Examining the relations between psychosocial and caregiving factors with mental health among Vietnamese family caregivers of hospitalized lung cancer patients

Our study identified high levels of mental health concerns, especially mild-to-severe depression and anxiety symptoms among family caregivers for lung cancer patients in Vietnam. Notably, approximately one in ten caregivers reported moderate-to-severe levels of depression or anxiety, indicating a potential need for mental health services. Factors associated with lower risk of mental health concerns included stronger psychosocial conditions (e.g., higher quality of life and greater social support). Conversely, more challenging caregiving characteristics, such as heavier caregiving burden and higher preparedness were linked to a higher risk. Interestingly, readiness for future surrogate decision-making did not show a statistically significant association with mental health concerns. We also conducted an additional analysis to identify factors associated with the need for mental health services, aiming to prioritize those most in need of intervention. These findings mirrored those associated with mental health concerns (see Supplemental Table 1).

A high prevalence of mental health concerns was observed among family caregivers, with 36.6% reporting mild-to-severe symptoms of depression or anxiety. This is more than double the percentage observed among caregivers for a broader range of cancers in Vietnam (16.5%)¹⁶, emphasizing the greater challenges faced by lung cancer caregivers^6,7, with about two-thirds of our study participants receiving palliative care. Our findings align with a previous study in China showing that 45.4% of caregivers for advanced non-small cell lung cancer patients reported slight to extreme anxiety or depression symptoms³⁸. We also observed substantial prevalences of mild-to-severe depression (29.2%) and mild-to-severe anxiety (27.4%), which are notably higher than those reported in another Chinese study (at 19.2%)¹². However, our findings are comparable to a study of advanced lung cancer caregivers, which exhibited depression and anxiety prevalence of 32.6% and 25.5%, respectively³⁹. These findings suggest that lung cancer caregivers may need more attention with mental health screening and mental health services to help ameliorate the impact of caregiving on their well-being.

Of particular concern is the fact that approximately 10% of caregivers in our study exhibited moderate-to-severe symptoms that meet the threshold for mental health services, with 6.6% needing support for depression and 8.9% for anxiety. Our study findings are higher than those found in a similar study among lung cancer caregivers in China, which reported 5.5% of participants who were diagnosed with depression and required treatment¹². This discrepancy may be attributed to differing definitions of the need for mental health services as well as the ongoing impacts of COVID-19, as the previous study population was evaluated prior to the pandemic. This data again underscores the need for more mental health support services integrated into lung cancer care system. Routine mental health assessments during hospital visits, caregiver support groups, and readily accessible counseling services are essential to reduce the mental health burden on caregivers and improve their overall well-being.

Among all demographic characteristics, only being female was included in the multivariable model, which revealed a positive association with depression. Earlier investigations support this outcome^3,40,41. Particularly, a systematic review reported that female caregivers were significantly more likely to experience depression compared to male caregivers (57.6% vs. 34.4%, respectively)³. A prior study indicated that genetic, biological and environmental factors contribute to this disparity⁴². In our study, most lung cancer patients were male (77.4%), and within Vietnamese culture,​ women or wives are typically responsible for the care of their ill family members⁴³.​ This caregiving role is expected regardless of the patient’s sex, with women often serving as the primary providers at the bedside during illness⁴³. This responsibility likely increases their risk for depression. Using the Stress-Appraisal Model, Swinkels et al. suggested the interaction between caregiver sex and caregiving burden⁴⁴. However, the inclusion of the interaction term in our final model did not yield significant results. These findings highlight the need for further research into specific stressors that may be unique to female caregivers, which can help guide specific interventions for this population.

Lung cancer caregivers experiencing better quality of life reported lower mental health concerns in our study. Multiple studies demonstrated the negative association between mental health concerns and quality of life^40,45,46. When caregivers have a higher quality of life—meaning they experience satisfaction, fulfillment, and overall well-being—it acts as a buffer against these mental health challenges. A prior study also showed that a decade-long improvement in wellbeing reduced the risk of mental illness, whereas declines in wellbeing increased that risk⁴⁷. Additionally, we found that caregivers with greater social support from friends reported fewer anxiety symptoms, likely due to their ability to share experiences related to a family member’s cancer diagnosis, understand the treatment process, and access cancer resources⁴⁸. Strong social connections are crucial for lung cancer caregivers, as such support can significantly reduce caregiving burden and enhance coping abilities, ultimately leading to a higher quality of life and lower mental health concerns⁴⁸. Conversely, caregivers lacking adequate social support often experience heightened levels of anxiety, depression, and distress⁴⁹. Hence, improving caregivers’ quality of life and strengthening social support networks should be prioritized in public health strategies in Vietnam.

It is interesting that in this study, greater caregiving preparedness was associated with a higher likelihood of reporting mild-to-severe depression. Our subgroup analysis revealed similar findings across various groups, including male caregivers, caregivers with a caregiving duration of > 8 h per day, and caregivers of advanced lung cancer patients. This finding contradicts existing literature⁵⁰, which suggests that when caregivers feel adequately equipped to handle their responsibilities, it generally leads to lower stress, healthier coping strategies, reduced burden, and more positive health-related behaviors. One possible explanation is that greater caregiving preparedness may increase caregivers’ awareness of caregiving challenges and demands⁵¹, along with perceived competency (e.g., knowledge, skills, and ability to perform tasks)⁵². This awareness can make caregivers more attuned to the complexities and emotional toll of the role, which could contribute to heightened stress and anxiety. In many Asian cultures, those who are well prepared are often chosen for caregiving roles. There is also a cultural norm that “it is better to care for someone than being taken care of,” which drives family caregivers to their best efforts⁵³. This dynamic could explain why even well-prepared caregivers reported higher mental health concerns, highlighting the need for further qualitative research to explore this phenomenon.

Additionally, we found that caregivers with higher caregiving burden were more likely to report mental health concerns. When caregivers face increased demands for physical care, emotional support, and appointment scheduling—it can take a toll on their mental health⁵⁴. Once these demands exceed their available resources, caregivers feel overwhelmed and report elevated stress levels⁵⁵, which negatively affect their mental health. However, as our study is cross-sectional, we cannot determine if caregiving burden causes mental health concerns, or vice versa. Longitudinal studies are needed to establish causality and track changes over time. Despite this limitation, our findings emphasize the need for interventions to reduce caregiver burden and improve mental health. Hence, the expansion of family assistance programs—such as in-home nursing, home care services, and respite care —for cancer patients are essential, especially since most existing programs in Vietnam primarily focus on the elderly⁵⁶. Previous studies have demonstrated the effectiveness of these programs for both patients and caregivers^50,57. By focusing interventions on reducing caregiving burdens through family assistance programs and mental health services, we can enhance caregiver well-being and in turn, improve the quality of care they provide.

We found no statistical association between readiness for future surrogate decision-making and mental health concerns. In Western contexts, there is a strong emphasis on patient-centered care, and research has demonstrated that effective and transparent communication between health professionals and patients is crucial for ensuring high-quality care delivery⁵⁸. However, in Vietnam, healthcare decisions, including diagnoses and treatments, are predominantly determined by the recommendations of healthcare providers, even when they involve costly procedures or services at all levels of care⁵⁹. Therefore, the lack of association between readiness for surrogate decision-making and mental health concerns suggests that enhancing family involvement in decision-making might not directly address caregivers’ mental health issues. Given caregiver’s critical role in medical decision making and care for cancer patients in Vietnam⁹, it is still beneficial to engage families in these processes to help them navigate the healthcare system more effectively. Although a change from paternal decision making to patient-centered care requires a cultural shift in the way medicine is practiced in Vietnam, this approach could further mitigate caregiver stress and improve overall mental health outcomes.

Previous studies have identified significant associations between patients’ characteristics (e.g., gender, treatment method, metastatic stage)^3,41, caregivers’ characteristics (e.g., age, education, and relationship with patients)^18,40,41, and caregiving characteristics (e.g., during of caregiving)⁴⁰ with mental health concerns. Such associations among these covariates were not found in the adjusted model in our study, possibly due to reliance on self-reported treatment information from the caregivers. Further research, including use of the medical records, is needed to assess the impact of these variables on mental health concerns among family caregivers of lung cancer patients in LMICs.

Our findings are highly relevant to other LMICs with similar healthcare constraints and collectivist culture, where family caregivers often face significant mental health challenges due to a lack of formalized support systems⁶⁰. Much like Vietnam, other LMICs (e.g., Cambodia) also experienced limited access to mental health services and rely heavily on family caregivers for cancer care, especially in rural areas⁶¹. The high caregiving burden, coupled with limited resources, can significantly impact caregivers’ mental well-being, leaving them vulnerable to anxiety and depression. Thus, integrating mental health support services for caregivers into cancer care systems is crucial in LMICs.

Study limitations

This study is subject to certain limitations. First, cross-sectional design is a primary limitation, as it precludes the establishment of causality between psychosocial and caregiving factors and mental health outcomes. Future research employing longitudinal designs is crucial to determine the temporal course of caregiving-related mental health, including its persistence and potential for change. Second, data collection was restricted to a single provincial hospital in a predominantly rural area and focused on family caregivers, which may limit the generalizability of the findings to other urban oncological settings and other types of caregivers (e.g., formal/paid caregivers) in Vietnam. Additionally, approximately 4% of caregivers (about 10 participants) declined to participate due to patients being discharged at the time of the survey. Despite these limitations, the results provide valuable exploratory insights into caregiving experiences and their association with mental health concerns in this specific setting. Third, while standardized scales (e.g., caregiving burden, preparedness for caregiving, and family decision-making self-efficacy) were utilized for the first time in Vietnam and demonstrated high internal consistency, further factor analyses are needed to confirm their validity. Furthermore, self-reported measures used to assess mental health, caregiving burden and preparedness are subject to social desirability bias or distress levels. While data collectors with medical background and research experience were instructed to ensure participant comfort, future studies should consider objective measures and clinical observations to improve data validity. Finally, previous studies have shown the relationship between chronic conditions, physical health issues, and other social determinants of health^62,63 on mental health among caregivers of cancer patients. However, we did not collect these factors, which may limit our understanding of their combined impact on caregiver mental health. Accounting for these factors would enhance the accuracy and comprehensiveness of the findings.

Clinical implications

High prevalence of mental health concerns in this study highlights the urgent need for mental health support for family caregivers of lung cancer patients, including routine mental health screenings, accessible counseling, and caregiver support groups integrated into the lung cancer care system. These measures will ensure that mental health support becomes a fundamental component of cancer care. Additionally, caregivers with higher caregiving burdens reported more mental health concerns, suggesting that programs such as in-home nursing, home care services, and respite care can ameliorate the caregiving burden, which, in turn, improves mental health outcomes for family caregivers. Hospital policies should be modified to better support caregivers by integrating these support systems into the cancer care framework, offering caregiver training programs, creating supportive infrastructure, and advocating financial assistance. Recognizing caregivers as integral parts of the cancer care team will enhance their mental health and overall well-being.