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Determinants of Depression in Caregivers of Geriatric Patients in Jeddah, Saudi Arabia: A Cross-Sectional Study

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22 July 2024

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24 July 2024

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Abstract
Conclusion: The study highlights the high prevalence of depression among caregivers of geriatric patients in Jeddah and underscores the significant impact of caregiving burden on mental health. These findings emphasize the need for targeted interventions, such as mental health support, respite care programs, and culturally sensitive educational training, to mitigate caregiver burden and enhance the well-being of caregivers.
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Subject: Medicine and Pharmacology  -   Psychiatry and Mental Health

1. Introduction

Caregiving in the context of geriatric patients is essential for ensuring the well-being and quality of life of older adults. It involves not only providing physical assistance but also emotional support, companionship, and advocacy for the needs of older individuals. Family caregivers, in particular, play a crucial role in supporting geriatric patients, especially as the population ages and the demand for long-term care increases [1]. Furthermore, caregivers often act as advocates for older adults, ensuring their preferences are respected in healthcare decision-making [2].
Caregiver burden encompasses the physical, emotional, social, and financial stressors faced by individuals providing care to impaired or ill individuals, resulting in an imbalance between caregiving demands and personal resources [3]. Juggling caregiving responsibilities with personal and professional commitments can be overwhelming, leading to caregiver burden and fatigue [4]. The negative reactions experienced by caregivers due to the demands of caregiving can lead to burnout and other adverse consequences, potentially affecting their ability to provide care [5,6,7]. Hence, this burden significantly influences the potential need for patient institutionalization [8], which may have a snowballing effect on healthcare system efficiency and the economy.
The relevance of studying caregiving burden in the context of geriatric patients arises from the increasing age-related morbidity and its associated health and economic burdens on societies. In Saudi Arabia, the aging population is projected to lead to a significant rise in the incidence of first strokes in the coming decade [9]. Moreover, despite only 3.2% of the Saudi population being over 65 years old, the prevalence of chronic conditions poses a considerable risk of severe complications in older individuals. Metabolic diseases, cancer, and chronic obstructive pulmonary disease (COPD) are on the rise, indicating a growing disease burden associated with aging [10,11,12]. Additionally, cardiovascular diseases, myocarditis, and thyroid cancer show age-specific patterns, with age-standardized rates reflecting the impact of aging on these conditions [13,14,15]. These figures are compounded by the increasing life expectancy, a key component of Saudi Vision 2030 [16]. Maintaining longevity and healthiness in line with this vision requires considering macroeconomics, socio-demographics, and health resources in shaping a population’s health and behavior [17].
Therefore, we conducted this study to estimate the prevalence of depression among caregivers of geriatric patients in Jeddah, Saudi Arabia, and to analyze its association with caregiver burden and various socio-demographic and caregiving parameters. Understanding the extent and impact of caregiver burden, particularly its correlation with depression, is crucial for developing targeted interventions that can mitigate these challenges. This data will provide valuable insights into the specific needs and stressors faced by caregivers, enabling healthcare providers and policymakers to devise effective support systems. Furthermore, this research can inform strategies to enhance the well-being of both caregivers and geriatric patients, ultimately improving the overall efficiency of the healthcare system and reducing economic burdens.

2. Methods

2.1. Design and Settings

A cross-sectional study was conducted among the population of Jeddah, Saudi Arabia, between January-March 2024. The study was ethically approved by the institutional review board of University of Jeddah (#UJ-REC-147).

2.2. Participants

The study targeted adult (18 years or older) residents of Jeddah who provide caregiving for a geriatric relative or Patintes. the study excluded who refused to participate, or had any of the following conditions: psychiatric issues, or were outside the target age range.

2.3. Sampling

Participants were recruited via various social media platforms. A convenience sampling technique was first employed to include all consenting participants. The recruitment strategy was complemented with a snowball sampling technique, where initial participants were encouraged to share the questionnaire with their own networks.

2.4. Data Collection

The data collection tool used in this study was an electronic questionnaire designed to gather information about the participants and their caregiving experiences. It comprised of 4 parts:
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Part 1 collected demographic data such as age, gender, marital status, education level, professional status, and monthly income.
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Part 2 focused on information on the relationship of the caregiver to the patient, caregiving frequency, living arrangements, caregiving mode, financial responsibility, and duration of caregiving.
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Part 3 consisted of a slightly modified version of the Patient Health Questionnaire-9 (PHQ-9) scale, used to screen for depression. The modification involved a cultural adaptation of the 9th item, which was rephrased from “Thought that you would be better off dead, or of hurting yourself” to “Feeling as though life isn’t worth living”. A meta-analysis including 58 eligible studies with a total of 17,357 participants and 2,312 cases of major depression evaluated the diagnostic accuracy of the PHQ-9 for detecting major depression. This study found that a cut-off score of 10 or above maximized the combined sensitivity (0.88, 95% CI 0.83 to 0.92) and specificity (0.85, 95% CI 0.82 to 0.88) among studies using semi-structured diagnostic interviews. Sensitivity was higher with semi-structured interviews compared to fully structured interviews and the Mini International Neuropsychiatric Interview (MINI). The PHQ-9 demonstrated similar sensitivity but potentially lower specificity for younger patients compared to older patients. Therefore, a cut-off score of 10 or above is recommended for use across different age groups and diagnostic settings [18]. The cutoff of 10 or above is relatively contested, with some studies showing that the cutoff is between 8 and 11. Therefore, the use of PHQ-9 should be complemented with a clinical assessment by a mental health professional [19].
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Part 4 assessed the caregiving burden using the short form of the Zarit Burden Interview (ZBI-12), which comprises of 12 items. Each item is rated on a scale from "Never" to "Almost always," reflecting how frequently caregivers experience specific challenges, such as lack of personal time, anger near the relative, health impact, etc. An overall ZBI-12 score is computed and interpreted as following: none-to-mild burden (0-10); mild-to-moderate (>10-20); and high (>20). This scale has excellent psychometric properties [20], and has been validated for assessing caregiver burden across various populations and caregiving settings [21,22].

2.5. Procedure

The questionnaire was edited for electronic administration using Google Forms. The link was distributed via social media platforms, including Facebook, Twitter, and LinkedIn, employing a snowball sampling technique to broaden reach. Participation was voluntary, with electronic informed consent obtained at the beginning. Confidentiality and anonymity were assured, with no personal identifying information collected.

2.6. Variables and Outcome

The dependent variable, being the primary outcome, is the depression status assessed using the PHQ-9 score and defined as a score ≥10. The other variables including caregiver’s demographic factors, caregiving parameters, and the ZBI-12 score were analyzed as the independent variables.

2.7. Statistical Methods

Data analysis was performed using IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY). Descriptive statistics were used to summarize the demographic characteristics, caregiving parameters, and responses to the PHQ-9 and the ZBI-12 scales. Means and standard deviations were calculated for continuous variables, while frequencies and percentages were used for categorical variables. The independent t-test was utilized to compare mean ages between groups with different depression statuses. Chi-square tests were employed to examine the associations between categorical variables and depression status, defined by a PHQ-9 score of 10 or higher. Multivariate logistic regression was conducted to identify independent predictors of depression among caregivers, with results presented as odds ratios (ORs) and 95% confidence intervals (CIs). Variables included in the regression model were selected based on their significance in univariate analyses and theoretical relevance. The multivariate model's explanatory power was assessed using the coefficient of determination (R²). Statistical significance was set at p < 0.05 for all tests.

3. Results

3.1. Participants Characteristics

Of 273 responses received, 4 (1.5%) did not provide consent for participation. This resulted in a total 269 participations. The average age of the participants was approximately 32 years (SD=15.01), ranging from 12 to 77 years. Gender distribution was nearly balanced. A majority were single (63.6%), followed by married (29.7%). Regarding education, the largest groups had completed a bachelor's degree (38.7%) or were college students (30.5%). Regarding professional status, 42.0% were students and 30.1% were employed. Monthly income data showed that 28.3% of the participants earned more than 10K SAR, while 33.1% earned less than 3K SAR (Table 1).

3.2. Caregiving Patterns

Among caregivers, 49.4% were sons or daughters of the patients, and the majority (65.1%) had been providing care for more than six months. The majority (60.6%) provided care daily, with 21.9% doing so for more than 8 hours daily, and 58.7% lived with the patient. The role of sole caregiver was less common, with 81.4% sharing caregiving duties. Financial responsibility was predominantly absent, with only 25.7% declaring financial responsibility for the patient (Table 2).

3.3. Depression Assessment Using PHQ-9 Scale

The patterns of answers to the PHQ-9 items are depicted in Table 3. Key findings included frequent feelings of tiredness or low energy, with a mean score of 2.36, and difficulty sleeping, with a mean score of 2.26. Losing interest in activities (mean score of 2.09) and trouble concentrating (mean score of 2.02) were also common. The least frequent symptoms were feeling life isn’t worth living (mean score of 1.66) and moving or speaking slowly or restlessly (mean score of 1.73). The PHQ-9 demonstrated high reliability with a Cronbach’s alpha of 0.890.
The assessment of total PHQ-9 scores showed a mean of 8.93 (SD 6.53) and a median of 9 (range 0-27). Normality testing indicated that the data were not normally distributed (Kolmogorov-Smirnov 0.099, p<0.001; Shapiro-Wilk 0.955, p<0.001). Using a cutoff score of ≥10, the prevalence of depression was found to be 45.4% (95% CI: 39.3, 51.5%).

3.4. Assessment of Caregiving Burden

In the assessment of caregiving burden using the ZBI-12 scale, the most concern-ing items were the feeling of needing to do more for the relative (23.0% often or almost always, mean score 2.49) and feeling they could have taken better care of the relative (25.6% often or almost always, mean score 2.49). Conversely, the least concerning items were the impact on caregivers' health (6.0% often or almost always, mean score 1.65) and feeling angry near their relative (7.0% often or almost always, mean score 1.76). The scale demonstrated high reliability with a Cronbach’s alpha of 0.912. For detailed item responses, see Table 4.
The assessment of overall ZBI-12 scores revealed the following distribution among participants: 152 individuals (56.5%) experienced no to mild burden (scores 0-10), 61 individuals (22.7%) reported mild to moderate burden (scores >10-20), and 56 individuals (20.8%) experienced high burden (scores >20).

3.5. Factors Associated with Likelihood of Depression among Caregivers

Factors associated with a higher likelihood of depression (PHQ-9 score ≥10) are presented in Table 5. Younger age was significantly associated with higher depression scores (mean age 27.84 vs. 35.37 years, p<0.001). Females were more likely to have depression compared to males (56.2% vs. 43.8%, p<0.001). Marital status also was significant, with single individuals showing a higher likelihood of depression (55.6%, p<0.001) compared to their counterparts. Professional status indicated that students had a higher depression prevalence (59.3%, p=0.001). Income levels revealed that those earning less than 6K SAR had higher depression rates (56.2% for <3K SAR and 56.9% for 3K-6K SAR, p=0.001). Regarding caregiving modalities, providing care for less than 8 hours daily was associated with the highest likelihood of depression (53.8%), compared to more than 8 hours daily (32.2%) or not providing daily care (44.3%), (p=0.028). The likelihood of depression was proportional to the level of caregiving burden, with caregivers experiencing none-to-mild burden (Zarit-12 score 0-10) showing a 25.0% likelihood of depression, while those with high burden (Zarit-12 score >20) showed an 83.9% likelihood of depression (p<0.001).
The bivariate correlation analysis of PHQ-9 and Zarit-12 scores showed moderate positive correlation with Spearman’s rho = 0.544 (p<0.001).

3.6. Independent Factors of Depression

Female gender was independently associated with a higher likelihood of depression (OR 2.50, 95% CI 1.30-4.80, p=0.006). Caregiving frequency was also significant, with caregivers providing care for less than 8 hours daily (OR 4.21, 95% CI 1.69-10.49, p=0.002) and those not providing daily care (OR 3.76, 95% CI 1.51-9.35, p=0.004) being more likely to experience depression compared to those providing more than 8 hours of daily care. Caregiving burden was also a strong predictor of depression. Those with mild-to-moderate burden had an OR of 6.18 (95% CI 2.94-13.00, p<0.001), and those with high burden had an OR of 22.75 (95% CI 8.75-59.13, p<0.001), compared to those with none-to-mild burden. Other factors such as age, marital status, professional status, and monthly income did not show significant associations in this model. The model explained 46.4% of the variance in the likelihood of depression (R² = 0.464). For detailed statistical values and further associations, refer to Table 6.

4. Discussion.

4.1. Summary of Findings

This study aimed to explore the prevalence and factors associated with depression among caregivers of geriatric patients in Jeddah, Saudi Arabia, highlighting the relevance of understanding caregiver burden and its impact on mental health. The study involved 269 participants, with an average age of 32 years, balanced gender distribution, and the majority being single (63.6%). Caregivers were primarily sons or daughters (49.4%) of the patients, with 65.1% providing care for over six months. Most caregivers (60.6%) provided daily care, and 58.7% lived with the patient. Shared caregiving duties were common (81.4%), and only 25.7% had financial responsibility for the patient. Based on the PHQ-9 scale, the most frequent depressive symptoms were tiredness or low energy and difficulty sleeping. The overall prevalence of depression (PHQ-9 score ≥10) was 45.4% (95% CI: 39.3, 51.5%). Caregiving burden assessed using the ZBI-12 scale indicated that 20.8% of caregivers experienced high burden, while 22.7% reported mild to moderate burden. The most concerning items were the feelings of needing to do more and having taken better care of the relative. While several factors were associated with higher depression likelihood the multivariate model identified female gender, caregiving frequency, and burden as independent predictors, explaining 46.4% of the variance in depression likelihood. Notably, caregiving frequency showed a paradoxical finding where caregivers providing care for less than 8 hours daily or not providing daily care had a higher likelihood of depression compared to those providing care for more than 8 hours daily.

4.2. The burden of Care: Depression and Caregiving

The prevalence of depression among caregivers of geriatric patients is a significant concern that has been extensively studied in various contexts. Studies have consistently shown that caregiving can lead to depression among caregivers, with some research indicating that approximately 52% of caregivers of geriatric patients had depression scores that warranted further evaluation [23]. This aligns with our findings showing a prevalence of 45.4% with a 95% CI of 39.3 to 51.5%. Furthermore, depression is highlighted as one of the most common psychological consequences of caregiving, affecting caregivers of patients with severe mental illness and dementia [24]. Caregivers of individuals with chronic illnesses like dementia, cancer, or heart failure are at increased risk of experiencing emotional distress and burnout [5,6,7]. The emotional impact of caregiving, combined with managing the care recipient's health, can contribute to caregivers' psychological strain and affect their quality of life [25].
The present study showed that caregiving burden is an independent factor for depression, with bivariate analysis showing a positive relationship between the two scores. The analysis of Zarit-12 scale score indicates that 43.5% of the caregivers are likely to experience significant caregiver burden, i.e. moderate or high scores. Caregiver burden encompasses the physical, emotional, social, and financial stressors faced by individuals providing care to impaired or ill individuals, resulting in an imbalance between caregiving demands and personal resources [26]. Assessing this burden is relevant as it influences the potential need for patient institutionalization [8].
Consistent with our findings, research indicates a substantial impact of caregiving burden on mental health. Caregiver burden has been linked to adverse psychological outcomes, such as depression and anxiety [27,28]. Persistent burden predicts depressive symptoms in dementia caregivers, underscoring the long-term impact on mental health [29]. Additionally, caregiver burden correlates with symptoms of depression and anxiety and is associated with poorer physical and psychological health outcomes, including increased stress and reduced quality of life [30,31].
Additionally, caregiver burden can compromise caregivers' overall well-being, impacting their ability to provide effective care [32]. Such effect extends across various caregiving contexts, such as caring for individuals with cancer, Parkinson's disease, and other chronic conditions [33,34]. We observed that the most concerning aspects of caregiving among the participants were feelings of needing to do more and regret for not having taken better care of their relative. These perceptions may indicate a lack of personal resources or conflict between caregiving duties and the caregivers' own needs. Additionally, given the relatively young age of the participants, such perceptions may relate to a lack of preparedness for caregiving or inadequate social support. Indeed, caregiver burden can interact with factors like preparedness for caregiving and social connectedness to impact caregivers' health-related quality of life and psychological well-being [28,35]. Caregivers lacking support, resources, and coping mechanisms may experience elevated burden, leading to negative health outcomes for both the caregiver and the care recipient [36]. Seeking social support, building self-efficacy, and interventions focusing on enhancing emotional intelligence and resilience are beneficial for caregivers' psychological well-being [25,37]. Further interventions proposed to alleviate caregiver burden include educational training programs and mindfulness interventions, aiming to reduce strain on caregivers and enhance their overall well-being [38,39].
In sum, caregiver burden is a multifaceted issue with significant implications for the health and well-being of caregivers and care recipients. Understanding the factors contributing to caregiver burden and implementing support strategies are crucial for promoting caregivers' overall well-being and ensuring quality care for those in need of assistance.

4.3. Other Factors of Depression

Factors contributing to depression among caregivers of geriatric patients are also multidimensional and can be categorized into caregiver- and care recipient-related factors. Among caregiver-related factors, younger age, female gender, single status, being student, and having low income were all associated with higher depression scores in the present study. However, only female gender remained significant in the adjusted analysis. In line with these findings, female caregivers, lower education levels, and lower perceived social support have been linked to higher levels of caregiver depression [40]. These factors may have a differential impact depending on the care recipient’s condition. For example, caregivers of patients with dementia have been found to experience higher levels of depression, with female caregivers often exhibiting significantly higher depression scores compared to male caregivers [41]. The emphasis on female gender is consistent with our findings, which show that female caregivers incur the highest risk of depression, as demonstrated in the adjusted analysis. On the other hand, social support was not investigated in the present study, although it constitutes a critical factor for caregiver’s mental health. Research showed that social support and the caregiver's perceived control over their lives can impact their risk of depression. Caregivers who experience social isolation, reduced control over their lives, and fear of inadequacy are at higher risk of depression [42]. This is likely consistent with our findings that show that sole caregivers and those living in the same household as the patient exhibit higher depression scores, although the analysis was not statistically significant. These findings highlight the importance of adequate social support and social connections in preventing depression among caregivers and mitigating eventual depressive symptoms.
On the other hand, we observed a paradoxical finding where caregivers dedicating more than 8 hours daily to caregiving experienced the lowest risk of depression compared to those who provided care less frequently, including those who did not provide care daily. This suggests that caregiving burden in the studied population is likely influenced by other factors, possibly cultural and spiritual. Muslim caregivers often draw strength and guidance from their faith, incorporating Islamic principles into their caregiving practices. The doctrine of Allah and adherence to religious rituals provide comfort, resilience, and a sense of purpose, influencing their emotional well-being and coping strategies [43]. These beliefs and practices not only shape the caregivers' approach to providing care but also influence their emotional well-being and coping strategies in the face of the challenges associated with caregiving. This dimension may explain why, in highly dedicated caregivers, the levels of depression are significantly lower, as the levels of dedication may correlate with higher spiritual value for caregiving. This relationship may relate to the dimension of preparedness for caregiving and social connectedness and their positive impact on caregivers' psychological well-being [28,35].
Although not explored in the present study, patient-related factors, including the type and severity of the patient's condition, cognitive impairment, and behavioral disturbances, also contribute to caregiver depression. Indeed, the burden of caregiving is more substantial when coupled with the challenges of caring for individuals with cognitive impairments, resulting in increased levels of depression among caregivers [44]. Caregivers of dementia patients, in particular, face challenges related to the care recipients' cognitive impairments, which can heighten burden and reduce caregivers' well-being [39]. The severity of patients' cognitive impairment is associated with increased levels of caregiver burden, emphasizing the relationship between patient condition and caregiver well-being [45]. The presence of chronic illness in elderly patients has also been identified as a risk factor for depression among caregivers [46]. Furthermore, caregivers of patients near the end of life, including those with dementia, have been found to experience high levels of anxiety and depression, underscoring the emotional toll of end-of-life care [47].

4.4. Implications for Action

The high prevalence of depression among caregivers of geriatric patients has significant public health implications, placing a considerable burden on healthcare resources and affecting the well-being of caregivers. Addressing this issue is crucial for improving the overall quality of care and societal well-being. Effective strategies should focus on providing mental health support, such as counseling and support groups, to alleviate the psychological strain on caregivers. Additionally, implementing respite care programs can offer temporary relief, reducing caregiver burnout. Respite care can take various forms, including in-home respite, short-term institutionalization, or adult day care, allowing caregivers a break from their caregiving responsibilities [48]. Studies have shown that respite care can effectively suppress caregiver burden, providing caregivers with much-needed relief from their caregiving duties [49,50]. Hence, respite care allows caregivers to engage in self-care activities, reducing stress and improving their quality of life. Additionally, in the context of Saudi Arabia, such programs would be more acceptable culturally than complete institutionalization.
Culturally sensitive interventions that build on Islamic values and practices can enhance the acceptability and effectiveness of these strategies within the community. Incorporating religious principles and rituals into caregiving support programs can provide caregivers with spiritual comfort, resilience, and a sense of purpose. Educational training programs tailored to the cultural context can further support caregivers in managing their burden [51,52].
Virtual education programs, such as the one evaluated by [53], have been effective in enhancing caregiver confidence and self-efficacy, demonstrating the potential of technology in delivering educational support. Moreover, the study by Parmar et al. (2022) emphasizes the importance of optimizing the integration of family caregivers in person-centered care through educational programs for the healthcare workforce [54].
By understanding and addressing the multifaceted nature of caregiver burden and the related factors and cultural dimensions, we can develop comprehensive support systems that promote caregivers' mental health and well-being. These initiatives not only benefit caregivers but also improve the quality of care provided to geriatric patients, ultimately contributing to a healthier and more resilient society.

4.5. Limitations

This study has several limitations that should be acknowledged. First, the cross-sectional design limits the ability to establish causality between caregiver burden and depression. Longitudinal studies are needed to explore the temporal relationship between these variables. Second, the use of self-reported questionnaires for assessing depression and caregiver burden may introduce response bias, as participants might underreport or overreport their symptoms and experiences. Third, the snowball sampling technique might have led to selection bias, as the initial participants and their networks may not be representative of the broader population of caregivers. Fourth, the study was conducted at a single hospital in Jeddah, Saudi Arabia, which may limit the generalizability of the findings to other regions and healthcare settings. Additionally, cultural factors specific to Saudi Arabia may influence caregiving experiences and the prevalence of depression, making it difficult to generalize the results to other cultural contexts. Lastly, the study did not consider care recipients' demographic and clinical factors, which have valuable implications for caregiver burden and the risk of depression.

5. Conclusions

This study highlights the significant prevalence of depression among caregivers of geriatric patients in Jeddah, Saudi Arabia, and emphasizes the crucial impact of caregiving burden on mental health. The findings reveal that younger age, female gender, single status, being a student, and low income are associated with higher depression scores among caregivers. Caregiving burden, as measured by the ZBI-12, is a strong predictor of depression, underscoring the need for effective support systems for caregivers.
Addressing these challenges aligns with the goals of Saudi Vision 2030, which emphasizes longevity and healthiness among the population. Targeted interventions such as mental health support, respite care programs, and culturally sensitive educational training are essential to mitigate caregiver burden and improve mental health outcomes. These strategies can help enhance the overall quality of care provided to geriatric patients, contributing to a more efficient healthcare system and reducing economic burdens.
By developing comprehensive support systems that consider the unique needs and cultural contexts of caregivers, we can promote their well-being and ensure better outcomes for both caregivers and the geriatric population they serve. Future research should focus on longitudinal studies to better understand the causal relationships and explore the effectiveness of various interventions in reducing caregiver burden and associated depression. This approach will not only support the caregivers but also contribute significantly to the broader goals of Saudi Vision 2030, fostering a healthier, more resilient society.

Author Contributions

Conceptualization, M.A.A ( Mohamemd A Aljunaid ); methodology, R.M.A ( Rayan Mesfer Alosaimi ); software, E.A.A ( Essa Ahmed Alazmi ); validation, H.H.A( Hosam Husain Alzobaidi ),; formal analysis, M.A.A.; investigation, A.A.A ( Ahmad Abdulaziz Afandi ); resources, R.M.A.; data curation, M.T.M ( Mohammed Talal Musslem ); writing—original draft preparation, M.M.A ( Mohammed Mohsen Aljarameez ); writing—review and editing, M.A.A; visualization, A.A.A; supervision, M.A.A; project administration, H.H.A; funding acquisition, E.A.A. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was ethically approved by the institutional review board of University of Jeddah (#UJ-REC-147).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Data for this study is available upon reasonable request from the first author.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Krieger, T., Specht, R., Errens, B., Hagen, U., Dorant, E. Caring for family caregivers of geriatric patients: results of a participatory health research project on actual state and needs of hospital-based care professionals. Int J Environ Res Public Health, 2020;17:5901. [CrossRef]
  2. Kondeti, A., Yadala, A., Rajya Lakshmi, N., Prakash, C., Palat, G., Varthya S. Assessment of caregiving burden of family caregivers of advanced cancer patients and their satisfaction with the dedicated inpatient palliative care provided to their patients: a cross-sectional study from a tertiary care centre in South Asia. Asian Pac J Cancer Prev, 2021;22: pp. 2109–15. [CrossRef]
  3. Roij, J., Brom, L., Sommeijer, D., Poll-Franse, L., Raijmakers, N. Self-care, resilience, and caregiver burden in relatives of patients with advanced cancer: Results from the EQUIPE study. Supportive Care Cancer, 2021;29:pp. 7975–84. [CrossRef]
  4. Bonne, S. Social care is medical care. JAMA Surg 2023;158:953. [CrossRef]
  5. Chen, K.H., Wells, J.L., Otero, M.C., Lwi, S.J., Haase, C.M., Levenson, R.W. Greater experience of negative non-target emotions by patients with neurodegenerative diseases is related to lower emotional well-being in caregivers. Dement Geriatr Cogn Disord, 2017;44:245–55. [CrossRef]
  6. Kajiwara, K., Kako, J., Noto, H., Oosono, Y., Kobayashi, M. Response to the article “Informal caregivers in stroke: Life impact, support, and psychological well-being—A Swedish Stroke Register (Riksstroke) study.” Int J Stroke, 2019;14: pp. NP1. [CrossRef]
  7. Settineri, S., Frisone, F., Alibrandi, A., Merlo, E. Vulnerability and physical well-being of caregivers: what relationship? J Mind Med Sci, 201. pp. 95–102. [CrossRef]
  8. Riedijk, S., Vugt, M., Duivenvoorden, H., Niermeijer, M., Swieten, J., Verhey, F., et al. Caregiver burden, health-related quality of life and coping in dementia caregivers: A comparison of frontotemporal dementia and Alzheimer’s disease. Dement Geriatr Cogn Disord 2006;22: pp. 405–12. [CrossRef]
  9. Al-Senani, F., Al-Johani, M., Salawati, M., Alhazzani, A., Morgenstern, L., Ravest, V., et al. An epidemiological model for first stroke in Saudi Arabia. J Stroke Cerebrovasc Dis, 2020;29:104465. [CrossRef]
  10. Alfaris, N. Management of obesity in Saudi Arabia during the era of COVID-19: a clash of two pandemics. Obesity, 2020;29:pp. 18. [CrossRef]
  11. Da’ar O, El-Metwally A, Abu-Saris R, Jazieh A. A finite and stable exponential growth-adjusted indirect cost of cancer associated with discounted years of life lost in Saudi Arabia. Heliyon 2018;4:e00637. [CrossRef]
  12. Alqahtani, J. Prevalence, incidence, morbidity and mortality rates of COPD in Saudi Arabia: trends in burden of COPD from 1990 to 2019. PLoS One, 2022;17:e0268772. [CrossRef]
  13. Qian, J. The prevalence, disability-adjusted life years, and mortality of hypertensive heart disease and its attributable risk factors: results from the global burden disease study 2019. Arch Med Sci, 2023;19: pp. 1186–200. [CrossRef]
  14. Wang, X., Bu, X., Wei, L., Liu, J., Yang, D., Mann, D., et al. Global, regional, and national burden of myocarditis from 1990 to 2017: a systematic analysis based on the global burden of disease study 2017. Front Cardiovasc Med, 2021;8:692990. [CrossRef]
  15. Zhang, J., Lu, Y., Zhang, N., Yu, Z., Li, H., He, R., et al. Global burden of female breast cancer and its association with socioeconomic development status, 1990–2044. Cancer Rep, 2023;6. [CrossRef]
  16. Alharbi, R., Alnagar, D.K. Forecasting life expectancy at birth using time series and Holt’s method in Saudi Arabia according to Saudi Vision 2030. Adv Appl Stat, 2022;79: pp.121–130. [CrossRef]
  17. Wirayuda, A.A.B., Al-Mahrezi, A., Chan, M.F. Comparing life expectancy determinants between Saudi Arabia and United Arab Emirates from 1980–2020. Eur J Investig Health Psychol Educ, 2023;13: pp. 1293–305. [CrossRef]
  18. Levis B, Benedetti A, Thombs BD. Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis. BMJ 2019:l1476. [CrossRef]
  19. Costantini, L., Pasquarella, C., Odone, A., Colucci, M.E., Costanza, A., Serafini, G., et al. Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): A systematic review. J Affect Disord, 2021;279: pp. 473–483. [CrossRef]
  20. Bédard, M., Molloy, D.W., Squire. L., Dubois. S., Lever, J.A., O’Donnell, M. The Zarit Burden interview: A new short version and screening version. The Gerontologist, 2001;41: pp. 652–657. [CrossRef]
  21. Gratão, A.C.M., Brigola, A.G., Ottaviani, A.C., Luchesi, B.M., Souza, É.N., Rossetti, E.S., et al. Brief version of Zarit Burden Interview (ZBI) for burden assessment in older caregivers. Dement Neuropsychol, 2019;13: pp. 122–129. [CrossRef]
  22. Rajabi-Mashhadi, M.T., Mashhadinejad, H., Ebrahimzadeh, M.H., Golhasani-Keshtan, F., Ebrahimi, H., Zarei, Z. The Zarit Caregiver Burden Interview Short Form (ZBI-12) in spouses of Veterans with Chronic Spinal Cord Injury, Validity and Reliability of the Persian Version. Arch Bone Jt Surg, 2015;3: pp. 56–63.
  23. Chen, C. Y., Chen, J. H., Ree, S. C., Chen, C. H., & Yu, S. H. Attributional styles are associated with care burden in geriatric depression: older adults and their caregivers in Taiwan. Aging Clin Exp Res, 2024;36: pp. 106. [CrossRef]
  24. Sun, X., Ge, J., Meng, H., Chen, Z., Liu, D. The influence of social support and care burden on depression among caregivers of patients with severe mental illness in rural areas of Sichuan, China. Int J Environ Res Public Health, 2019;16: pp. 1961. [CrossRef]
  25. Okeke, B.O. Social support seeking and self-efficacy-building strategies in enhancing the emotional well-being of informal HIV/AIDS caregivers in Ibadan, Oyo state, Nigeria. SAHARA-J, 2016;13: pp. 35–40. [CrossRef]
  26. van Roij, J., Brom, L., Sommeijer, D., van de Poll-Franse, L., Raijmakers, N., & eQuiPe study group. Self-care, resilience, and caregiver burden in relatives of patients with advanced cancer: results from the eQuiPe study. Supportive Care Cancer, 2021;29: pp. 7975–7984. [CrossRef]
  27. Ehsan, N., Johar, N., Saleem, T., Khan, M.A., Ghauri, S. Negative repercussions of caregiving burden: Poor psychological well-being and depression. Pak J Med Sci, 2018;34: pp. 1452-1456. [CrossRef]
  28. Yuen, E.Y.N., Wilson, C.J. The relationship between cancer caregiver burden and psychological outcomes: the moderating role of social connectedness. Curr Oncol, 2021;29: pp. 14–26. [CrossRef]
  29. Liang, X., Guo, Q., Luo, J., Li, F., Ding, D., Zhao, Q., et al. Anxiety and depression symptoms among caregivers of care-recipients with subjective cognitive decline and cognitive impairment. BMC Neurol 2016;16: pp. 191. [CrossRef]
  30. Johnston, E. A., Goodwin, B. C., Myers, L., March, S., Aitken, J. F., Chambers, et al. Support-seeking by cancer caregivers living in rural Australia. Aust N Z J Public Health 2022;46: pp. 850–857. [CrossRef]
  31. Özkan Tuncay, F., Kars Fertelli, T. Effects of the caregiver burden perceived by caregivers of patients with neurological disorders on caregiver wellbeing and caregiver stress. Perspect Psychiatr Care, 2019;55: pp. 697–702. [CrossRef]
  32. Johnston, E. A., Collins, K. E., Vicario, J. N., Sibthorpe, C., Ireland, M. J., Goodwin, B. C. Changes in rural caregivers’ health behaviors while supporting someone with cancer: A qualitative study. Cancer Med, 2024;13. [CrossRef]
  33. van Hienen, M. M., Contarino, M. F., Middelkoop, H. A. M., van Hilten, J. J., Geraedts, V. J. Effect of deep brain stimulation on caregivers of patients with Parkinson’s disease: A systematic review. Parkinsonism Relat Disord, 2020;81: pp. 20–27. [CrossRef]
  34. Conroy, É., Kennedy, P., Heverin, M., Leroi, I., Mayberry, E., Beelen, A., et al. Informal caregivers in amyotrophic lateral sclerosis: a multi-centre, exploratory study of burden and difficulties. Brain Sci, 2021;11:1094. [CrossRef]
  35. Onu, D.U., Orjiakor, C.T., Onyedire, N.G., Amazue, L.O., Allison, T.J. Preparedness for caregiving moderates the association between burden and health-related quality of life among family caregivers of stroke patients in Nigeria. S Afr J Psychol, 2022;52: pp. 338–50. [CrossRef]
  36. Khanal, B., Chalise, H.N. Caregiver burden among informal caregivers of rural older persons in Nepal. J Health Care and Research, 2020;1: pp. 149–156. [CrossRef]
  37. Nasim, B., Kausar, S., Zaheer, S., Bashir, A., Fareed, S. Demographic characteristics, stress and emotion regulation in the caregivers of elderly hemodialysis patients. JHRR, 2024;4: pp. 1055–1061. [CrossRef]
  38. Abdelzaher, E., Elakkad, R., Rohaiem, S., Abdellah, A., Hamza, S. Caring for geriatric dementia patients in Egypt: The effect of an educational training program for caregivers. EJGG, 2022;9: pp. 11–9. [CrossRef]
  39. Sánchez-Pérez, A., Mendialdua-Canales, D., Hurtado-Pomares, M., Peral-Gómez, P., Juárez-Leal, I., Espinosa-Sempere, C., et al. The ATENción Plena en Enfermedad de Alzheimer (ATENEA—Mindfulness in Alzheimer’s Disease) Program for Caregivers: Study Protocol for a Randomized Controlled Trial. Healthcare, 2022;10: pp. 542. [CrossRef]
  40. Baider, L., Goldzweig, G., Jacobs, J.M., Ghrayeb, I.M., Sapir, E., Rottenberg, Y. Informal caregivers of older Muslims diagnosed with cancer: A portrait of depression, social support, and faith. Palliat Support Care, 2021;19: pp. 598–604. [CrossRef]
  41. Pöysti, M.M., Laakkonen, M.L., Strandberg, T., Savikko, N., Tilvis, R.S., Eloniemi-Sulkava, U., et al. Gender differences in dementia spousal caregiving. Int J Alzheimers Dis, 2012;2012:1–5. [CrossRef]
  42. Alqahtani, M.S., Alshbriqe, A.A., Awwadh, A.A., Alyami, T.A., Alshomrani, M.S., Alhazzani, A. Prevalence and risk factors for depression among caregivers of Alzheimer’s disease patients in Saudi Arabia. Neurol Res Int, 2018; 2018: pp. 1–7. [CrossRef]
  43. Seephom, S., Jittanoon, P., Balthip, K. Muslim caregivers’ experiences in caring for patients receiving peritoneal dialysis. J Ren Care, 2023;49: pp. 6–14. [CrossRef]
  44. Gaugler, J.E., Mittelman, M.S., Hepburn, K., Newcomer, R. Clinically significant changes in burden and depression among dementia caregivers following nursing home admission. BMC Med, 2010;8: pp. 85. [CrossRef]
  45. Black, C.M., Ritchie, C.W., Khandker, R.K., Wood, R., Jones, E., Hu, X., et al. Non-professional caregiver burden is associated with the severity of patients’ cognitive impairment. PLoS One, 2018;13:e0204110. [CrossRef]
  46. Cong, L., Dou, P., Chen, D., Cai, L. Depression and associated factors in the elderly cadres in Fuzhou, China: A community-based study. Int J Gerontol, 2015;9: pp. 29–33. [CrossRef]
  47. Padayachey, U., Ramlall, S., Chipps, J. Depression in older adults: prevalence and risk factors in a primary health care sample. SAFP, 2017;59: pp. 61–6. [CrossRef]
  48. Gaugler, J.E., Jutkowitz, E., Shippee, T.P., Brasure, M. Consistency of dementia caregiver intervention classification: an evidence-based synthesis. Int Psychogeriatr, 2017;29: pp. 19–30. [CrossRef]
  49. Lopez–Anuarbe, M., Kohli, P. Understanding male caregivers’ emotional, financial, and physical burden in the United States. Healthcare, 2019;7: pp. 72. [CrossRef]
  50. Newkirk, L.A., Dao, V.L., Jordan, J.T., Alving, L.I., Davies, H.D., Hewett, L., et al. Factors associated with supportive care service use among California Alzheimer’s disease patients and their caregivers. J Alzheimer’s Dis, 2020;73: pp. 77–86. [CrossRef]
  51. Mirhosseini, S., Hosseini Nezhad, F.S., Haji Mohammad Rahim, A., Basirinezhad, M.H., Bakhshiarab, A., Saeedi, M., et al. Care burden and the predictive role of spiritual well-being and religious coping: A cross sectional study among Iranian family caregivers of patients with stroke. Health Sci Rep, 2024; pp. 7. [CrossRef]
  52. O’Callaghan, C., Seah, D., Clayton, J.M., Welz, M., Kissane, D.W., Georgousopoulou, E., et al. Palliative caregivers’ spirituality, views about spiritual care, and associations with spiritual well-being: a mixed methods study. Am J Hosp Palliat Care, 2020;37: pp. 305–313. [CrossRef]
  53. Noel, M.A., Lackey, E., Labi, V., Bouldin, E.D. Efficacy of a virtual education program for family caregivers of persons living with dementia. J Alzheimer’s Dis, 2022;86: pp. 1667–1678. [CrossRef]
  54. Parmar, J.K., L’Heureux, T., Anderson, S., Duggleby, W., Pollard, C., Poole, L., et al. Optimizing the integration of family caregivers in the delivery of person-centered care: evaluation of an educational program for the healthcare workforce. BMC Health Serv Res, 2022;22:364. [CrossRef]
Table 1. Participants’ characteristics (n=269).
Table 1. Participants’ characteristics (n=269).
Parameter Level Mean SD
Age (years) 31.96 15.01
Range 12 77
Parameter Level Frequency Percentage
Gender Male 132 49.1
Female 137 50.9
Marital status Single 171 63.6
Married 80 29.7
Divorced 13 4.8
Widowed 5 1.9
Education level Uneducated 3 1.1
Secondary school 57 21.2
College (not graduated) 82 30.5
Bachelor's 104 38.7
Post-graduate 23 8.6
Professional status Employed 81 30.1
Student 113 42.0
Retired 30 11.2
Unemployed 45 16.7
Monthly income <3K SAR 89 33.1
3K-6K SAR 51 19.0
6K-10K SAR 53 19.7
>10K SAR 76 28.3
Table 2. Caregiving Parameters.
Table 2. Caregiving Parameters.
Parameter Level Frequency Percentage
Relationship to the patient Son / Daughter 133 49.4
Brother / Sister 43 16.0
Spouse 10 3.7
Father / Mother 4 1.5
Grandparent 23 8.6
Grandchild 20 7.4
Other 30 11.2
Not mentioned 6 2.2
Caregiving frequency >8 hours daily 59 21.9
<8 hours daily 104 38.7
Not daily 106 39.4
Same habitat with the patient No 111 41.3
Yes 158 58.7
Caregiving mode In alternance 219 81.4
Sole caregiver 50 18.6
Financial responsibility No 200 74.3
Yes 69 25.7
Caregiving duration Less than 6 months 94 34.9
More than 6 months 175 65.1
Table 3. Answers to the Patient Health Questionnaire-9 Items (PHQ-9) scale.
Table 3. Answers to the Patient Health Questionnaire-9 Items (PHQ-9) scale.
Item Never A Few Times Sometimes Always Mean (SD)
Losing interest or pleasure in doing things 86 (32.0) 89 (33.1) 77 (28.6) 17 (6.3) 2.09 (0.92)
Feeling sad or unhappy 107 (39.8) 73 (27.1) 72 (26.8) 17 (6.3) 2.00 (0.96)
Difficulty sleeping or staying asleep 91 (33.8) 54 (20.1) 87 (32.3) 37 (13.8) 2.26 (1.07)
Feeling tired or having little energy 70 (26.0) 72 (26.8) 87 (32.3) 40 (14.9) 2.36 (1.03)
Poor appetite or overeating 115 (42.8) 65 (24.2) 62 (23.0) 27 (10.0) 2.00 (1.03)
Feeling bad about yourself or that you are a failure 143 (53.2) 59 (21.9) 41 (15.2) 26 (9.7) 1.81 (1.02)
Trouble concentrating 102 (37.9) 84 (31.2) 59 (21.9) 24 (8.9) 2.02 (0.98)
Moving or speaking so slowly or the opposite – being so fidgety or restless 151 (56.1) 54 (20.1) 50 (18.6) 14 (5.2) 1.73 (0.94)
Feeling as though life isn’t worth living 170 (63.2) 41 (15.2) 38 (14.1) 20 (7.4) 1.66 (0.98)
Cronbach’s alpha = 0.890.
Table 4. Answers to the Short Form Zarit Burden Interview (ZBI-12) scale.
Table 4. Answers to the Short Form Zarit Burden Interview (ZBI-12) scale.
Item Never Rarely Sometimes Often Almost Always Mean (SD)
Do you feel that because of the time you spend with your relative, you do not have enough time for yourself? 117 (43.5) 57 (21.2) 70 (26.0) 21 (7.8) 4 (1.5) 2.03 (1.07)
Do you feel conflicted and stressed between worrying about your relative and other duties such as your job or family? 111 (41.3) 59 (21.9) 64 (23.8) 27 (10.0) 8 (3.0) 2.12 (1.15)
Do you feel angry when you are near your relative? 154 (57.2) 50 (18.6) 46 (17.1) 13 (4.8) 6 (2.2) 1.76 (1.04)
Do you feel that your relative negatively affects your relationships with other family members? 154 (57.2) 44 (16.4) 41 (15.2) 27 (10.0) 3 (1.1) 1.81 (1.09)
Do you feel tense towards your relative? 149 (55.4) 48 (17.8) 47 (17.5) 21 (7.8) 4 (1.5) 1.82 (1.07)
Do you feel that you do not have enough privacy because of your relative? 154 (57.2) 55 (20.4) 35 (13.0) 22 (8.2) 3 (1.1) 1.75 (1.04)
Do you feel that your health has been affected after taking part in caring for your relative? 172 (63.9) 38 (14.1) 43 (16.0) 12 (4.5) 4 (1.5) 1.65 (1.00)
Do you feel that your social life has been harmed because of your relative? 148 (55.0) 46 (17.1) 42 (15.6) 23 (8.6) 10 (3.7) 1.89 (1.17)
Do you feel that you have lost control of your life since your relative became ill? 159 (59.1) 49 (18.2) 38 (14.1) 17 (6.3) 6 (2.2) 1.74 (1.06)
Do you feel unsure about the proper treatment for your relative? 142 (52.8) 53 (19.7) 47 (17.5) 24 (8.9) 3 (1.1) 1.86 (1.07)
Do you feel that you need to do more for your relative? 85 (31.6) 59 (21.9) 63 (23.4) 31 (11.5) 31 (11.5) 2.49 (1.35)
Do you feel that you could have taken better care of your relative? 89 (33.1) 52 (19.3) 59 (21.9) 45 (16.7) 24 (8.9) 2.49 (1.34)
Values are frequencies (percentages); Cronbach’s alpha = 0.912.
Table 5. Factors associated with likelihood of depression indicated by PHQ-p score ≥10.
Table 5. Factors associated with likelihood of depression indicated by PHQ-p score ≥10.
Factor Level Depression Status p-Value
No (PHQ-9 Score <10) Yes (PHQ-9 Score >=10)
Age (mean, SD) 35.37 15.33 27.84 13.58 <0.001*§
Gender Male 87 65.9 45 34.1
Female 60 43.8 77 56.2 <0.001*
Marital status Single 76 44.4 95 55.6
Married 59 73.8 21 26.3
Divorced 9 69.2 4 30.8
Widowed 3 60.0 2 40.0 <0.001*
Education level Uneducated 2 66.7 1 33.3
Secondary 30 52.6 27 47.4
College 42 51.2 40 48.8
Bachelor's 55 52.9 49 47.1
Post-graduate 18 78.3 5 21.7 0.202
Professional status Employed 53 65.4 28 34.6
Student 46 40.7 67 59.3
Retired 22 73.3 8 26.7
Unemployed 26 57.8 19 42.2 0.001*
Monthly income <3K SAR 39 43.8 50 56.2
3K-6K SAR 22 43.1 29 56.9
6K-10K SAR 31 58.5 22 41.5
>10K SAR 55 72.4 21 27.6 0.001*
Relationship to the patient Son / Daughter 80 60.2 53 39.8
Brother / Sister 16 37.2 27 62.8
Spouse 4 40.0 6 60.0
Father / Mother 3 75.0 1 25.0
Grandparent 15 65.2 8 34.8
Grandchild 10 50.0 10 50.0
Other 17 56.7 13 43.3
Not mentioned 2 33.3 4 66.7 0.148
Caregiving frequency >8 hours daily 40 67.8 19 32.2
<8 hours daily 48 46.2 56 53.8
Not daily 59 55.7 47 44.3 0.028*
Same habitat with the patient No 68 61.3 43 38.7
Yes 79 50.0 79 50.0 0.068
Caregiving mode In alternance 123 56.2 96 43.8
Sole caregiver 24 48.0 26 52.0 0.295
Financial responsibility No 105 52.5 95 47.5
Yes 42 60.9 27 39.1 0.229
Caregiving duration < 6 months 50 53.2 44 46.8
>6 months 97 55.4 78 44.6 0.725
Caregiving burden (ZBI-12 score) None-to-mild (0-10) 114 75.0 38 25.0
Mild-to-moderate (10-20) 24 39.3 37 60.7
High (>20) 9 16.1 47 83.9 <0.001*
Test used: § independent t-test; otherwise, chi square test was used. * Statistically significant result (p<0.05).
Table 6. Independent factors of depression indicated by PHQ-p score ≥10 (multivariate regression model).
Table 6. Independent factors of depression indicated by PHQ-p score ≥10 (multivariate regression model).
Predictor Level OR 95%CI p-value
Age (mean, SD) 0.97 0.94 1.00 0.089
Gender Female 2.50 1.30 4.80 0.006*
Marital status Single § Ref - - 0.314
Married 0.39 0.14 1.10 0.075
Divorced 0.47 0.08 2.76 0.406
Widowed § 1.50 0.15 15.17 0.730
Professional status Employed Ref - - 0.794
Student § 1.35 0.51 3.55 0.541
Retired 1.76 0.49 6.26 0.386
Unemployed § 1.19 0.42 3.33 0.742
Monthly income <3K SAR 0.97 0.39 2.39 0.945
3K-6K SAR 2.43 0.95 6.23 0.064
6K-10K SAR 1.37 0.53 3.53 0.518
>10K SAR Ref - - 0.194
Caregiving frequency >8 hours daily Ref - - 0.006*
<8 hours daily 4.21 1.69 10.49 0.002*
Not daily 3.76 1.51 9.35 0.004*
Caregiving burden (ZBI-12 score) None-to-mild (0-10) Ref - - <0.001*
Mild-to-moderate (10-20) 6.18 2.94 13.00 <0.001*
High (>20) 22.75 8.75 59.13 <0.001*
§ These categories were analyzed as dummy variables in another model, but showed no significance. The model explained 46.4% of the variance of the outcome variable (R2 = 0.464).
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