Abstract
Objective
This study aimed to assess the of anxiety and depression among family caregivers (FCs) of postoperative patients with cervical cancer, and explore associated factors.
Methods
This single-center cross-sectional study enrolled 323 pairs of postoperative patients with cervical cancer and their caregivers. The assessments were conducted using a general information questionnaire, the Hospital Anxiety and Depression Scale (HADS), the Perceived Social Support Scale (PSSS), the Zarit Burden Interview (ZBI), and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire for Cancer (EORTC QLQ-C30). The associated factors were analyzed using binary logistic regression. The correlation between anxiety, depression, and quality of life was analyzed using Spearman correlation analysis.
Results
The prevalence rate of anxiety among FCs was 29.1%, while the prevalence of depression was 21.1%. Solo caregiving (odds ratio [OR] = 2.196, 95% confidence interval [CI]: 1.230–3.919), high social support (OR = 0.248, 95% CI: 0.090–0.680), severe caregiving burden (OR = 3.916, 95% CI: 1.774–8.644), and short sleep duration (OR = 0.479, 95% CI: 0.259–0.885) were independently associated factors for anxiety in FCs. Meanwhile, Monthly income (OR = 0.420, 95% CI: 0.222–0.797), high social support (OR = 0.242, 95% CI: 0.083–0.708), and severe caregiving burden (OR = 4.280, 95% CI: 1.860–9.846) were independently associated factors for depression in FCs. The EORTC QLQ-C30 score was negatively correlated with the HADS-A (P < 0.001, r = −0.679) and HADS-D scores (P < 0.001, r = −0.546).
Conclusion
Individuals who are sole caregivers, have an month income below ¥6,000, sleep less than 6 hours, experience low perceived social support, and bear a high caregiving burden are at a significantly higher risk of developing symptoms of depression and anxiety. Therefore, in clinical practice, particular attention should be directed toward the psychological well-being of FCs, and provide personalized psychological intervention measures.
Keywords: cervical cancer, family caregivers, anxiety, depression, caregiving burden
Introduction
Cervical cancer, which is also known as invasive cervical carcinoma, is the most common female reproductive organ tumor and is the second most common malignant tumor among women in China after breast cancer.1 Globally, approximately 604,000 new cervical cancer cases and 342,000 cervical cancer-related deaths were reported in 2020.2 Cervical cancer is commonly considered a disease of the middle-aged and elderly, as it predominantly affects women aged 45–60 years. However, the prevalence of cervical cancer among younger women has recently been increasing, which can be attributed to lifestyle and behavioral factors.3,4
Surgery is the primary treatment for early-stage cervical cancer. Family members, such as spouses and children are typically responsible for daily care after surgery. In addition to bearing the full burden of managing the daily needs of patients, family caregivers (FCs) face psychological stress and financial burdens due to disease progression and uncertainties. The mental health of the caregivers has been overlooked. Previous studies have reported that the FCs of patients with cancer commonly experience psychological distress, including anxiety and depression.5,6 For example, Li et al7 conducted a study on 641 pairs of cancer patients and their FCs in China to explore the influence of anxiety and depression on dyadic quality of life. The results showed that nearly one-third of family caregivers exhibited symptoms of anxiety (32.8%) or depression (31.2%), and there was a significant negative correlation between anxiety, depression, and dyadic quality of life. A Malaysian study revealed that 47.4% of caregivers experienced caregiving burden to varying degrees, ranging from mild to severe, which adversely affected their quality of life.8 The most common psychological manifestations among these non-professional caregivers were anxiety (29.7%) and depression (20.4%). Psychological issues adversely affect the physical and mental health of caregivers by suppressing the immune function and increasing the risk of chronic diseases. Additionally, psychological issues indirectly affect by functioning as an emotional contagion, exacerbating the psychological burdens of patients, decreasing treatment adherence and confidence in recovery, and adversely affecting the quality of life of patients. Therefore, the mental health concerns of FCs must be addressed and managed to enhance the overall recovery outcomes of patients and improve the quality of life of the family.
Although the psychosocial burden of family caregivers of cervical cancer patients has received increasing attention and some qualitative studies have preliminarily revealed the difficulties faced by this group. For example, in-depth interviews conducted by Gosse et al9 with 13 male partners of cervical cancer patients in Tanzania revealed that caregivers commonly experience emotional distress, financial pressure, social role disruption, and changes in sexual relationships, all of which are significantly associated with the risk of anxiety and depression. However, most existing literature consists primarily of qualitative descriptions, and there is a lack of large-scale quantitative studies to systematically assess the prevalence, severity, and contributing factors of anxiety and depression in this population. At the same time, existing domestic research has generally focused on the broader population of cancer caregivers, and there is a lack of specific quantitative studies targeting family caregivers of cervical cancer patients following surgery, making it difficult to provide evidence-based support for targeted psychological interventions for this group.
This study uses the stress and coping theory by Folkman10 and the health-related quality of life model by Wilson and Cleary11 as a framework to construct an analytical path of “caregiver factors - caregiver psychological state - patient quality of life.” According to stress and coping theory, when caregivers undertake postoperative care tasks, their cognitive appraisals and coping resources influence the risk and severity of negative emotions. According to the health-related quality of life model, the psychological state of caregivers, as a key external social and psychological factor, will affect the patient’s symptom management compliance, functional rehabilitation support, and psychological adaptation process, and thereby influence the overall quality of life of the patient. Therefore, this study aims to systematically assess the associated factors of anxiety and depression among family caregivers of patients with cervical cancer after surgery. It will also analyze the relationship sis for developing targeted psychological intervention strategies. This approach is intended to between caregivers’ mental health and patients’ quality of life, with the goal of providing a bamprove the mental health of FCs and optimize the overall rehabilitation environment for patients.
Methods
Study Design and Setting
This study used convenience sampling to consecutively recruit postoperative cervical cancer patients who met the inclusion criteria and their primary family caregivers from the Department of Obstetrics and Gynecology at the Affiliated Hospital of Jiangnan University, between May 2022 and July 2024.
All participants were informed that study participation was voluntary. After obtaining written informed consent from eligible patients, the researchers asked them to designate a primary family caregiver, then contacted these caregivers to obtain their signed informed consent forms.
Inclusion and Exclusion Criteria
The inclusion and exclusion criteria were as follows:
Patients with Cervical Cancer
Inclusion criteria: aged ≥ 18 years; patient was diagnosed with cervical cancer by pathology and underwent surgical treatment; patients between 28 and 35 days post-surgery (ie, 4 to 5 weeks post-surgery) who have been discharged from the hospital; and relatively stable condition, conscious and able to express their willingness correctly. Exclusion criteria: people with a combination of other cancers; the presence of audiological disorders or previous mental or cognitive disorders, such as anxiety, depression; and receiving mental disorder treatments.
Family Caregivers
Inclusion criteria: aged ≥ 18 years; spouse, parent, or child of patients with the capacity to provide care; individuals with healthy cognitive function and the ability to complete the questionnaire independently; individuals who agreed to voluntarily participate and provided signed informed consent. Exclusion criteria: individuals with cognitive impairment or unclear verbal expression; individuals with a history of psychiatric or psychological disorders; individuals who are already on anti-anxiety or antidepressant medications; paid professional caregivers, such as nannies or nursing aides.
Research Tools
General Demographic Data
A self-designed general information questionnaire was developed to capture the sociodemographic characteristics of caregivers, including gender, age, marital status, educational attainment, place of residence, employment status, income, relationship to the patient, cohabitation status, prior caregiving experience, daily caregiving hours, solo caregiving, and personal health status.
Hospital Anxiety and Depression Scale (HADS)
The HADS12 consists of two subscales for anxiety and depression, with each subscale containing 7 items, used to assess the severity of anxiety and depression. The total score range of the subscale is 0 to 21 points, with scores of 0–7 indicates no symptoms, 8–10 indicates possible symptoms, and 11–21 indicates the presence of symptoms. The Chinese version of the HADS exhibited good internal consistency and validity among patients with cancer. Questions 1, 3, 5, 7, 9, 11, and 13 were related to the evaluation of anxiety, while questions 2, 4, 6, 8, 10, 12, and 14 were related to the evaluation of depression. In this study, only respondents with a score of 11 or higher were defined as positive cases. All prevalence rates are calculated based on this threshold.
Perceived Social Support Scale (PSSS)
PSSS, which is a self-report scale developed by Zimet et al,13 examines the self-perception of individuals and their subjective experience of social support. This scale comprises the following three dimensions: the Perceived Family Support Dimension (Items 1, 4, 6, and 11), the Perceived Friends Support Dimension (items 2, 7, 9, and 12), and the Perceived Other Support Dimension (items 3, 5, 8, and 10). The items were scored using a 7-point Likert scale (ranging from “Strongly Disagree” (1 point) to “Strongly Agree” (7 points)). The interpretation of the total score is as follows: Scores 12–36: low support; scores 37–60: moderate support; scores 61–84: high support. The total scores are directly proportional to the degree of social support received by the individual. The Chinese version of the PSSS has been validated by Jiang,14 who demonstrated its excellent reliability (Cronbach’s α = 0.99). The Cronbach’s α value determined in this study was 0.87.
Zarit Burden Interview (ZBI)
The ZBI,15 which was developed by Zarit et al, was used to assess the burden of caregivers. This 22-item scale measures multiple dimensions, including time-dependent burden, functional limitations, physical burden, social burden, emotional burden, and financial burden. Each item is scored using a 5-point Likert scale (ranging from “Never” (0 points) to “Always” (4 points)). The total score ranges from 0 to 88 points. The scores are directly proportional to the degree of caregiving burden. The interpretation of the scores is as follows: scores 0–20: mild burden; scores 21–40: moderate burden; scores 41–60: heavy burden; scores 61–88: extremely heavy burden.
Quality of Life Questionnaire for Cancer Patients (EORTC QLQ-C30)
The EORTC QLQ-C30 is widely used to evaluate the quality of life of patients with malignant tumors.16 This questionnaire comprises the following items: Functional domains: physical functioning, role functioning, cognitive functioning, emotional functioning, and social functioning; symptom domains: fatigue, pain, nausea, and vomiting; single-item questions: dyspnea, insomnia, loss of appetite, constipation, diarrhea, and financial difficulties; overall health rating. The total number of items is 30. Items 29 and 30 are scored on a 7-point scale (1–7 points). All other items are scored on a 4-point scale (1–4 points). The maximum score is 100 points. High scores on functional dimensions and overall health indicate improved quality of life, while those on symptom dimensions indicate poor quality of life. The questionnaire is completed independently by the patient.
Sample Size
This study used the Events Per Variable (EPV) rule of binary logistic regression to estimate the sample size. Specifically, with a predefined EPV of ≥10 and a planned inclusion of 8 predictor variables, we determined that the required number of positive outcome events was at least 80. Based on this and on an estimated outcome event rate of 30% from previous literature, we calculated the minimum total sample size to be approximately 80/0.30 ≈ 267 cases. Furthermore, accounting for an estimated 20% rate of missing or invalid questionnaires, we ultimately expanded the target sample size to 267/(1–0.20) ≈ 334 cases. In this study, 350 questionnaires were distributed in the study, and 323 were returned, yielding a response rate of 92.28%.
Data Collection Process and Quality Control
Data collection for this study commenced four to five weeks postoperatively and was conducted jointly by two investigators who had undergone standardized training. The investigators explained the purpose of the study, the voluntary nature of participation, and the principle of confidentiality to eligible participants via telephone or in-person communication. They also provided explanations of the questionnaire items and established a mechanism for addressing any questions. After obtaining consent from participants, a Chinese electronic questionnaire created on the Wenjuanxing platform was sent via WeChat. The questionnaire link remained active for 7 days, during which participants could complete it at their convenience. The average time to complete a single questionnaire is 8 minutes. To improve the response rate, two standardized reminders were sent to non-respondents on the 3rd and 7th days after the link was distributed.
During the data collection process, the research team implemented strict quality control measures to ensure the quality of the completed questionnaires. After the questionnaires were returned, they were first checked for completeness and logical consistency, and invalid questionnaires with a large number of missing values or obvious logical inconsistencies were excluded. Subsequently, the questionnaire data was entered into an electronic database using a double-entry method, and a cross-check was conducted after entry to ensure data accuracy.
Statistical Analysis
Data were analyzed using SPSS 26.0 software. Quantitative data are represented as mean ± standard deviation. Means were compared using independent samples t-tests and analysis of variance. Qualitative data are described as frequency and composition ratios. The associated factors were determined using binary logistic regression. A bivariate analysis of the relationship between associated factors and quality of life was conducted using Spearman correlation analysis. Differences were considered significant at P < 0.05.
Results
Demographic and Clinical Characteristics of Caregivers and Patients
This study surveyed 323 pairs of patients and their FCs. Characteristics of patients: The 41–60 age group constituted the largest proportion (70%), those under the age of 40 account for 11.1%; 91% of the patients were married, 72.8% have a high school education or below, only 39.9% were working, and 93.5% had medical insurance. Characteristics of FCs: The 41–60 age group constituted the largest proportion (51.4%). Males accounted for 67.5% of FCs, while females comprised 32.5%. 87.6% of FCs were married, 62.5% had a high school education and below, while 37.5% had a College degree or above; 65.9% were working; 57.3% had a family monthly income below 6,000 yuan; Spouses constituted the majority of FCs 65.3%; 60.3% of FCs daily care time more than 8 hours; 28.5% of FCs bore the caregiving responsibility alone; 51.7% of FCs experienced moderate caregiving burden, while 16.1% faced heavy caregiving burden; 10.5% reported low social support; 13.9% of FCs had their own health issues; 26.6% of FCs slept less than 6 hours daily (Table 1).
Table 1.
Patients and Family Caregivers Characteristics
| Characteristics | Patients [n (%)] | Family Caregivers [n (%)] |
|---|---|---|
| Gender | ||
| Male | 0 | 218 (67.5) |
| Female | 323 (100) | 105 (32.5) |
| Age (years) | ||
| 18~40 | 36 (11.1) | 109 (33.7) |
| 41~60 | 226 (70.0) | 166 (51.4) |
| >60 | 61 (18.9) | 48 (14.9) |
| Marital Statusa | ||
| Married | 294 (91.0) | 283 (87.6) |
| Others | 29 (9.0) | 40 (12.4) |
| FCs relationship with patients | ||
| Spouse | 204 (63.2) | |
| Others | 119 (36.8) | |
| Educational levels | ||
| High school and below | 235 (72.8) | 202 (62.5) |
| College degree or above | 88 (27.2) | 121 (37.5) |
| Place of residence | ||
| Village | 166 (51.4) | 151 (46.7) |
| City | 157 (48.6) | 172 (53.3) |
| Working status | ||
| Working | 129 (39.9) | 213 (65.9) |
| Not Working | 194 (60.1) | 110 (34.1) |
| Monthly Income (yuan) | ||
| <6000 | 242 (74.9) | 185 (57.3) |
| ≥6000 | 81 (25.1) | 138 (42.7) |
| Medical expense payment method | ||
| Medical insurance | 302 (93.5) | |
| Self-paying | 21 (6.5) | |
| Living with the patient | ||
| Yes | 246 (76.1) | |
| No | 77 (23.9) | |
| Daily Care Time (h) | ||
| <8 | 128 (39.6) | |
| ≥8 | 195 (60.4) | |
| Caregiving Experience | ||
| Yes | 107 (33.1) | |
| No | 216 (66.9) | |
| Solo caregiving | ||
| Yes | 92 (28.5) | |
| No | 231 (71.5) | |
| Health issues | ||
| Yes | 45 (13.9) | |
| No | 278 (86.1) | |
| Sleep time (h) | ||
| 4~6 | 86 (26.6) | |
| 6~8 | 189 (58.5) | |
| ≥8 | 48 (14.9) | |
| PSSS | ||
| 12~36 | 34 (10.5) | |
| 37~60 | 205 (63.5) | |
| 61~84 | 84 (26.0) | |
| ZBI | ||
| ≤20 | 104 (32.2) | |
| 21~40 | 167 (51.7) | |
| ≥41 | 52 (16.1) |
Notes: Others includes: Divorced, Widowed, and Never married;
Abbreviations: PSSS, Perceived social support scale; ZBI, Zarit burden interview.
Univariate Analysis of Anxiety and Depression in FCs
HADS-A and HADS-D scores varied between FCs. In particular, caregivers with an education level of high school or below, monthly income below ¥6,000, sole caregiving responsibility, a daily sleep duration of less than 6 hours, PSSS scores of 12–36, and ZBI scores of ≥ 41 exhibited significantly higher HADS-A and HADS-D scores than other caregivers (P < 0.05) (Table 2).
Table 2.
Univariate Analysis of Anxiety and Depression in FCs
| Variables | HADS-A | t/F | P-value | HADS-D | t/F | P-value | ||
|---|---|---|---|---|---|---|---|---|
| N (%) | Mean±SD | N (%) | Mean±SD | |||||
| Gender | t=−0.41 | 0.684 | t=−0.89 | 0.377 | ||||
| Male | 66 (30.3) | 8.59 ±3.28 | 45 (20.6) | 8.02±3.12 | ||||
| Female | 28 (26.7) | 8.75± 3.73 | 23 (21.9) | 8.36±3.34 | ||||
| Age (years) | F=1.45 | 0.235 | F=1.02 | 0.614 | ||||
| 18~40 | 27 (24.8) | 8.45± 3.53 | 18 (16.5) | 7.83±2.97 | ||||
| 41~60 | 49 (29.5) | 8.55± 3.30 | 37 (22.3) | 8.18±3.17 | ||||
| >60 | 18 (37.5) | 9.42±3.58 | 13 (27.1) | 8.60±3.71 | ||||
| Marital Status | t=−0.19 | 0.849 | t=0.59 | 0.556 | ||||
| Married | 84 (29.6) | 8.66±3.42 | 60 (21.2) | 8.09±3.19 | ||||
| Others | 10 (25.0) | 8.54± 3.55 | 8 (20.0) | 8.43±3.22 | ||||
| Relationship with patients | t=−0.32 | 0.747 | t=−1.23 | 0.222 | ||||
| Spouse | 64 (31.4) | 8.55±3.28 | 42 (20.6) | 7.93±3.04 | ||||
| Others | 30 (25.2) | 8.68±3.61 | 26 (21.8) | 8.37±3.30 | ||||
| Educational background | t=3.28 | 0.001* | t=2.80 | 0.005* | ||||
| High school and below | 68 (33.7) | 9.11±3.63 | 50 (24.8) | 8.49±3.42 | ||||
| College degree or above | 26 (21.5) | 7.89±2.93 | 18 (14.9) | 7.53±2.69 | ||||
| Place of residence | t=0.85 | 0.397 | t=0.06 | 0.950 | ||||
| City | 48 (30.5) | 8.49±3.44 | 35 (21.9) | 8.12±3.27 | ||||
| Village/Township | 46 (27.9) | 8.82±3.42 | 33 (20.3) | 8.14±3.12 | ||||
| Working Status | t=0.54 | 0.590 | t=0.39 | 0.969 | ||||
| Working | 58 (27.5) | 8.53±3.29 | 46 (21.8) | 8.09±3.22 | ||||
| Not Working | 36 (38.3) | 8.74±3.61 | 22 (32.4) | 8.08±2.99 | ||||
| Monthly Income (RMB) | t=2.65 | 0.008* | t=3.72 | <0.001* | ||||
| <6000 | 66 (35.7) | 9.07±3.58 | 50 (27.0) | 8.81±3.66 | ||||
| ≥6000 | 28 (20.3) | 8.07±3.13 | 18 (13.0) | 8.59±3.34 | ||||
| Living with the patient | t=0.85 | 0.398 | t=0.38 | 0.458 | ||||
| Yes | 72 (29.3) | 8.56±3.30 | 51 (20.7) | 8.05±3.15 | ||||
| No | 22 (28.6) | 8.94±3.81 | 17 (22.1) | 8.36±3.34 | ||||
| Daily Care Time | t=−1.07 | 0.284 | t=−1.12 | 0.264 | ||||
| <8 h | 35 (27.3) | 8.39±3.29 | 23 (18.0) | 7.88±3.09 | ||||
| ≥8 h | 59 (30.3) | 8.81±3.51 | 45 (23.1) | 8.29±3.26 | ||||
| Caregiving Experience | t=0.68 | 0.499 | t=0.84 | 0.402 | ||||
| Yes | 27 (25.2) | 8.46±3.49 | 20 (18.7) | 7.91±3.19 | ||||
| No | 67 (30.0) | 8.74±3.31 | 48 (22.2) | 8.23±3.20 | ||||
| Solo caregiving | t=−3.02 | 0.003* | t=−1.36 | 0.176 | ||||
| Yes | 40 (43.5) | 9.60±3.71 | 23 (25.0) | 8.52±3.24 | ||||
| No | 54 (23.4) | 8.27±3.24 | 45 (19.5) | 7.97±3.17 | ||||
| Health issues | t=−1.41 | 0.161 | t=−1.26 | 0.212 | ||||
| Yes | 17 (37.8) | 9.31±3.71 | 14 (31.1) | 8.82±4.11 | ||||
| No | 77 (27.7) | 8.54±3.37 | 54 (19.4) | 8.01±3.01 | ||||
| Sleep time (h) | F=9.25 | 0.001* | F=6.25 | 0.002* | ||||
| 4~6 | 40 (46.5) | 9.92±3.82 | 28 (32.6) | 9.07±3.56 | ||||
| 6~8 | 42 (22.2) | 8.13±3.13 | 32 (16.9) | 7.82±2.96 | ||||
| ≥8 | 12 (25.0) | 8.10±3.05 | 8 (16.7) | 7.40±2.66 | ||||
| PSSS | F=9.63 | <0.001* | F=6.34 | 0.002* | ||||
| 12~36 | 17 (50.0) | 10.03±4.30 | 13 (38.2) | 8.97±4.03 | ||||
| 37~60 | 65 (31.7) | 8.87±3.34 | 47 (22.9) | 8.35±3.14 | ||||
| 61~84 | 12 (14.3) | 7.37±2.76 | 8 (9.5) | 7.11±2.49 | ||||
| ZBI | F=10.24 | <0.001* | F=9.00 | <0.001* | ||||
| ≤20 | 26 (25.0) | 8.30±3.08 | 15 (14.4) | 7.59±3.12 | ||||
| 21~40 | 35 (21.0) | 8.20±3.27 | 29 (17.4) | 7.90±3.74 | ||||
| ≥41 | 33 (63.4) | 10.50±3.84 | 24 (46.2) | 9.71±3.14 | ||||
Note: *P<0.05.
Abbreviations: PSSS, Perceived social support scale; ZBI, Zarit burden interview.
Binary Logistic Regression of Factors Associated with Anxiety in FCs
The results of the logistic regression analysis show that, sole caregiving responsibility, perceived social support scores, caregiving burden scores, and sleep duration are independent factors associated with anxiety in FCs. Specifically, the odds of anxiety among FCs in the solo caregiving group is 2.196 times higher than that among FCs with helpers (odds ratio (OR) = 2.196, 95% confidence interval (CI): 1.230–3.919). Perceived social support was negatively correlated with anxiety; compared with the low social support group (12–36 score), the odds of anxiety were reduced by 75.2% in the high social support group (61–84 score) (OR = 0.248, 95% CI: 0.090–0.680). Caregiving burden was positively correlated with anxiety. The odds of anxiety in the high caregiver burden group (ZBI ≥ 41) are 3.916 times higher than those in the low caregiver burden group (ZBI ≤ 20) (OR = 3.916, 95% CI:1.774–8.644). Compared with FCs with sleep duration less than 6 hours, those sleeping 6–8 hours had 52.1% lower odds of anxiety (OR = 0.479, 95% CI: 0.259–0.885). (Table 3).
Table 3.
Binary Logistic Regression of Factors Associated with Anxiety in FCs
| Variable | β | SE | Wald | P | OR | 95% CI |
|---|---|---|---|---|---|---|
| Educational background | −0.252 | 0.302 | 0.696 | 0.404 | 0.777 | 0.430–1.405 |
| Monthly income (yuan) | −0.586 | 0.298 | 3.867 | 0.049 | 0.556 | 0.310–0.998 |
| Solo caregiving | 0.787 | 0.295 | 7.085 | 0.008 | 2.196 | 1.230–3.919 |
| Sleep time (4~6) h | Ref | |||||
| 6~8 | −0.737 | 0.313 | 5.530 | 0.019 | 0.479 | 0.259–0.885 |
| ≥8 | −0.636 | 0.444 | 2.053 | 0.152 | 0.530 | 0.222–1.263 |
| PSSS (12~36) | Ref | |||||
| 37~60 | −0.491 | 0.422 | 1.353 | 0.245 | 0.612 | 0.268–1.399 |
| 61~84 | −1.396 | 0.516 | 7.324 | 0.007 | 0.248 | 0.090–0.680 |
| ZBI (≤20) | Ref | |||||
| 21~40 | −0.271 | 0.317 | 0.733 | 0.392 | 0.762 | 0.410–1.419 |
| ≥41 | 1.365 | 0.404 | 11.418 | 0.001 | 3.916 | 1.774–8.644 |
Abbreviations: SE, Standard Error; OR, Odds ratio; CI, Confidence interval; PSSS, Perceived social support scale; ZBI, Zarit burden interview.
Binary Logistic Regression of Factors Associated with Depression in FCs
The results of the logistic regression analysis show that, monthly income, perceived social support scores, and caregiving burden scores are independent factors associated with depression in FCs. Compared with FCs whose monthly income was less than 6,000 yuan, those with a monthly income of more than 6,000 yuan had 58% lower odds of depression (OR = 0.420, 95% CI: 0.222–0.797). Compared with the low social support group (scores 12–36), the high social support group (scores 61–84) had 75.8% lower odds of depression (OR = 0.242, 95% CI: 0.083–0.708). The odds of depression in the high caregiving burden group (ZBI ≥ 41) were 4.28 times higher than those in the low caregiving burden group (ZBI ≤ 20) (OR = 4.280, 95% CI: 1.860–9.846) (Table 4).
Table 4.
Binary Logistic Regression of Factors Associated with Depression in FCs
| Variable | β | SE | Wald | P | OR | 95% CI |
|---|---|---|---|---|---|---|
| Educational background | −0.273 | 0.331 | 0.679 | 0.410 | 0.761 | 0.397–1.457 |
| Monthly income (RMB) | −0.867 | 0.327 | 7.048 | 0.008 | 0.420 | 0.222–0.797 |
| Sleep time (4~6) h | Ref | |||||
| 6~8 | −0.436 | 0.331 | 1.738 | 0.187 | 0.647 | 0.338–1.236 |
| ≥8 | −0.492 | 0.483 | 1.037 | 0.308 | 0.611 | 0.237–1.576 |
| PSSS (12~36) | Ref | |||||
| 37~60 | −0.409 | 0.425 | 0.925 | 0.336 | 0.664 | 0.289–1.529 |
| 61~84 | −1.418 | 0.547 | 6.718 | 0.010 | 0.242 | 0.083–0.708 |
| ZBI (≤20) | Ref | |||||
| 21~40 | 0.306 | 0.359 | 0.724 | 0.395 | 1.358 | 0.671–2.746 |
| ≥41 | 1.454 | 0.425 | 11.697 | 0.001 | 4.280 | 1.860–9.846 |
Abbreviations: SE, Standard Error; OR, Odds ratio; CI, Confidence interval; PSSS, Perceived social support scale; ZBI, Zarit burden interview.
Relationship Between FCs Psychological State and Postoperative Quality of Life in Patients
The EORTC QLQ-C30 scores of FCs with anxiety were significantly lower than those of FCs without anxiety (49.65 ± 3.36 vs 57.76 ± 4.24, P < 0.05). The EORTC QLQ-C30 scores of FCs with depression were significantly lower than those of FCs without depression (49.74 ± 3.10 vs 56.91 ± 4.91, P < 0.05) (Table 5).
Table 5.
Relationship Between FCs Psychological State and Postoperative Quality of Life in Patients
| Group | EORTC QLQ-C30 | t | P | |
|---|---|---|---|---|
| Anxiety | Yes | 49.65 ± 3.36 | 18.21 | <0.001 |
| No | 57.76 ± 4.24 | |||
| Depression | Yes | 49.74 ± 3.10 | 14.79 | <0.001 |
| No | 56.91 ± 4.91 |
Bivariate Analysis of the Relationship of Anxiety, Depression, and Associated Factors with the EORTC QLQ-C30
The EORTC QLQ-C30 score was negatively correlated with the HADS-A (P < 0.001, r = −0.679) and HADS-D scores (P < 0.001, r = −0.546) (Table 6).
Table 6.
Bivariate Analysis of the Relationship of Anxiety, Depression, and Associated Factors with the EORTC QLQ-C30
| 1) | 2) | 3) | 4) | 5) | 6) | 7) | 8) | 9) | |
|---|---|---|---|---|---|---|---|---|---|
| 1) HADS-A | 1 | ||||||||
| 2) HADS-D | 0.472** | 1 | |||||||
|
−0.130* | −0.117* | 1 | ||||||
|
−0.168** | −0.170** | 0.185** | 1 | |||||
|
0.200** | 0.061 | −0.063 | −0.185** | 1 | ||||
|
−0.190** | −0.149** | 0.129* | 0.085 | −0.007 | 1 | |||
|
−0.227** | −0.201** | 0.031 | 0.052 | 0.077 | 0.153** | 1 | ||
|
0.204** | 0.212** | −0.140* | −0.002 | 0.108 | −0.144** | 0.098 | 1 | |
|
−0.679** | −0.546** | 0.154** | 0.141* | −0.154** | 0.275** | 0.258** | −0.257** | 1 |
Notes: **P<0.01, *P<0.05.
Discussion
Currently, patients with cancer in China depend on the family support systems, especially FCs, for postoperative care. The prolonged recovery period of patients with cancer contributes to the negative psychological emotions of FCs, resulting from the sustained burden and stress of long-term caregiving. These negative emotions may impact the treatment adherence and postoperative recovery of patients. Therefore, this study examined the prevalence of anxiety and depression among FCs of postoperative patients with cervical cancer. The rates of anxiety and depression among FCs were 29.1% and 21.1%, respectively. Meanwhile, the combined anxiety-depression comorbidity rate was 14.8%. Binary logistic regression analysis revealed that monthly income, sole caregiving responsibility, sleep duration, PSSS scores, and ZBI scores were the independent risk factors influencing anxiety and depression among FCs.
This study identified low income (< ¥6000/month) as an independent associated factor for anxiety and depression, which is consistent with the findings of previous studies.17,18 Economic stress indirectly impacts the mental health of FCs by limiting access to healthcare resources and increasing life uncertainties. Low-income groups often face the dual burden of treatment costs and household livelihoods. Individuals in these groups cannot sufficiently devote time and energy to self-psychological adjustment, which can increase the risk of anxiety or depression.
Sole caregiving responsibility was also an independent associated factor for anxiety symptoms (OR = 2.196, 95% CI: 1.230–3.919). This indicates that FCs who undertake caregiving alone had 2.196 times higher odds of experiencing anxiety symptoms than non‑independent caregivers (ie, those with assistants or multiple people sharing the care). The stress levels of FCs increase when they lack collaborative caregiving support. FCs must shoulder multiple responsibilities, including daily patient care, condition monitoring, and emotional support, alone without other family members or social support. This prolonged, high-intensity caregiving pattern promotes anxiety. Furthermore, independent caregivers often face challenges, such as poor time management and restricted social activities, which further exacerbate their psychological burden. Additionally, independent caregiving may also impact the sleep quality of FCs, establishing a vicious cycle that leads to the persistent worsening of anxiety symptoms. A multidisciplinary collaborative care support system must be established based on the biopsychosocial model. This system should integrate community healthcare resources, professional institutional support, and family social capital. The establishment of a three-tiered prevention intervention system provides FCs with a comprehensive support network, serving as an effective intervention strategy to alleviate their psychological burden and improve their mental health status.
Previous studies have reported that sleep duration is correlated with the pathogenesis of anxiety and depressive disorders.19,20 In this study, FCs with a daily sleep duration of 6~8 hours had 52.1% lower odds of anxiety symptoms than those with less than 6 hours of sleep (OR = 0.479, 95% CI: 0.259–0.885). This result is consistent with the conclusions of most previous studies, and further corroborates the importance of adequate sleep for maintaining the mental health of FCs. This is because adequate sleep allows the brain to rest and recover, stabilizing nervous system functions. Adequate sleep helps FCs recover physical strength and regulate emotions during high-intensity caregiving tasks, thereby enhancing their ability to cope with stress and reducing anxiety.21–23 Conversely, chronic sleep deprivation disrupts the neuroendocrine system of FCs, increases sympathetic nervous system excitability, and consequently diminishes their emotional regulation capacity and psychological resilience, making them more prone to anxiety.24,25 Therefore, monitoring FCs’ sleep patterns and implementing effective measures to improve sleep quality, such as providing guidance on sleep hygiene, holds significant importance for preventing and alleviating their anxiety symptoms.
Chindaprasirt et al26 demonstrated that prolonged, demanding caregiving responsibilities lead to negative outcomes, such as restricted personal social interactions, career stagnation, irritability, and loss of life balance. This study demonstrated that high caregiving burden (ZBI score ≥ 41) significantly increased the risk of developing anxiety and depression, serving as a strong predictor for both conditions. Caregivers with high burdens exhibit increased risks of developing anxiety and depression. The burden levels were positively correlated with risk severity. This indicates the cumulative detrimental effects of long-term caregiving stress on mental health. The underlying mechanism can be attributed to the synergistic interaction of physiological and psychosocial pathways. At the pathophysiological level, sustained high-stress states activate the hypothalamic-pituitary-adrenal axis, leading to the aberrant upregulation of cortisol.27–29 This directly disrupts emotional regulation by interfering with neurotransmitter balance. At the psychosocial level, high-burden FCs become socially isolated due to their long-term commitment to caregiving roles, preventing access to effective support. Additionally, FCs lack time for self-regulation, which establishes a vicious cycle of “stress accumulation and emotional deterioration.”
High perceived social support (PSSS scores 61–84) was significantly and negatively associated with anxiety (OR = 0.248, 95% CI: 0.090–0.680) and depression (OR = 0.242, 95% CI: 0.083–0.708). This indicates that robust social support networks effectively mitigate the detrimental impact of caregiving stress on the mental health of FCs by providing emotional comfort and tangible assistance. High perceived social support helps FCs reevaluate stressful events as manageable challenges, mitigating the negative impact of caregiving stress and preventing the onset of emotional disorders. In addition to providing tangible solutions for FCs and alleviating their objective burdens, social support networks fulfill their emotional needs for belonging and self-esteem, directly enhancing psychological resilience. Previous studies have indicated that an increased number of sources of social support enhances caregiving motivation and decreases the risk of health deterioration in caregivers.30,31 Strong social support mitigates the stress of FCs.
Additionally, data analysis demonstrates that anxiety and depression scores among FCs are significantly and negatively correlated with patients’ postoperative EORTC QLQ-C30 scores. This may be because the negative emotions of FCs adversely affected the patients’ psychological state through an “emotional contagion” effect. On the other hand, FCs may become less able to assist with patient rehabilitation and provide emotional support due to their own emotional exhaustion, thereby indirectly affecting patients’ rehabilitation and recovery of quality of life. This indirectly affects the rehabilitation of patients and their quality of life.31 The rehabilitation environment of patients constitutes a dyadic system involving both the patient and their caregivers. Focusing on the patient and neglecting the mental health of their caregivers will hinder the achievement of optimal rehabilitation outcomes. Therefore, integrating psychological assessment and support for FCs into routine clinical interventions is crucial for enhancing the overall quality of life and long-term rehabilitation outcomes of patients.
This study elucidated the epidemiological characteristics and primary determinants of anxiety and depression among FCs following cervical cancer surgery, thereby addressing the limitation in existing literature that predominantly emphasizes patients’ mental health while neglecting caregivers’ psychological well-being. Furthermore, the research identified the synergistic mechanisms within the patient-caregiver dyad during rehabilitation, confirmed the significant bidirectional association between caregivers’ psychological states and patients’ quality of life, and established a theoretical basis for implementing family-centered, systematic psychological intervention strategies in clinical practice.
Limitations
This study has the following limitations: First, the study employed convenience sampling and the sample was drawn from a single center, which may limit the generalizability of the results. Second, the cross-sectional design does not allow for inferences regarding causal relationships or temporal sequences among variables. Third, data collection relies primarily on self-reporting. Although measures such as anonymous completion are implemented, the influence of social desirability bias on response accuracy cannot be completely eliminated. Fourth, the recruitment for this study began in early 2022 during the COVID-19 pandemic. The clinical nursing environment and heightened psychosocial pressures during this period likely influenced the experiences of caregiver. However, this study cannot fully rule out this confounding factor, which may affect the reliability of the findings. Future research plans to employ a multicenter, stratified random sampling approach to broaden the scope of the sample and enhance the generalizability of the findings. Utilize a longitudinal study design to conduct in-depth exploration of causal relationships among variables through long-term follow-up. And incorporate objective or external validation metrics to strengthen the reliability of the evidence.
Conclusion
Sole caregiving responsibility, monthly income below ¥6,000, a daily sleep duration under 6 hours, low perceived social support, and high caregiving burden were independently associated with an increased risk of developing depression and anxiety symptoms. Therefore, in clinical practice, particular attention should be directed toward the psychological well-being of FCs with the aforementioned characteristics. Implementing interventions such as enhanced social support, improved sleep quality, and reduced caregiver burden are applied to high-risk groups to alleviate anxiety and depression symptoms, thereby improving patient quality of life. Future Longitudinal and interventional studies are required to establish causal relationships and evaluate the effectiveness of various intervention models in improving caregiver mental health and patient outcomes, thereby providing stronger evidence to support the development of a family-centered cancer rehabilitation system.
Funding Statement
No external funding has been received for conducting the study.
Data Sharing Statement
Data supporting the findings of this study are available from the corresponding author upon reasonable request.
Ethics Approval and Consent to Participate
The study was conducted in accordance with the Declaration of Helsinki (as was revised in 2013). The study was approved by Ethics Committee of the Affiliated Hospital of Jiangnan University (No.LS2021347). Written informed consent was obtained from all patients and their family caregivers who participated in the study.
Disclosure
The authors affirm that no conflicts of interest exist regarding this research.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data supporting the findings of this study are available from the corresponding author upon reasonable request.