Health Of Family Caregivers Research Articles

Predictors of mental well-being among family caregivers of adults with intellectual and developmental disabilities during COVID-19.

Internationally, stresses related to the COVID-19 pandemic negatively affected the mental health of family caregivers of adults with intellectual and developmental disabilities (IDDs). This cross-sectional study investigated demographic, situational and psychological variables associated with mental wellbeing among family caregivers of adults with IDDs during the COVID-19 pandemic. Baseline data from 202 family caregivers participating in virtual courses to support caregiver mental well-being were collected from October 2020 to June 2022 via online survey. Mental well-being was assessed using total scores from the Warwick-Edinburgh Mental Wellbeing Scale. Demographic, situational and psychological contributors to mental well-being were identified using hierarchical regression analysis. Variables associated with lower levels of mental well-being were gender (women); age (<60 years old); lack of vaccine availability; loss of programming for their family member; social isolation; and low confidence in their ability to prepare for healthcare, support their family member's mental health, manage burnout and navigate healthcare and social systems. Connection with other families, confidence in managing burnout and building resilience and confidence in working effectively across health and social systems were significant predictors of mental well-being in the final regression model, which predicted 55.6% of variance in mental well-being (P < 0.001). Family caregivers need ways to foster social connections with other families, and support to properly utilise healthcare and social services during public health emergencies. Helping them attend to their needs as caregivers can promote their mental health and ultimately improve outcomes for their family members with disabilities.

Can cessation of caregiving for parents relieve family caregivers' psychological distress? A longitudinal study using 17-wave nationwide survey data in Japan.

Informal caregiving of older parents adversely affects the mental health of family caregivers. However, the psychological effects of caregiving cessation and the trajectories of these effects have rarely been examined in Japan. This study addresses this gap. Based on a 17-wave nationwide population-based survey in Japan, we analyzed longitudinal data from 8,280 individuals aged 50-59 years in 2005 who started caring for their older parents in 2006 or later and ceased caregiving by 2021. We identified the timings of caregiving onset and cessation and examined the trajectory of psychological distress (PD), defined as a Kessler score ≥ 5 on the 6-item Kessler scale (range 0-24). Linear mixed models were used to assess the trajectory of PD that evolved after caregiving cessation over the subsequent three years. After adjusting for covariates, the probability of PD decreased by 5.6 percentage points (from 40.8%; 95% confidence interval [CI], 4.1-7.0) for female caregivers and by 1.9 percentage points (from 31.7%; 95% CI, 0.3-3.5) for male caregivers at caregiving cessation, remaining stable in subsequent years. For women, higher PD risks related to co-residence with a care recipient diminished quickly upon cessation of caregiving, while the unfavorable impacts of no social activity, extended duration of care, and long-hour daily care persisted in subsequent years. For male caregivers, the impact was generally more limited. These results suggest that changes in mental health following caregiving cessation warrant serious consideration when developing support programs for former family caregivers.

The impact of religious spiritual care training on the spiritual health and care burden of elderly family caregivers during the COVID-19 pandemic: a field trial study

BackgroundFamily caregiving is associated with many physical and psychological problems for caregivers, but the effect of spiritual support on reducing their issues during a crisis is also the subject of research. The study aims to examine the impact of religious spiritual care training on the spiritual health and care burdens of elderly family caregivers during the COVID-19 pandemic.MethodsThe randomized controlled field trial involved 80 Iranian family caregivers in Bushehr City, who were selected by convenience sampling based on the inclusion criteria and divided into experimental (40 people) and control (40 people) groups by simple random sampling in 2021 and 2022. Data collection was conducted using spiritual health and care burden questionnaires using the Porsline software. The virtual intervention included spiritual and religious education. Four virtual sessions were held offline over two weeks. The first session was to get to know the participants and explain the purpose, The second session focused on the burden of care, the third on empowerment, and the fourth on mental health and related issues. In the control group, daily life continued as usual during the study.ResultsMean changes in existential health (3.40 ± 6.25) and total spiritual health (5.05 ± 11.12) increased in the intervention group and decreased in the control group. There were statistically significant differences between the two groups for existential health (t = 3.78, p = 0.001) and spiritual health (t = 3.13, p = 0.002). Cohen’s d-effect sizes for spiritual health and caregiving burden were 0.415 and 0.366, respectively. There was no statistically significant difference in mean changes in religious health (p = 0.067) or caregiving burden (p = 0.638) between the two intervention and control groups.ConclusionGiven that the religious-spiritual intervention had a positive effect on existential health and no impact on religious health or care burden, it is recommended that comprehensive planning be undertaken to improve the spiritual health of family caregivers to enable them to better cope with critical situations such as a COVID-19 pandemic.Trial registrationIRCT code number IRCT20150529022466N16 and trial ID number 48,021. (Registration Date2020/06/28)

How do care-related beliefs contribute to depression and anxiety in family caregivers of people with dementia? Testing a cognitive vulnerability-stress model

Objectives Care-related beliefs are considered risk factors for decreased mental health in family caregivers of people with dementia. However, their exact role in the caregiver stress process remains unclear. Hence, we tested a cognitive vulnerability-stress model of depression and anxiety in family caregivers of people with dementia. Method A cross-sectional study was conducted using baseline data from a caregiver intervention trial (N = 322). Within Bayesian moderated mediation analysis, we examined mediation of effects of objective demands (severity of dementia, challenging behavior, caregiving intensity, caregiving duration) on depression and anxiety via subjective caregiver burden and moderation by care-related beliefs in four domains (dysfunctional caregiving standards, dysfunctional attitudes towards dementia, functional self-care-related beliefs, functional acceptance-related beliefs). Results The relation between objective demands and subjective burden was amplified by dysfunctional caregiving standards and dysfunctional attitudes towards dementia and mitigated by functional self-care-related beliefs. Further, functional acceptance-related beliefs attenuated the effect of subjective caregiver burden on depression. Conclusion The study provides preliminary evidence for a cognitive vulnerability-stress model of depression and anxiety in family caregivers of people with dementia. The results indicate that the four-domain model of care-related beliefs is a valuable framework for future research and may serve as a heuristic model for cognitive-behavioral therapy in this population.

What Has the Pandemic Taught Us About Caregiving? Mental Health in Family Caregivers of People with Dementia One Year After the Lock-Down Due to the COVID-19 Pandemic.

Caregiving for a person with dementia is considered a situation of chronic stress, with consequences on caregivers' physical and psychological health. The usual challenges of dementia care were intensified during the pandemic due to the risk of contagion, social isolation measures, and decrease in healthcare resources. The COVID-19 pandemic increased the stress both in the persons with dementia and their caregivers. This commentary reflects on the long-term effects of the pandemic on caregivers' mental health, focusing on the study by Olavarría and colleagues and drawing future research lines for culturally diverse family caregivers.

Physical pain among family caregivers to older adults: A scoping review of the literature.

Scholarship on the health of family caregivers to older adults continues to expand. Although existing research suggests that many family caregivers experience pain, which impacts their ability to perform caregiving tasks and is associated with care recipients' unmet needs, the scope of research on family caregivers' pain remains poorly characterized. We conducted a scoping review of research on pain among family caregivers to older adults to characterize existing evidence and identify knowledge gaps. We searched multiple databases spanning from January 2012 to July 2023, identified eligible studies using predefined inclusion/exclusion criteria, and extracted key data (e.g., study design/methodology, pain measurement, caregiver pain type, and major findings). We identified 46 eligible studies conducted in the United States (n = 19) and internationally (n = 27). Studies often focused on caregivers for older adults with specific health conditions, such as cancer (n = 11), dementia (n = 8), or stroke (n = 3). The most commonly employed pain measure was a single-item dichotomous question about pain (n = 16), followed by a visual numeric or visual analog scale (n = 11). Nine studies (five randomized controlled trials) reported on five caregiver pain management interventions, including yoga/exercise programs and caregiver education programs. Existing research on family caregivers' pain offers an important foundation. However, more robust research designs are necessary. We identify possibilities for future studies in addition to opportunities for systematic investigations to support the family caregivers being relied upon to care for the increasing number of older adults.

Psychological Distress, Multicare Needs and Social Resource Utilisation of Family Caregivers of People With Dementia: A Descriptive-Correlational Study.

The population of people with dementia increases yearly, imposing a growing burden on family caregivers. Psychological distress impacts the mental health of family caregivers of people with dementia. Caregiver psychological distress can result in increased social resource utilisation and unmet multicare needs. The study explored the psychological distress of family caregivers of people with dementia and examined the impact on social resource utilisation and multicare needs. A descriptive-correlational study collected data in Taiwan from a cross-sectional sample of family caregivers of people with dementia using a self-report questionnaire. Data were analysed using linear and logistic regression. A total of 301 caregivers provided data for analysis. Nearly two-thirds of caregivers were female with a mean age of 57 years old (SD = 12). Over half of the family caregivers of people with dementia experienced mild-to-moderate psychological distress. The greater the psychological distress, the greater the probability of using social resources (1.09 times per 1-point increase, p = 0.002). Psychological distress was positively associated with the number of caregivers' care needs (β = 0.371, p < 0.001). Findings of this study can assist healthcare professionals in better understanding the psychological distress and care needs of caregivers. Services designed to meet the needs of family caregivers will improve psychological distress.

Mental health of family caregivers: does the complimentary roles of personality trait, social support and resilience matter?

Mental health of family caregivers: does the complimentary roles of personality trait, social support and resilience matter?

Aging Well Together: Promoting Brain Health for Aging Individuals with IDD and Their Families

Adults with intellectual and developmental disabilities (IDD) have been historically excluded from participating in aging-focused research, continue to experience barriers accessing appropriate health care, and encounter distinct challenges as they age compared to people without IDD. These challenges and their effects often extend to their immediate support system, including family caregivers, including parents, siblings, and other kin. Family caregivers, often in the role of 'perpetual caregivers,' can struggle to support aging adults with IDD as they also concurrently experience the effects of their own aging, potentially hindering their ability to provide lifelong care. As parents age, the burden of care may shift to others within this support network such as siblings who, due to various constraints (e.g., geographic location, personal obligations, and financial restrictions) can also experience challenging caregiving responsibilities. Research on the mental health of family caregivers has predominantly focused either on the impact of caregiving among parents of people with IDD (and to a lesser extent on siblings) or on late-life caregivers of aging adults without IDD. This leaves a significant gap in understanding how to support caregivers during mid-late adulthood as their family member with IDD ages or as they themselves undergo age-related changes. &#x0D; In this paper, we provide a brief overview of research on family caregiving of older adults with IDD, followed by a description of a national effort, The Brain Health-IDD initiative. This initiative aims to develop strategies that will support the promotion of brain health in aging adults with IDD and their family caregivers. As part of this effort, family caregivers, both siblings and parents of adults with IDD are working together with researchers and clinicians to co-design, co-deliver and evaluate a virtual education program for families. &#x0D; The paper concludes by reflecting on the program's importance from the perspective of sibling and parent caregivers. This inclusive approach emphasizes the broader responsibility of supporting families navigating the challenges of disability and aging in mid-late adulthood, highlighting the need for support and awareness across all levels of care. &#x0D;

The effect of emotional freedom techniques (EFT) on anxiety and caregiver burden of family caregivers of patients with heart failure: A quasi-experimental study.

Family members are at the forefront of providing care to patients with chronic illnesses, such as heart failure (HF). Since patient caregiving can affect the mental and physical health of family caregivers, the implementation and training of new psychological interventions by nurses are considered important and necessary for family caregivers. Therefore, the aim of this study was to evaluate the effect of emotional freedom techniques (EFTs) on anxiety and caregiver burden of family caregivers of patients with HF. This study was a quasi-experimental study, in which 91 family caregivers participated. The family caregivers were assigned into two groups of intervention (n = 46) and control (n = 45). Data were collected using a demographic information form, Zung Self-Rating Anxiety Scale (SAS), and Caregiver Burden Inventory (CBI) developed by Novak and Guest. The intervention group underwent EFT training within six sessions, while the control group received no training. Descriptive statistics (mean, standard deviation, and absolute and relative frequency) and inferential statistical tests such as Chi-square, Fisher's exact, and independent t-tests were run, and the data were analyzed by Statistical Package for the Social Sciences (SPSS) version 23 software. The findings showed that the intervention group had a significant improvement in reducing anxiety (P > 0.001). In addition, EFT significantly reduced caregiver burden among family caregivers of HF patients (P > 0.001). EFT could significantly reduce anxiety and caregiver burden in family caregivers of patients with HF in our study. Therefore, nurses working in clinical settings are recommended to learn and use EFT to reduce the anxiety and caregiver burden of patients' family caregivers.

Self-Reported Well-Being of Family Caregivers of Children with Medical Complexity

ObjectiveProvide an in-depth and psychometrically rigorous profile of the emotional well-being and sleep-related health of family caregivers of children with medical complexity (CMC). MethodsCross-sectional survey study of family caregivers of CMC receiving care from a pediatric complex care center between May 2021 and March 2022. Patient Reported Outcomes Measurement Information System Short-Forms (PROMIS-SF) assessed global mental health, emotional distress (anxiety, depression, anger), psychological strengths (self-efficacy, emotional regulation, meaning and purpose), and sleep-related health (fatigue, sleep-related impairment). Student’s t-tests compared the sample’s mean T-scores to US population norms. Pearson’s correlation coefficient (ρ) examined associations between measures of psychological strengths and emotional distress. Unadjusted linear regression analyses explored relationships between well-being outcomes and child and caregiver characteristics. ResultsCompared to US population norms, caregivers of CMC (n = 143) reported significantly lower global mental health and emotional regulation ability as well as elevated symptoms of anxiety, depression, anger, fatigue, and sleep-related impairment (all P < .01). Whereas participants reported a significantly higher sense of meaning and purpose (P < .05), levels of self-efficacy were not significantly different from population norms. We observed moderate-to-strong inverse relationships between psychological strengths and emotional distress (ρ range, −0.39 to −0.69); with the strongest inverse associations found between emotional regulation ability and emotional distress. In exploratory analyses, caregiver race and ethnicity, socioeconomic status, and child health insurance type were significantly associated with caregiver well-being. ConclusionFamily caregivers of CMC report poor well-being, most notably, increased symptoms of anxiety and reduced global mental health and sleep-related health.

The Mediating Effect of Psychological Resilience between Individual Social Capital and Mental Health in the Post-Pandemic Era: A Cross-Sectional Survey over 300 Family Caregivers of Kindergarten Children in Mainland China

In the context of the impact of the post-COVID-19 pandemic on families, this study explores the impact of individual social capital and psychological resilience on the mental health of family caregivers of kindergarten children in mainland China. This study included a sample of 331 family caregivers from Zhaoqing City, Guangdong Province, and the researchers applied the Personal Social Capital Scale (PSCS-16), Connor–Davidson Resilience Scale (CD-RISC-10), and Depression Anxiety Stress Scale (DASS) to assess social capital, psychological resilience, and mental health. Findings indicate a positive relationship between bridging social capital and mental health, while psychological resilience is negatively associated with depression, anxiety, and stress. Psychological resilience is identified as a mediator between social capital and mental health outcomes in this study. These insights highlight the importance of enhancing social capital and psychological resilience to improve family caregivers’ mental health and the need for targeted interventions.

Theoretically Based Factors Associated With Stroke Family Caregiver Health.

Most persons who have had strokes are cared for at home by family members-many of whom experience depressive symptoms and quality of life changes as a result of providing care. The objective of this study is to determine theoretically based factors associated with unhealthy days in stroke family caregivers. Secondary data analysis was conducted using baseline data from a large randomized controlled clinical trial testing the Telephone Assessment and Skill-Building Kit program with 254 family caregivers of persons who have had strokes. Guided by a conceptual model derived from Lazarus' transactional approach to stress, data were analyzed using multiple regression with unhealthy days as the dependent variable and theoretically based factors as independent variables. Caregivers were mostly female (78%), White (71%), spouses (47%), or adult children (29%). Caregivers reported nine unhealthy days on average within the past month. A total of 37.8% of the variance in unhealthy days was explained by caregiver task difficulty, level of optimism, threat appraisal, depressive symptoms, and life changes with depressive symptoms being the strongest individual predictor because of shared variance. Unhealthy days is an important part of stroke family caregiver health. Factors associated with unhealthy days in this study provide areas to consider in future intervention development.

Theoretically Based Factors Associated With Stroke Family Caregiver Health.

Theoretically Based Factors Associated With Stroke Family Caregiver Health.

Design, Implementation and Evaluation of a Health Promotion Program for Family Caregivers of Chronic Mental Disorders: A Mixed Methods Study.

Family caregivers of patients with chronic mental disorders who are responsible for taking care of the patient face many problems that can endanger the psychosocial health of these people. This study was conducted to develop, implement, and evaluate a psychosocial health promotion program for family caregivers of patients with chronic mental disorders. This research is an exploratory sequential mixed-method study conducted using a qualitative-quantitative design. A qualitative study was conducted to explain the needs and psychosocial problems and the solution to improve the psychosocial health of family caregivers of patients with chronic mental disorders in two psychiatric care centers in Isfahan were conducted. Then the program was written based on Kern's programming development approach. In the quantitative stage, a part of the developed program was implemented as virtual group psychoeducation for 67 caregivers, and its impact on caregivers' burden of care was evaluated. The findings from the qualitative phase of the study led to the emergence of 3 main categories and the findings from the quantitative phase of the study indicated that the implementation of the compiled program causes a significant reduction in the burden of care in family caregivers of chronically mentally ill patients (p<0.05). The current program was prepared and developed using an evidence-based approach. Policymakers and members of the mental health team can take a valuable step toward reducing the care burden of family caregivers of chronic mental patients by using the content of the developed mental health promotion program.

FINANCIAL DIFFICULTY, HEALTH BEHAVIORS, AND MENTAL HEALTH OF FAMILY CAREGIVERS DURING THE COVID-19 PANDEMIC

Abstract The COVID-19 pandemic greatly burdened family caregivers in the United States and across the globe as they and their family members often suffered from the COVID-19 virus and its societal implications, like social isolation and a shift to remote healthcare. This study examines the impact of the COVID-19 pandemic on financial difficulty, health behavior, and mental health outcomes among family caregivers for older adults across the intersectionality of gender and race. Using the 2020 National Health and Aging Trends Study (NHATS) COVID-19 supplement for Family Members and Friends, our sample included adult family or friend caregivers of Medicare beneficiaries aged 65 or older in the US (N = 2,062). We modeled the interrelationships between financial difficulty, health behaviors, and mental health outcomes using a structural equation model. The results indicate that within the intersectionality framework, during the pandemic, female caregivers reported less vigorous activity, more changes in walking and sleeping patterns, and more eating and watching TV than before the pandemic compared to male counterparts. Compared to white caregivers, during the pandemic, non-white caregivers showed less vigorous activity and more changes in walking, sleeping, I eating, and TV watching patterns than before the pandemic. Financial difficulty was significantly and positively associated with negative mental health. Active behavior was significantly and negatively associated with negative mental health. Health professionals should consider the interrelationships between sociodemographic factors, physical activity levels, and financial difficulties that have come to light during the pandemic when designing future programs and policies to improve family caregiver health.

Factors Associated With Dementia‐Related Behaviors Among Caregivers Experiencing Poor Sleep

AbstractBackgroundNeuropsychiatric symptoms of dementia are common and have the potential to negatively impact the physical and mental health of family caregivers, hindering their ability to provide care. Such impact may be worse among caregivers experiencing poor sleep. This study aimed to explore factors associated with the frequency of and caregivers’ distress to dementia‐related problematic behaviors.MethodThis was a cross‐sectional study, using data from a clinical trial of dyadic sleep intervention for persons living with dementia (PLWD) and their family caregivers. Dementia‐related behaviors were measured using a 24‐item, Revised Memory and Behavioral Problems Checklist (RMBPC): total scores of frequencies and caregivers’ distress; scores for three subscales (memory‐related, depression, and disruptive behaviors). Caregiver‐related variables included demographic background, Zarit Burden Interview (ZBI), Positive Aspects of Caregiving (PAC), Pittsburgh Sleep Quality Index (PSQI), and Center for Epidemiological Studies of Depression (CESD). Patient‐related variables included activities of daily living (ADLs), instrumental ADLs (IADLs), and Mini‐Mental State Examination (MMSE) scores. A total of 47 dyads were included in the analysis (caregivers: n = 29 spouses, n = 17 non‐spouses; 40% Whites). Pearson correlation analyses were conducted.ResultHigher ZBI and CESD scores were significantly associated with higher RMBPC frequency total (r = 0.41, r = 0.48, respectively; p&lt;0.01) and caregiver distress total scores (r = 0.58, r = 0.43, respectively; p&lt;0.01). Lower PAC (r = ‐0.31, p = 0.04) and higher MMSE scores (r = 0.37, p = 0.03) were also associated with higher caregiver distress total scores. ZBI and CESD scores were associated with RMBPC‐depression subscale scores (frequency/caregiver distress). There were positive associations between CESD and MMSE with RMBPC‐disruptive behaviors (frequency), and ZBI and PAC scores with RMBPC‐disruptive behaviors (caregiver distress). No patient or caregiver‐related factors were associated with RMBPC‐memory subscale scores. There was no significant association between PSQI scores and RMBPC total/subscale scores. Patient factors were not significantly associated with RMBPC frequency total or caregiver distress total scores.ConclusionDementia‐related problems, particularly depressive symptoms and disruptive behaviors of PLWD are associated with both positive and negative aspects of caregiving. Future studies will need to further examine how each RMBPC subscale of behavior contributes to caregiver burden or perceived caregiving experiences among family caregivers.

P11: Psychosocial longitudinal correlates of mental and physical health of family caregivers of people with dementia

There is a general consensus that providing care for a relative that has dementia is associated with negative outcomes for caregivers’ mental health. There seem to be also associations with negative physical health outcomes, although the literature on this topic is more scarce. Most of the available research consist in studies with a cross-sectional design. Longitudinal studies focused on psychosocial correlates of mental and physical health of the caregivers are lacking, mostly those analyzing the influence of factors such as behavioral and psychological symptoms of the dementia, caregivers` dysfunctional thoughts, and caregivers’ ambivalent and guilt feelings. The aim of this presentation will be to describe the findings from the Madrid Caregivers Longitudinal Study, that consist in a two year follow-up of family caregivers of people with dementia. Several models will be described testing the longitudinal effect of psychosocial variables on caregivers’ distress (depression and anxiety) and cardiovascular health (measured through biomarkers of inflammation). The practical implications of the findings will be discussed.

Analysis of factors associated with family disease burden and correlation with social support among family caregivers of patients with severe mental illnesses.

Caregivers are responsible for the home care of family members with severe mental illnesses (SMIs) and their lives are often subject to changes that can create stress and burden. The purpose of this study was to explore the current state of family disease burden and its correlation with social support among family caregivers of SMIs patients. Using a random sampling method, a total of 1,108 family caregivers of SMIs patients in community health service centers were selected. A general information questionnaire of family caregivers and patients, the Family Disease Burden Scale, and the Social Support Rating Scale were used. The score of the Family Disease Burden Scale of 1108 family caregivers was 16.57 ± 10.65. Family disease burden was negatively correlated with social support (p < .05). The main influencing factors of family disease burden were average annual family income, duration of illness, distance to medical care, risk of unpredictable behavior, social support, caregiver-patient relationship, gender, and comorbid chronic conditions (p < .05). Family caregivers of SMIs patients have a relatively low level of caregiver-perceived social support. Interventions to enhance perceived social support could help maintain the health of family caregivers and improve the quality of family care.

Impact of visitation restrictions on the mental health of family caregivers during the COVID-19 pandemic: A mixed methods study.

To examine the mental health conditions of family caregivers residing away from their loved ones who experienced visitation restrictions during the coronavirus disease 2019 pandemic. A mixed-methods design applying the Kessler Scale-10 for the quantitative measurement of psychological distress and an open-ended question for qualitative analysis. The participants were recruited from care facilities between February and September 2021. This cross-sectional study included 197 family caregivers who were utilizing formal residential care services for their loved ones. Using thematic analyses, open-ended responses regarding the impact of visitation restrictions were coded. These themes were then examined to determine thematic patterns across caregiver characteristics. Thirteen themes were identified regarding the impact of visitation restrictions. Many participants reported primary harmful effects as follows: 'inability to confirm the type of care and lifestyle assistance provided to an older relative' and 'difficulty communicating with an older relative because of the inability to converse face-to-face'. Younger age, being employed, poor sleep, poor relationship quality with the care recipient and experiencing harmful effects from the visitation restrictions were associated with psychological distress. Our findings suggest that to maintain positive mental health after a care transition, it is important for family caregivers to take part in the care of their loved ones and ensure information sharing between the care recipient's family and institution. These findings suggest that both residents and family caregivers living outside facilities may feel distressed due to separation. Therefore, institutional care staff needs to consider how to adjust facility procedures or communication with family caregivers. The comments obtained from the participants in this survey helped to shape the study design and are expected to contribute to the further development of quality facility care.