A community-based cross-sectional study on stressors and gender differences in coping strategies among primary caregivers of cardiovascular disease in the capital city of India, New Delhi

Introduction

Cardiovascular diseases (CVD) have emerged as the leading cause of morbidity and mortality globally. These diseases alone account for 32% (17.9 million) of global deaths worldwide.1 In India, according to the Global Burden of Disease study conducted in 2015, the standard cardiovascular disease death rate is estimated to be 272 per one lakh population, which is higher than the global average of 235 per lakh population.2 The impact of these diseases goes beyond mortality rates as they often follow a chronic course, presenting their own set of significant challenges. As per National family Health Survey (NFHS-5), around every 4^th individual aged 15 years or above (26.6% among men and 23.6% among women) has elevated blood pressure (Systolic ≥140 mm of Hg and/or Diastolic ≥90 mm of Hg) or taking medicine to control blood pressure (%).3

In such chronic conditions, it is observed that most families tend to take care of their impaired relatives at home rather than at the institute.4 Providing home care for these chronic illnesses adds to various responsibilities of the caregivers-financial, physical, emotional, or social. These responsibilities strained over a longer period, manifest as stressors.4

Stressors are defined as “the conditions, experiences, and activities that are problematic to people, that is, that threaten them, thwart their efforts, fatigue them, and defeat their dreams”. These stressors impact the physical, social, and psychological life of caregivers, resulting in poor physical health, social isolation, increased stress and burden, and affect the quality of life of caregivers.5 These stressors, if not coped up effectively; over a prolonged duration, lead to different mental adverse outcomes such as depression and anxiety. Stressors can be categorized into two distinct types: primary stressors and secondary stressors. Primary stressors are the ones that initiate subsequent processes and predominantly originate from the patient's requirements and the nature and extent of care necessitated by these requirements. It is believed that the responsibilities of caregiving can, in turn, give rise to additional issues referred to as secondary stressors. These are stressors that arise from the caregiver's deep involvement in the long-term care of the patient.4

Research has shown that different individuals adopt different ways to cope with similar stressors. These physiological responses developed by caregivers to handle the stressors are called ‘coping”. Coping has been defined as “constantly changing cognitive and behavioral efforts to manage the specific external or internal demands that are appraised as taxing or exceeding the resources of the person.”6, 7

Coping strategies can be broadly classified into two categories: problem-focused coping and emotion-focused coping.6, 8 These categories serve as a framework for understanding how individuals respond to and manage stressors. Problem-focused coping strategies involve activities such as problem-solving, planning, and seeking information or advice to address the stressor directly. On the other hand, emotion-focused coping strategies focus on managing and regulating emotional responses to stressors. Rather than tackling the stressor itself, these strategies aim to reduce the negative emotional impact it has on the individual. Examples of emotion-focused coping strategies include seeking emotional support from others, expressing emotions through communication or writing, engaging in relaxation techniques, or participating in activities that provide emotional comfort.

Research suggests that there may be gender differences in the utilization of coping strategies to deal with stressors. Previous studies have explored these gender differences and found variations in preferred coping strategies.9, 10, 11, 12

In this study, we aim to explore how coping strategies differ based on the gender of the caregiver. Understanding and addressing these differences can help tailor support and interventions to the specific needs of women and men caregivers.

Materials and Methods

A community-based cross-sectional study was conducted for a duration of one year in the rural area of Palam in Delhi. The study protocol of this research was approved by the Institutional Ethics Committee before the commencement of the study.

The study focused on caregivers of individuals with CVD. The inclusion criteria for the caregiver of individuals with cardiovascular disease were: Age to be over 18 years old, of either gender, needed to be a family member of the individual with cardiovascular disease, and should have been providing care for more than 3 months

The sample size was determined based on the calculation using the lowest prevalence of stressors in primary caregivers, which was reported as 40%13 in a previous study. A 95% confidence level and a 5% allowable error were considered in the sample size calculation. The sample size to include caregivers in this study was calculated to be 384.

Results

Out of the total 384 caregivers who were included in the study, stressors were found in 347 caregivers. Out of them, the primary stressor was observed in 82.6% of caregivers, while the secondary stressor was identified in 79.4% of caregivers.

These 347 individuals were then further assessed for various coping strategies employed by them to handle the stressors. Among primary caregivers, the proportion of women (58%) was more than men (42%).

Coping strategies

Coping strategies employed by individuals in the context described were categorized into problem-focused and emotion-focused strategies and were studied under eight coping strategies based on the Ways of coping (WOC) Questionnaire developed by Folkman and Lazarus (Figure 1).

Figure 1

Gender-wise distribution of coping strategies among primary caregivers with stressors of caregiving (N=347)

Among all strategies, planful problem-solving (85.9%) was found to be the most commonly preferred coping strategy. The high percentage suggests that a large majority of individuals actively engaged in problem-solving behaviors to manage the situation. Though this strategy was found to be slightly more in women (87%) as compared to men (84.2%), no statistically significant association was found (p = 0.457). (Table 2)

Table 2

Gender-wise distribution of coping strategies among primary caregivers with stressors of caregiving (N=347)

Coping strategies			Gender (N=347)				Total		p-value
			Men n=146	% 42%	Women N = 201	% 58%	Total N= 347	% 100%
Problem-Oriented Coping Strategies
1.	Confrontive coping	Present	86	59	93	46.3	179	51.6	0.02
		Not Present	60	41	108	53.7	168	48.4
2.	Planful problem solving	Present	123	84.2	175	87	298	85.9	0.457
		Not Present	23	15.8	26	13	49	14.1
Emotion focussed Coping Strategies
3.	Accepting responsibility	Present	105	72	164	81.6	269	77.5	0.033
		Not Present	41	28	37	18.4	78	22.5
4.	Positive appraisal	Present	80	54.8	133	66.2	213	61.4	0.032
		Not Present	66	45.2	68	33.8	134	38.6
5.	Distancing	Present	43	29.5	83	41.3	126	36.3	0.024
		Not Present	103	70.5	118	58.7	221	63.7
6.	Self-controlling	Present	90	61.6	149	74.1	239	68.9	0.013
		Not Present	56	38.4	52	25.9	108	31.1
7.	Escape Avoidance	Present	49	33.6	81	40.3	130	37.5	0.201
		Not Present	97	66.4	120	59.7	217	62.5
Both problem and emotion-focused strategies
8.	Seeking social support	Present	76	52	129	64.2	205	59	0.023
		Not Present	70	48	72	35.8	142	41

Among problem-focused coping strategies, a significant portion of caregivers (51.6%) also employed confrontive coping strategies to tackle the problem head-on by communicating with the patient and establishing boundaries. In addition, men caregivers (59%) reported using confrontation coping more frequently compared to women caregivers (46.3%). The difference was found to be statistically significant (p = 0.02).

While assessing emotion-focused coping strategies, accepting responsibility (77.5%), self-controlling (68.9%), and positive appraisal strategy (61.4%) were found to be the most commonly adopted coping strategies focused on managing emotions amidst challenges. These above three strategies were more likely to be adopted by women as compared to men caregivers with differences being statistically significant. (Accepting responsibility: p = 0.033, self-controlling: p = 0.013, positive appraisal: 0.032).

Escape avoidance (37.4%) and distancing (36.3%) were also found to be other emotion-focused strategies employed by primary caregivers. There was no significant difference in the use of escape avoidance between men caregivers (33.6%) and women caregivers (40.3%) (p = 0.201) while distancing (p = 0.024) was found to be significantly higher among women caregivers.

Seeking social support, for both problem as well as emotional coping, employed by 59% of individuals, highlights the importance of seeking help, guidance, and understanding from others during challenging times. Women caregivers were more likely to seek social support compared to men caregivers. The difference was statistically significant (p = 0.023).

This study suggests that there were gender differences in the utilization of specific coping strategies among caregivers, with variations in confrontive coping, accepting responsibility, positive appraisal, distancing, self-control, and seeking social support.

Discussion

Coping strategies are diverse and adaptable to the array of stressors they confront. From Folkman and Lazarus' Ways of Coping Questionnaire (as referenced in our study and Mataud, 2004);17 Charles Carver and colleagues' COPE (Coping Orientation of Problem Experience), documented in the Kelly et al. (2012)18 and Melendez et al (2012);19 Coping strategy scale (CSS) and perceived stress (PSS) employed in Tamares et al. (2002),20 coping strategies are broadly divided into two core categories based on the intention and function of coping efforts, i.e., emotion-focused and problem-solving.

In our study, we found that planful problem-solving strategies (85.9%) were the most adopted coping strategy among primary caregivers, irrespective of their gender. This is consistent with metanalysis conducted by Tamares et al (2002)20 and a study conducted on the elderly by Melendez et al (2012)19 where no evidence was found that problem-solving had gender association. The high percentage of use of this strategy suggests that a large majority of individuals actively engaged in problem-solving behaviours to manage the situation. For both men and women caregivers, promoting planful problem-solving coping strategies can be beneficial. Our study also did not find a gender association, it is still important to encourage and support caregivers in developing effective problem-solving skills. This can include providing education on problem-solving techniques i.e., organizing workshops, online resources, or educational materials specifically tailored for caregivers., or joining support groups can provide them with a platform to share experiences, exchange ideas, and learn from others who are going through similar situations for practical advice on problem-solving. Other problem-solving strategies such as - making caregivers aware of available resources like helplines, caregiver support centres, or government health facilities, where they can seek assistance or guidance.

Among other problem-oriented coping strategies, our study findings suggest that men caregivers reported using confrontive coping more frequently than their women counterparts. (p-value: 0.02). Indeed, numerous studies such as Endler et al. (1990)21 and Mataud et al. (2004),17 Ptacek et al. (1994)22 also revealed that men tend to rely more on problem-focused or instrumental approaches when dealing with stressful situations. While our study found high use of planful problem-solving strategies among caregivers, it is worth considering the potential role of Confrontive coping strategies in certain situations. These strategies aim to address the underlying issue head-on rather than avoiding or evading it. In the context of caregiving, there might be situations where confrontive coping strategies could be useful. For example, if a caregiver is facing challenges with inadequate support from family members or external services, assertively expressing their needs and advocating for additional assistance may be necessary. This can involve open communication, assertive discussions, or even seeking external support to address the specific issue.

Caregiving can be emotionally challenging, and caregivers often experience a range of emotions such as stress, anxiety, sadness, and guilt. Emotion-focused coping strategies play a crucial role in helping caregivers effectively manage and regulate these emotions. In our study, we observed notable gender differences in the utilization of emotion-focused coping strategies. Women caregivers exhibited a higher tendency for emotion-focused coping strategies such as accepting responsibility and engaging in positive appraisal. Conversely, women caregivers were more likely to employ distancing as a coping mechanism and demonstrated higher levels of self-control. These findings of a higher prevalence of emotion-focused coping strategies among women caregivers are consistent with findings from previous studies conducted by Sinha et al. (2018),23 Lam et al (2015),24 Kelly et al. (2008),18 Mataud et al. (2004),17 Tamres et al. (2002)20 (meta-analysis), Rose and Rudolph (2006) (review),25 Endler et al. (1990)21 and Ptacek et al. (1994).22 These metanalyses indicate that starting from early developmental stages, certain strategies are commonly observed in women.

Socialization and expectations differ with gender within many societies. Women are often socialized to be more attuned to emotions and encouraged to express their feelings openly. They may be more comfortable seeking emotional support from others and utilizing strategies such as talking about their emotions, seeking validation, or engaging in self-care activities to cope with stress whereas men are expected to face the situations head-on and be assertive in their decisions. This might be the reason for the observed difference among the coping strategies adopted by men and women caregivers.

Though emotion-focused strategies are needed to channel the emotions a caregiver goes through during the process of caregiving, these coping strategies must be associated with positive outcomes. These emotion-focused strategies should promote the well-being or quality of life of caregivers, and not worsen them. E.g., employing strategies such as humor, praying, and meditation may be associated with positive outcomes and others such as drinking/ smoking can be associated with adverse effects on the health of caregivers.

In this context, support groups and healthcare providers play a crucial role. Maintaining open communication with caregivers, assessing their needs, and providing assistance in managing emotions can ensure that emotion-focused coping strategies are adopted in a healthier manner.17 It is worth noting that our study also identified that women caregivers tended to employ distancing as a coping mechanism, suggesting a need for emotional space or detachment from the demands of caregiving. Healthcare providers should support women caregivers in using this coping strategy effectively, striking a balance between involvement and emotional self-preservation.

Addressing the mental health aspects of caregiving is vital in the planning and implementation of national mental health services. Establishing health-promoting information desks for patients and their caregivers after hospital discharge can serve as a crucial link in facilitating stress-free caregiving. Similarly, primordial prevention of stress-related risk factors in families affected by health conditions can be achieved through screening and counseling of vulnerable family members.

In the context of seeking social support as a coping strategy that encompasses both problem-solving and emotion-focused approaches, a notable gender difference was observed in our study. Men caregivers demonstrated a lower likelihood of seeking social support compared to women caregivers, indicating that women may be more inclined to seek assistance and emotional support from others. Similar findings were also found in studies conducted by Lam et al (2015),24 Sinha et al. (2018)23 and Melendez et al (2102).19 To address this gender disparity and promote support for all caregivers, it is important to implement measures that facilitate social support within the community. One effective approach is the establishment of social support networks, such as community groups and societies, where caregivers can come together and share their coping experiences. These platforms provide opportunities for caregivers to connect with others who may be facing similar challenges, offering a sense of camaraderie and understanding. Additionally, organizing participatory events or meetings within the living community can contribute to reducing the stressors associated with caregiving. By fostering a supportive community environment, we can encourage men caregivers to actively seek social support and benefit from the shared experiences and insights of their peers. As a community, it is our responsibility to ensure that these support groups are inclusive and welcoming to all caregivers, regardless of gender. By actively promoting the importance of social support and creating supportive environments, we can help alleviate the burden of caregiving and enhance the well-being of all caregivers.

Conclusion

In conclusion, when it comes to coping strategies among caregivers, there are variations observed between genders. Caregiving responsibilities, particularly in the context of cardiovascular diseases, can have a significant impact on caregivers' well-being and mental health. By understanding the unique challenges faced by male and female caregivers, tailored interventions and coping strategies can be developed to meet their specific needs. This may involve providing access to support groups, counselling services, and education on self-care practices. By implementing gender-sensitive approaches, we can better support caregivers and help them navigate the challenges of caregiving.

Source of Funding

Nil.

Conflict of Interest

Nil.