Dissertations and Theses

Date of Degree

6-5-2025

Document Type

Dissertation

Degree Name

Doctor of Philosophy (Ph.D.)

Department

Community Health and Social Sciences

Advisor(s)

Victoria Khanh Ngo, PhD

Committee Members

Sasha Fleary, PhD

Glen Johnson, PhD

Subject Categories

Epidemiology | International Public Health | Mental and Social Health | Psychiatric and Mental Health | Public Health | Research Methods in Life Sciences

Keywords

Depression, Anxiety, Resilience, Quality of life, Family caregivers, Cancer patients, Low-income settings, Vietnam

Abstract

Background: In high-income countries, cancer patients typically receive care from a dedicated bedside team. However, in low- and middle-income countries (LMICs), caregiving is primarily a family responsibility, deeply influenced by collectivism and filial piety. Family members often provide extensive support, including physical, mental, social, financial, and surrogate decision-making. Lung cancer represents one of the greatest health burdens in LMICs, where limited healthcare resources further amplify the strain on family caregivers. However, little is known about the impact of caregiving-related stressors on mental health and factors that promote emotional well-being, particularly in LMICs. To address this gap, we conducted a 3-part study on family caregivers of hospitalized lung cancer patients in Vietnam to examine the interrelationships between caregiving and psychosocial factors that impact caregiver’s emotional well-being. The aims of the study are to: (Aim 1) examine caregiver’s mental health concerns (depression and anxiety) and their associations with caregiving and psychosocial factors; (Aim 2) assess resilience and its associated factors; and (Aim 3) explore the role of resilience in mediating the relationship between depressive symptoms and quality of life to identify potential mechanisms of change.

Methods: We conducted a cross-sectional study at a provincial general hospital’s oncology center. By using consecutive sampling, we recruited 213 family caregivers and data was collected on emotional well-being (depression, anxiety, and resilience), psychosocial factors (quality of life and social support) and caregiving factors (burden, preparedness for caregiving, and surrogate decision-making). Using the same dataset, we applied Poisson regression with robust error variance (modified Poisson) and multivariable linear regression models to evaluate factors associated with mental health concerns (including depression and anxiety - Aim 1) and resilience (Aim 2), respectively. Additionally, structural equation modeling and bootstrap method were employed to further evaluate the mediating effects of resilience on the relationship between depressive symptoms and quality of life (Aim 3).

Results: Among the 213 family caregivers, the majority were aged 40 or older (80%), with 68% being female. Over half (62.4%) had less than a high school education, and 48.8% worked as farmers. Most reported an income less than US $197 per month (57.8%), significantly lower than the national average income of approximately US $323. Over 83% were spouse/partner or children, underscoring the familial responsibility they shouldered. In contrast, the lung cancer patients were predominantly senior adults (81.2% from 60-72 years old). Over three-quarters (77.5%) were male, and 56.8% were in an advanced stage of lung cancer (stages III and IV), with 47.9% receiving medication for palliative care.

Our findings indicate that 36.6% of family caregivers experienced mild-to-severe depression or anxiety, while 50.2% reported low resilience. Higher caregiving burden and lower quality of life were linked to a higher likelihood of mental health concerns. Female caregivers and those with better preparedness for caregiving had a higher probability of mild-to-severe depression, whereas greater social support from friends was associated with a lower probability of mild-to-severe anxiety. Factors linked to better resilience included higher preparedness for caregiving, improved quality of life, greater social support from family, and, notably, higher caregiving burden. In contrast, longer hospital stays and greater depression severity were associated with lower resilience. Readiness for surrogate decision-making was not significantly related to mental health concerns or resilience.

Caregivers reported a lower quality of life compared to the general Vietnamese population, with only 27.2% expressing good or very good overall life satisfaction and contentment. Quality of life was significantly associated with sociodemographic factors, including age, sex, education, employment status, income, and relationship to the patient (all p< 0.01). In adjusted models, depressive symptoms was negatively associated with quality of life, whereas resilience was positively linked to better quality of life. Resilience partially mediated the relationship between depressive symptoms and quality of life, accounting for 15.5% of the total effect.

Conclusions: Family caregivers of lung cancer patients in this cohort exhibited high mental health concerns, low resilience, and low quality of life. To more effectively support cancer patients, it is important to address mental health needs associated with caregiving burden and support preparedness for caregiving, particularly for caregivers supporting patients with long hospital stays. Furthermore, given the direct and indirect influence of resilience on the relationship between depression and quality of life, a dual focus on both mental health screening and resilience promotion may mitigate the negative impacts of depression on quality of life. Longitudinal data is necessary to evaluate the causal relationship between these factors, and qualitative data is needed to better understand how caregiving dynamics influence mental health, given the positive association between better preparedness for caregiving and higher mental health concerns, and higher caregiving burden and higher resilience.

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