INTRODUCTION:

The increasing growth of elderly is a global phenomenon and it is considered as a growing concern throughout countries (1). In addition to the increasing number of elderly, the number of elderly with Alzheimer is increasing because the age is a risk factor for increase of Alzheimer disease (2). Alzheimer is a chronic progressive nervous disease and it is determined with deficit of cognitive performance (3, 4).

It is estimated that the number of people with Alzheimer will increase from 35 million people in 2010 to 115 million people in 2050 globally (5). According to Iran Alzheimer association, there are about 212000 people with Alzheimer in Iran. Disturbance in memory, thinking, speaking and lack of ability to do activity daily living could change the individual with Alzheimer into a dependent person who requires care (6). More often, family members are responsible to take care of the patient with Alzheimer. It is reported that 80% of Alzheimer patients are cared by family members (7). Studies indicate that taking care of a patient with Alzheimer is stressful and it could influences on all physical, mental, spiritual, social and financial dimensions of caregivers life and the quality of life (QoL) of caregivers will be reduced (8) QoL of caregivers of patients with Alzheimer is lower than that of caregivers who care patients with other physical and chronic diseases. Such reduction of caregivers’ QoL can be effective on quality of cares provided by caregivers (5).

Researchers examined many interventions to promote QoL of caregivers of patients with Alzheimer. One of such interventions is problem-oriented coping strategies training. Previous studies showed that problem oriented coping strategies (problem solving) can lead to improvement of caregivers’ QoL (9). Generally, coping strategies are divided into two types: problem-oriented and emotion-oriented. Problem oriented strategies include active encounter with the problem, problem planning and solving while emotion oriented strategies include denial, seeking for help and support and concentration on emotion. Such coping behaviors protect individuals from physical and mental problems and impairments (10, 11, and 12).

Review of literature showed that there are some studies that examined the effects of coping training. Results of the study conducted by Garand et al., indicated that education of problem oriented skills reduced depression and anxiety and increased mental health of caregivers of patients with cognitive deficits (13). In the study conducted by Seid et al., results suggested that education of problem oriented skills improved QoL children with persistent asthma (14). Results of the study conducted by Porter et al., showed that QoL and self-efficiency of patients with lung cancer and their caregivers was improved after education of coping skills (15). In the context of Iran some studies evaluated he effects of coping training. Fatehi et al., found that education of coping strategies promoted the score of QoL of patients under hemodialysis (9). Also, results of the study done by Sharifi et al., indicated that group education of problem solving skill was effective and suitable on reduction of burnout of women who took care of their patients (16). However, there is no agreement between researchers about which coping strategy is more effective on problem solving and stress reduction (17).

Islamic and Iranian culture focuses on taking care of elderly at home. Besides, taking care of elderly with Alzheimer at personal home could prevent negative consequences of keeping elderly with Alzheimer in nursing home. Thus, this study conducted to examine the effect of problem oriented coping strategies training on quality of life of family caregivers of elderly with Alzheimer.

MATERIAL AND METHODS:

The present study is a randomized clinical trial with two experimental and control groups. In this study, 72 family caregivers of elderly with intense and moderate Alzheimer were chosen by purposeful sampling and were randomly allocated in control and intervention groups. For random allocation, researchers put 72 cards (on which the words C (Control) and E (Experimental) were written) on a box and each participant selected a card randomly.

People with Alzheimer who referred to hospitals supervised by Kerman University of Medical Sciences and office of neurologists in Kerman city were included in this study. Inclusion criteria were being immediate family members of the patient who take care of the patient at home, being able to read and write, having taken care of the patient for one year and more, lack of cognitive disease and not being previously trained about coping strategies. Participants excluded from the study in case of death of patient with Alzheimer, no tendency to continue participation in the study and occurrence of a stressful event such as death of family members and close relative or divorce.

The sample size was calculated with 95% confidence and 80% power and standard deviation was derived from the study conducted by Mansouri et al, (7) as 36 persons.

Instruments:

The questionnaire contained two parts:

1) Demographic information includes information related to the caregiver: age, gender, education, economic status, job, time duration of relationship with patient before disease, time duration of relationship with patient after disease, type of relationship between caregiver and patient, approximate hours of taking care of patient daily. As well as information related to patient: age, gender, intensity of Alzheimer and time duration of affection to disease.

2) 36-item Short Form Health Survey (SF-36) To examine participants’ quality of life we used Iranian version of 36-item Short Form Health Survey (SF-36) (Montazeri et al., 2005). SF36 quality of life questionnaire is a standard and general instrument for studying mental and physical health and was designed by Varosherbon in 1992 in America and its validity was measured in several groups. In Iran, its validity and reliability were measured by Montazari et al (2005) and its Cronbach alpha was reported between 0.77 and 0.99. SF36 is a 36-item instrument and measures the following eight health concepts: physical functioning (10items), role limitations due to physical problems (4items), bodily pain (2 items), vitality (4items), general health perception (5items), social function (2items), role limitations due to emotional problems (3items), and mental health (5items). Scores for each category range from 0 to 100, and higher scores indicating better health status (18). The scores between 0 and 33 are for poor life quality, between 34 and 66 for moderate life quality and between 67 and 100 for good life quality.

Data collection:

The questionnaires were completed before intervention. Then, educational intervention was done during 8 sessions for 45 minutes one day a week for intervention group. The eight educational sessions were included primary evaluation, clinical interview, problem solving, anger management, stress and adaptive copings, coping with negative affects and cognitive regeneration, strategies for making effective relationship, review of sessions and conclusion of learned things (19).

All educations sessions were held by the first researcher in form of face to face education. In all session 36 participants were presented. Three sessions were held about Alzheimer disease for control group. Two weeks after intervention, the questionnaire was completed by participants of both groups for a second time.

Statistical analysis:

Data from the questionnaires were analyzed using software Statistical Package for Social Scientists 16 (SPSS 19). Kolmogorov- Smirnov test showed that the distribution of data was normal. Pair T test was applied to compare mean score of QoL before and after intervention and independent T test was used to compare mean score of two groups. One way variance analysis (ANOVA) and Pearson correlation coefficient were used to measure the relationship between demographic information and scores of QoL.

Ethical considerations:

The present study is a part of thesis of Master Sciences of geriatric nursing and it was approved by Rafsanjan nursing and midwifery school and confirmed by ethical committee of Rafsanjan University of Medical Sciences by No. 1394.1394.175. In addition, the present study has been registered in database of Iranian clinical trials with code No: IRCT2016050327736N1. An informed written consent was taken from participants and they were ensured that the information was confidential and they could leave the study whenever they wanted.

RESULTS:

Participants:

Results showed that most of caregivers participated in the study were female (65%), housewife (52%), with under diploma level of education (44%), and moderate economic status (51%). Majority of elderly were women (65%) with intense Alzheimer (55%).

Comparing QoL based on demographic information:

Mean score of QoL in male caregivers was higher than that in female caregivers. Mean score of QoL in self-employed participants was higher than that in participants with other jobs. Mean score of QoL in people with economically good status was higher than others. Mean score of QoL in people with level of education more than diploma was more than that in people with other educational degrees. But only there was seen a significant difference between economic status and life quality (P < 0.05). According to Tukey test, there was a significant difference between mean score of QoL and economically good, moderate and poor status (P < 0.05). Demographic information of both groups was compared in table 1.

Table 1: demographic information of experimental and control groups

Personal features		Control group	Subject group	P
Age: mean (standard deviation)		(9.62) 47.13	(8.53) 52.44	0.016
Gender: No (%)	Female	(57.4) 27	(42.6) 20	0.083
Gender: No (%)	Male	(36) 9	(64) 16	0.083
Education: No (%)	Illiterate	(54.5) 6	(45.5) 5	0.632
	Under diploma	(56.2) 18	(43.8) 14
	Diploma	(50) 7	(50) 7
	Upper diploma	(35.7) 5	(64.3) 9
Job: No (%)	Employee	(28.6) 4	(71.4) 10	0.103
	Self- employed	(50) 4	(50) 4
	Retired	(14.3) 1	(85.7) 6
	Farmer	(50) 1	(50) 1
	Housewife	(60.5) 23	(39.5) 15
Economic status	Poor	(45) 9	(55) 11	0.084
	Moderate	(62.2) 23	(37.8) 14
	Good	(28.6) 4	(71.4) 10

The effect of intervention on QoL of intervention group:

Results showed significant increase of mean total score of QoL in intervention group after the education (60.32) compared to before education (52.17) (P = 0.001). Before intervention, the highest mean score of QoL in this group was related to physical functioning (68.88) and the lowest mean score was related to emotional problems (39.06). After intervention, the highest mean score of QoL was related to emotional problems (83.33) and the lowest mean score was associated to general health perception(51.33).

The effect of intervention on QoL of control group:

Findings indicated that mean total score of QoL increased after intervention compared to before intervention but such increase was not statistically significant (P = 0.471).

Table 2: comparing mean score and standard deviation of of QoL and its dimensions in two groups before intervention

	Control		Intervention		T statistic	P value
	Mean	Standard deviation	Mean	Standard deviation	T statistic	P value
General health perception	46.23	21	44.81	13.09	0.345	0.731
Physical functioning	64.44	24.03	68.88	22.06	- 0.817	0.417
Role limitations due to physical problems	44.23	39.68	40.54	33.81	0.424	0.673
Role limitations due to emotional problems	43.51	41.26	39.06	19.12	0.470	0.640
social function	58.79	23.43	60.73	19.53	- 0.380	0.705
bodily pain	55.48	24.21	54.37	23	0.199	0.843
vitality	48.63	20.81	47.85	14.37	0.185	0.854
Mental health	54.90	17.93	57.34	9.65	- 0.718	0.475
Total Score	53.86	14.66	52.17	13.63	0.508	0.613

Table 3: Comparing mean Score and standard deviation of QoL and its’ dimensions in two groups after intervention

	Control		Intervention		T statistic	P value
	Mean	Standard deviation	Mean	Standard deviation	T statistic	P value
General health perception	44.62	14.86	51.33	10.28	- 2.22	0.029
Physical functioning	56.66	23.11	71.91	23.29	- 1.14	0.257
Role limitations due to physical problems	38.19	12.70	57.45	36.30	- 2.03	0.046
Role limitations due to emotional problems	52.77	14.44	83.33	25.81	- 3.69	0.001
social function	58	24.04	70.74	15.15	- 2.69	0.009
bodily pain	57.43	21.08	56.98	17.78	0.098	0.922
vitality	51.14	17.61	65.03	12.72	- 3.83	0.001
Mental health	52.78	12.49	62.39	10.91	- 3.49	0.001
Total score	55.57	14.50	60.32	10.16	- 1.60	0.112

Before intervention the highest mean score of QoL in this group was associated with physical functioning (64.44) and the lowest mean score was associated with emotional problems (43.51). After intervention, the highest mean score of QoL was related to with social function (58) and the lowest mean score was associated with role limitations due to physical problems (38.19).

Comparing QoL in both groups before and after intervention:

As illustrated in table 2, mean total score of QoL (P = 0.613) and mean score of QoL dimensions (P > 0.05) was not significantly different in both groups before intervention.

Mean score of QoL increased in all dimensions (except bodily pain) in intervention group compared to control group. The increase was statistically significant (P < 0.05) in all dimensions except bodily pain and physical functioning dimensions. The highest difference of mean score of QoL was related to emotional problems in both groups (30.55) and the lowest difference was related to physical bodily pain (- 0.45). Results of independent T test indicated that total mean score of QoL increased in intervention group after intervention compared to control group (55.57) but such increase was not statistically significant (P = 0.112).

DISCUSSION:

The present research was conducted to determine the effect of problem-oriented coping strategies training on QoL of caregivers of elderly with Alzheimer. This study findings indicated that QoL of caregivers was moderate. Although the QoL of caregivers was reported low in the study conducted by Bruvik et al., which assessed QoL of patients with dementia and their family caregivers (20) and also in the study conducted by Hazzan et al., that examined the relationship between QoL of caregivers and the quality of care given to patients with Alzheimer (5). This difference between current study and previous studies may be due to demographic and cultural differences, different customs and traditions and different in commitment and being interested in caring of elderly.

Total mean score of QoL in intervention group increased significantly after the educational intervention. This result was in agreement with the results of Choubforoush Zadeh et al., who studied the effectiveness of stress management training on QoL of infertile women (21). As well as the study of Fatehi et al., who studied the effect of coping strategies training on QoL of patients under hemodialysis (9). Also, findings of present study indicated that QoL scores of intervention group increased considerably in all dimensions except in bodily pain and physical functioning compared to control group. The result is in agreement with results of Hafari et al, who studied the effect of stress management training on QoL of caregivers of unable elderly (22). Coping strategies training would change the attitude and enhance mental health by the mean of increasing ability of problem solving, self-confidence, self-reinforcement and reduction of stress. Such training may be effective on physical problems and pain if number of educational sessions are increased and integrated with a regular exercise (23). In addition, most of care givers participated in the study was middle aged and affection to physical problems is common in such age.

Caregivers with poor financial conditions experience more caring pressure compared to other caregivers. Nevertheless, poor financial condition has a negative effect on general health of caregivers resulting in reduction of QoL of caregivers with low economic status. Results showed that although total mean score of QoL increased in experimental group after the intervention compared to control group, their difference was not statistically significant. In this direction, results of Kheirabadi et al., suggested that education of coping strategies did not change significantly QoL of patients with irritable bowel syndrome (19). While results of Seid et al., (14) study who examined the impact of education of problem solving skills for vulnerable families of children with persistent asthma and results of Tarkhan et al., (24) study who evaluated the effect of group education of immunity against stress on systolic and diastolic blood pressures and QoL of women with hypertension suggested the significant effect of the education on QoL of participants. The reason may be due to different under study populations, different beliefs and views of participants, effect of culture governing on the society or the intervention. In addition, it is clear that problem-oriented coping strategies have few effects on QoL of participants regarding physical dimension. Generally, this dimention deal with issues such as running, walking, lifting objects and it is not expected that education of problem-oriented coping strategies increase abilities of participants in this regard. Therefore, insignificant difference of mean scores of participants had been expectable. Few increase of QoL in this dimension influenced on total score of life quality and the there is no statistically significant difference in total score of life quality before and after intervention.

CONCLUSION:

Concerning high prevalence Alzheimer in the country and the main role of family caregivers on caring such patients, coping with stress resulted from caring such people is very important. In present research, although mean life quality of individuals after education did not increase significantly compared to control group, caregivers were satisfied with such educations and wanted to continue more educational programs and appointments (gathering) of caregivers. Therefore, formal and regular education of coping strategies can improve life quality of caregivers in long term.

ACKNOWLEDGMENT:

The present study is a part of thesis of Master Sciences of geriatric nursing. The researchers appreciate research assistant of Rafsanjan University of Medical Sciences due to financial supports. They also appreciate related authorities and caregivers of patients with Alzheimer who participated in the study.

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Received on 13.11.2016 Modified on 28.12.2016

Asian J. Nur. Edu. and Research.2017; 7(2): 168-172.

DOI: 10.5958/2349-2996.2017.00034.9