Odisha.

Preliminary results from our study reveal that nearly 46% of the respondents exhibit abnormal levels of anxiety, a finding somewhat consistent with a study conducted among caregivers’ of oral cancer patients at a tertiary care hospital in central India, where 69.5% experienced anxiety.25 Additionally, 43.4% of caregivers in our study were found to be depressed, a finding consistent with a meta-analysis reporting a pooled prevalence of 42.08% among cancer caregivers.26 This finding is partly consistent with findings from a South Indian cancer research institute where 52.5% of caregivers had depression.13 A 2022 study by Parth Belapurkar et al., similarly reported that 65.5% of caregivers of oral cancer patients suffered from depression. Further, the study showed 44.8% caregivers were under psychological stress which co-relates with a study27 indicating that 40%-60% of caregivers of patients with advanced cancer face psychological distress. However, it is higher than the 30% stress level found among caregivers of hospitalized cancer patients in a study conducted in Bhubaneswar.6 These high levels of psychological distress may stem from numerous challenges faced by the caregivers.

Socio-demographic factors such as gender, age, education, religion, marital status, employment, and economic status did not have a significant correlation with anxiety, depression, or stress levels among caregivers. However, there was a distinct association between being the “only caregiver” and elevated levels of stress, anxiety, and depression. According to a recent survey of 2024 conducted in the United States, 75.6% of cancer caregivers reported a negative impact on their mental health with anxiety (37.29%), depression (33.9%), or other disorders (4.41%) being the most common issues.28

Interestingly, our study found that caregivers of patients covered by the BSKY coverage reported far lower levels of worry compared to those without BSKY coverage. This suggests that financial support initiatives like BSKY may help alleviate some of the stress and strain of caregiving.

The duration of accompaniment (time spent as a caregiver) was not significantly associated with anxiety or stress levels. However, caregivers who had been accompanying the patient for 6-12 months were more likely to experience depression compared to those who had been caregiving for a longer duration. In line with our findings, a meta-analysis estimating the prevalence of depression and identifying factors influencing depression and quality of life among cancer caregivers found that longer caregiving duration, unemployment, financial difficulties, and being female were positively associated with depression.29 This could be attributed to the initial adjustment period and the challenges faced during the early stages of care giving.

Despite the high prevalence of mental health issues among caregivers, a considerable proportion (54.3%) lacked insurance coverage. Our qualitative findings also revealed that the caregivers’ financial burden significantly contributed to their mental stress which is consistent with certain international studies.30 This highlights the need for policy initiatives and programs that provide access to mental health services and support for caregivers, regardless of their financial status. Improving the financial obstacles to receiving mental health treatment may be a critical first step towards enhancing caregivers’ wellbeing and, eventually, the kind of care they offer to the cancer patients.

Study Limitations

This study has some inherent limitations. Firstly, the sample size, primarily drawn from a single healthcare facility, limits the generalizability of our findings. To enhance the robustness and applicability of these findings, future research should consider conducting longitudinal studies on larger and more diverse population cohorts. Expanding participant recruitment across various settings and regions would further strengthen the study’s generalizability. Additionally, this study did not account for certain pertinent factors contributing to caregiver distress such as relationship with the patient, availability of financial support, physical strain, family background, and social support. Addressing these factors in future research will offer a more comprehensive understanding of caregiver well-being. Lastly, our analysis was confined to data collected within two-month timeframe, highlighting the need for further investigation to explore the long-term impacts of the factors studied.

Conclusion

Our study found a high prevalence of anxiety, depression and stress among caregivers of cancer patients. With anxiety at 45.2%, depression at 43.4%, and stress at 44.8%, it is evident that caregivers of cancer patients exhibited moderate to severe mental health challenges which could pertain to a number of factors, including their role demands. Moreover, the sheer exposure to suffering of one’s loved ones might contribute to inducing stress. Additionally, financial pressure, being the ‘only’ caregiver, the duration of accompaniment and availability (or lack) of social support are important determinants of caregiver’s mental health. Tertiary care hospitals of cancer patients ought to develop and establish an extensive set of support services for caregivers which may include formation of support groups, provision of psychiatric counselling, and delivery of respite care for the caregivers. Such services may focus on strengthening the coping mechanism, acquisition of skill sets and development of attitude aimed at handling stress, controlling emotions and reducing adverse reactions to human sufferings. Relaxation and mindfulness techniques when followed through pre-determined schedule can and does assist in lowering anxiety and combating stress. Further, tailor-made counselling sessions may be of immense help for those visiting the hospital on a regular basis. Finally, for benefit of a large number of caregivers attending various public and private hospitals across the country, the public health intervention strategies need to incorporate the key components of individualized approach to manage mental health in general and those of caregivers in particular. This research sets the stage for future investigations especially to identify factors that most significantly affect caregivers of cancer patients, both positively and negatively, which will provide meaningful information and help policy makers to develop targeted interventions.

Author contributions

SS and BP conceptualized the study; SS and BP finalized the data collection tools; SS, NP, JR and SRP analysed the data and drafted the manuscript; NP and BP finalized the manuscript.

Ethics and consent

The data collection tools were translated into Odia language. Prior to conducting interviews, written informed consent was obtained from each participant. To maintain privacy and confidentiality, responses were coded. Participants were informed of their full rights to skip or ignore any question, withdraw from the study at any point, and that no monetary compensation was provided. The study received ethical approval from the Institutional Ethics Committee, Kalinga Institute of Medical Sciences (KIMS), KIIT Deemed to be University, Odisha (Ref no - KIIT/KIMS/IEC/1496/2024) on 19-01-2024, and was conducted in accordance with the amended Declaration of Helsinki, with the protocol approved by the ethics committee.

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Samal S, Panda N, Rath J et al. Mental health status of caregivers of cancer patients attending a tertiary care hospital in Bhubaneswar, Odisha [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1403 (https://doi.org/10.12688/f1000research.157319.1)
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Open Peer Review

Current Reviewer Status:
AWAITING PEER REVIEW
AWAITING PEER REVIEW
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Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 21 Nov 2024
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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