Breast cancer is a worldwide public health burden [1, 2], and the second in death cases among Jordanians after cardiovascular diseases [3]. The role of the caregivers is very demanding and affects their mental and physical well-being [4]. Case-control studies revealed the devastating effect of work stress on mental health, especially depression, among caregivers [5, 6]. Caregiving for the vulnerable elderly has been described as a stressful phase that can lead to a lack of mental and physical health of caregivers [7]. Several studies demonstrated a variety of stressors that caregiver health and QOL are affected by, including social, mental functioning, or physical health [8, 9] and behaviors such as reduced exercise or rest and ignoring themselves while working with those patients with breast cancer [9].

Some other studies also revealed that the rate of depression among caregivers of cancer

patients were greater than that of the general population [6, 8, 9]. Moreover, they reported that cancer care can lead to an increase in the risk of sleep disturbances, anxiety, depression, and end with decrements in QOL [6, 10]. A cross-sectional study of psychological distress among cancer patients and their family caregivers revealed that both members developed the same levels of distress [11]. This study aims to estimate the prevalence of depression among caregivers and its impact on the mental and healthy functioning of the caregivers of breast cancer patients in Jordan.

This study was a cross-sectional where a survey was distributed to the Jordanian caregivers of breast cancer patients between May 2019 and September 2019 at King Abdullah University Hospital (KAUH) and King Hussein Medical Center, which are tertiary care facilities in Jordan hosting more than 400 beds each. The sample of the study included a total of 122 (54 females and 68 male) caregivers of breast cancer patients. The study was approved by the institutional review board at the Jordan University of Science and Technology, Irbid-Jordan (Approval number 66/2018). Informed consent has been obtained from the study participants and Helsinki Declaration has been followed for the study. The participants were interviewed after being introduced to the aim of the study and accepted to provide signed informed consent. The study questionnaires included one for sociodemographic information, another, which was the 36 QOL Short Form (SF-36) Scale, and the third one, which was based on Beck’s Depression Inventory (BDI), concerned with evaluating depression status.

The number of breast cancer caregivers who participated in this study was 122 (n=54 females and 68 males. Almost two-thirds of the caregivers’ participants were married (59.8%), without children, and employed (63.1%). Moreover, a high proportion of caregivers finished high school education (46.7%), while merely 3.3% of caregivers were illiterate. Table 1 summarizes the demographic information of the caregivers' participants. The predominance of depression among patients was 27.9%. As shown in Table 2, it is distributed as 21.3% with mild depression, 13.1% with moderate depression, and 8.2% with severe depression.

The reliability, variability of scales, and central tendency of the SF-36 QOL survey among the caregivers were shown in Table 3. Whereas the association between the study variables and the SF-36 QOL subscales was shown in Table 4. An association between the age of the patients and the MH scale was found (P=0.007). A link was found between the marital status of caregivers and the BP (P=0.015), the BDI (P=0.009), and the SF (P=0.008). As well, the siblings’ number of those caregivers was considerably connected with the mental health (P=0.040) subscale. Moreover, the monthly income of caregivers was associated with BP (P=0.042).

The living place or residency of caregivers was noticeably connected with the RF (P=0.013) and RE (P=0.027) subscales. Caregivers’ educational level, profession, and average sleep hours during the day were not associated with any subscale of the SF-36 QOL questionnaire. Regarding the status of depression, having a history of depression among family members was associated with RF(P=0.009), RE (P=0.005), SF (P=0.003), and VT (P=0.001) subscales. Besides, the physical activity of caregivers was connected with the RF (P=0.030), GH (P=0.018), RE (P=0.015), and MH (P=0.003) subscales. As a final point, the BDI-II index displayed a substantial relationship with marital status (P=0.009) as displayed in Table 4.

The current study investigated the level of depression and its association with QOL among breast cancer caregivers in Jordan. In line with the cut-off points of the BDI-II rating scale, which was employed to reveal the level of depression and its severity among the caregivers of breast cancer patients, 27.9% of the participants showed clear depression symptoms. Those participants were categorized as follows: caregivers with mild symptoms of depression (21.3%), caregivers with moderate symptoms of depression (13.1%), and caregivers with severe symptoms of depression (8.2%). Considerably, the symptoms of depression among the participating caregivers were significantly linked to their marital status.

A previous study has revealed that the prevalence of depression among breast cancer caregivers was 24.8%)mild, moderate, and severe) in Iran region [14]. Another study, using a validated instrument, showed that approximately 42% of the caregivers for cancer patients were suffering from depression symptoms. This high level of depression prevalence probably affects the QOL of the caregivers [15, 16]. A systematic review using 19 studies focusing on the needs, intervention, motivation of caregivers, and even the consequences of caregiving [17], revealed that the most important correlations with QOL among caregivers were employment status, income, and the severity of their disease. Moreover, the psychosocial challenges were the most predominant among those caregivers [17-19].

The present study compared patients concerning different age groups with the subscales of the SF-36 scoring system; mental health scores of old caregivers were considerably revealed lower than young caregivers. Studies from the literature have revealed a significant and immediate reduction in mental health status after the caregiver period [5, 20] such as the study from Iran which showed that caregivers of breast cancer women who were also family members reported high effects on their quality of life including high psychological stress directly after diagnosis and the subsequent few months [21]. Results of the present study showed that the caregivers (married, single, or others) had reduced scores in BDI-II and social functioning, while their mean bodily pain scores were considerably higher (P < .015). A new study reported that the most widespread problems of physical nature that were expressed by caregivers involved pain, sleep disturbances, fatigue, loss of appetite, loss of physical strength, loss of physical strength, and weight loss [22].

An Australian study reported the direct physical health impact of caregiving, including back, shoulder, and neck problems, tiredness and exhaustion, weight problems, leg and foot problems, arthritis, and stress-related diseases [23, 24]. Another study by Grbich et al. (2001)identified that caregivers generally reported strain off the legs and back, with constant tiredness feeling from lifting their patients.

The present study revealed that a higher number of siblings tended to be connected with emotional well-being. Other studies indicated that positive relationships between caregivers and patients and family members were critical as caregivers’ burden becomes important during the period of patients with end-life stages [25]. In families that have less conflict and more interconnected relationships, there is less burden on caregivers as the whole family can help each other in taking care of the sick or elderly members. In agreement with that, the relationship between married couples can also affect the burden on caregivers, whereas couples with pleasant relationships have shown minimal depression and reported better health, and felt less restrained [25].

Moreover, current findings showed that the monthly income of caregivers has been associated with bodily pain, and this may be one of the factors that affected the working hours of the caregivers and their income. This was consistent with other many studies that reported the relationship between the family income and breast cancer caregivers. Two studies informed that caregivers generally lost paid jobs or decreased their working hours as a result of the caregiving role [17, 26, 27]. Other studies explored the factors associated with QOL among caregivers of the same family members in Addis Ababa, Ethiopia [28]. They showed that a low income can affect and reduce the QOL of caregivers [28]. This finding is consistent with other studies where low income has a critical effect on caregivers' QOL and their ability to fulfill their demands, provide proper support for sufficient treatment, and access or use proper health facilities [17, 28]. In another study that was carried out in India, it was shown that caregivers are exposed to depressive disorders [29], despite the patients' stable health and low income. Spousal caregivers, who provide financial support for care and who reside with the patient, as well as the burden of household chores besides caring for patients, are most affected in this study [29].

In the current study, it was found that the residence/current location elucidates significant contributions to the domains of role limitation because of physical health and emotional problems. Current findings are consistent with a study that showed that the health subscale score was higher among caregivers who were living in the same city [30]. Moreover, other previous studies showed that the caregivers who lived in the urban area had lower QOL [30, 31]. When the hospital and place of living are in the same city, this may enable the caregiver and the patient to be familiar with the environment, so they receive more social support, spend less money, and thus the economic burden may be reduced, and they may also feel less anxiety [30, 31]. Furthermore, this study revealed a relationship between family history of depression with RF, RE, SF, and VT subscales. A previous study showed that caregivers who have a history of mental illness are more likely to experience severe distress or emotional disturbance [32]. As a result, caregivers are likely to become more susceptible to depression and stress, and to developing mental illness as the illness continues [32]. Another study showed that depression has become popular among patients with cancer and can influence the disease course, diagnosis of the disease, personal relationships, and the quality and lifestyle of the whole family [33]. The present study also found that the physical activity of caregivers related to the RF, GH, RE, and MH. These results are consistent with previous research which reported that in families of caregivers, the direct impact of physical activity on emotional distress and physical QOL of caregivers has an indirect impact on mental QOL [34]. Furthermore, depression problems are frequent among patients with breast cancer, consequently, having the potential to influence the prognosis of patients' disease, personal relations, clinical course, and the QOL of all family members. Depression effects on life quality can inversely function by reducing the patient’s-QOL, besides increasing the chance of prevention of recovery in patients as well as poorer prognosis in cancer patients [35, 36]. This has been shown in previous studies in several cancers including breast [3], colorectal [37], and hematological [38].

The present study might have some limitations since it included only two hospitals in Jordan. Besides, it was only conducted over 5 months. Thus, it might be limited in terms of the interventional and care services information that was provided to the patients. Further studies are recommended to examine several medical centers and can probably focus on more aspects of patients' services and interventions.

The age, number of siblings, marital status, monthly income, place of residence, family history of depression, and physical activity are all having a detrimental impact on the life quality of cancer caregivers from the same family. Those caregivers may benefit significantly from different kinds of support, including mental, financial, and home care services which in turn can enhance their QOL.