
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

39029087
MD-D-23-09998
00089
10.1097/MD.0000000000038910
3
6300
Research Article
Observational Study
Effects of the Internet-based rehabilitation information sharing program on psychological stress of family caregivers of inpatients: A non-randomized controlled study
https://orcid.org/0000-0003-3099-3536
Kozuki Wataru MSc ab*
Higuchi Yumi PhD Higu_reha@omu.ac.jp
c
Ueda Tetsuya PhD ueda@omu.ac.jp
c
Murakami Tatsunori PhD tatsunori_m_1011@yahoo.co.jp
c
Gen Aki MSc akinokirinsou925@yahoo.co.jp
c
a Graduate School of Comprehensive Rehabilitation, Osaka Prefecture University, Habikino, Japan
b Department of Rehabilitation, Tezukayama Rehabilitation Hospital, Osaka, Japan
c Graduate School of Rehabilitation Science, Osaka Metropolitan University, Habikino, Japan.
* Correspondence: Wataru Kozuki, Graduate School of Comprehensive Rehabilitation, Osaka Prefecture University, 3-7-30 Habikino, Habikino, Osaka 583-8555, Japan (e-mail: wataru.k.69@gmail.com).
19 7 2024
19 7 2024
103 29 e3891009 11 2023
20 6 2024
21 6 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

The psychological impact of Internet-based rehabilitation information provision on family caregivers of inpatients has not yet been investigated. This study investigated the impact of the Internet-based rehabilitation information sharing program on anxiety and depression among family caregivers of inpatients. Participants were patients admitted to a rehabilitation hospital and their families. The Internet and Communication Technology (ICT) group received weekly reports with photos and videos showing rehabilitation progress and patients’ activities of daily living, whereas the control group received only conventional care. The primary outcomes were the anxiety and depression scores of family caregivers, assessed at admission, discharge, and 1 month after discharge. Eighty-three participants were followed up (ICT group, n = 43; control group, n = 40). To minimize the impact of confounding factors, propensity-score matching was performed. Significant effects on anxiety (P = .03) and depression (P = .049) were found in the ICT group compared with the control group. The median difference in anxiety scores from discharge to 1 month post-discharge was −1.0 (interquartile range [IQR]: −2.0 to 0.8) in the ICT group versus 1.0 (IQR: −1.0 to 2.0) in the control group. The median difference in depression scores from admission to discharge was 0.5 (IQR: −1.0 to 2.8) in the ICT group and 2.0 (IQR: 1.0–3.8) in the control group. The Internet-based rehabilitation information sharing program may help reduce the family caregivers’ psychological stress, enabling improved patient care.

family caregivers
anxiety
depression
inpatient rehabilitation
internet-based
information sharing
OPEN-ACCESSTRUE
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pmc1. Introduction

Family caregivers of inpatients have been reported to have higher levels of anxiety and depression during hospitalization and immediately after patient discharge.[1,2] Additionally, the prolonged psychological stress in family caregivers has been shown to increase the rate of institutionalization and incidence of abuse of patients.[3,4] Currently, a lack of a supportive environment for patients exists in Japan owing to the low birth rate, aging population, and nuclear family structure.[5] Therefore, not only restoring patients’ function but also providing care and medical instructions by rehabilitation professionals for the various anxiety factors that each family caregiver may have is important.

Numerous studies on family interventions have been published. For instance, one study offering patient-specific care instructions to family caregivers of stroke inpatients documented improvements in anxiety, depression, quality of life (QOL), and caregiver burden.[6] Furthermore, sharing information on the disease and available social resources has been shown to enhance families’ QOL and satisfaction.[7] Additionally, regular telephone consultations were found to alleviate the burden on family caregivers.[8] However, most of these studies involved face-to-face or telephone interventions, which might have been difficult in working families to sustain. Internet-based information provision and family intervention have recently been reported as a sustainable intervention method. Intervention using the Internet and Communication Technology (ICT) by rehabilitation professionals is a feasible approach in families of inpatients who have limited opportunities to meet in person.

The number of ICT-based family intervention studies has been growing, with reports highlighting their effectiveness. For example, one study focusing on educating caregivers about patient care reported reductions in families’ anxiety and depression.[9] Moreover, complex interventions involving peer counseling and professional support have been significantly effective in reducing depressive symptoms among family caregivers.[10] However, most of these studies were interventions in families of patients after discharge from hospitals or patients living in the community; few were conducted including families of inpatients. Murakami et al[11] established a program, namely, the Internet-based rehabilitation information sharing (IRIS) program. The IRIS program provided rehabilitation information (such as progress in activities of daily living, ADL) on inpatients and enabled interactive communication with family caregivers using a Social Networking Service dedicated to medical and nursing care. Interventions using this program resulted in significant improvements in the ADL of patients. Such interventions during hospitalization may have a positive effect on the psychological stress in family caregivers. However, no studies have assessed or examined the effects of the IRIS program. Therefore, in this study, we aimed to examine the effects of the IRIS program on family caregivers’ anxiety and depression.

2. Methods

2.1. Design and subjects

This non-randomized controlled trial was conducted at a rehabilitation hospital in Osaka, Japan. Patients admitted to the hospital between October 2021 and December 2022 who signed the informed consent forms for the study were included. Patients who had been institutionalized prior to admission, discharged to places other than home, or transferred to another hospital were excluded from the study.

The included patients and their families were asked to fill out a questionnaire and informed about the scope of the information to be provided using ICT in the study. The participants who agreed to answer the questionnaire and requested the IRIS program were assigned to the ICT group. On the other hand, the participants who agreed to answer the questionnaire but did not request the IRIS program were allocated to the control group.

Explanation forms for the IRIS program were distributed to all participants, and posters were displayed in the corridors of the hospital wards. The description included the email address of the principal researcher. Family caregivers expressed their willingness to participate in the study via email. Assignment to the ICT group was determined by obtaining consent within 2 weeks after admission.

This study was approved by the Research Ethics Committee of the Graduate School of Comprehensive Rehabilitation, Osaka Prefecture University (Approval No. 2020-111). The participants, including patients and families, were provided an explanation about the study orally and in writing; their consent was obtained.

2.2. Procedures

In the ICT group, the IRIS program was started as soon as possible after enrollment was completed and maintained until discharge in addition to conventional care. The IRIS program was conducted by physical therapists; related information was provided to the family caregivers after confirming the appropriateness of the program. Family caregivers received information with photos and videos showing rehabilitation progress and ADL at least once a week. The information included photos and videos of patients undergoing standing and walking exercises during physical therapy, ADL exercises during occupational therapy, and examination of patients with higher brain dysfunction during speech–language therapy, according to the disease and physical functions. In the caregivers of patients who required assistance, instructional videos on how to assist them were provided. In addition, the families were encouraged to ask questions regarding rehabilitation. An overview of the IRIS program is shown in Figure 1.

Figure 1. Overview diagram of the Internet-based rehabilitation information sharing (IRIS) program.

Medical Care Station (Embrace Co., Ltd., Chiyoda, Tokyo, Japan) was used to provide information on the IRIS program. Medical Care Station has an approval system to restrict the members who can send and read messages, enabling the responsible person to manage group members.

In the control group, information on the progress of rehabilitation and ADL of the patients was provided to the families via conventional care processes (e.g., direct involvement in conferences). Questions and consultations from family caregivers were accepted during hospital visits.

2.3. Measurement

The assessments were conducted 3 times: at admission, discharge, and 1 month after discharge. The questionnaires, including questions pertaining to outcome and demographic data, were administered to family caregivers face-to-face or via mail.

The primary outcome was the Hospital Anxiety and Depression Scale (HADS) score, which is used to evaluate anxiety and depression.[12] The HADS is a 14-item instrument, with 7 items each for measuring anxiety and depression. Each subscale score ranges between 0 and 21, with high scores indicating high levels of anxiety and depression. Cutoff points were proposed to assess both subscales: 0 to 7, normal; 8 to 10, doubtful; and 11 or more, clinical problems.

QOL was evaluated as a secondary outcome using the SF-8 questionnaire,[13] which is a short version of the SF-36, a health-related QOL scale. Based on the scoring rules, 2 summary scores were calculated: Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. The standard national norm for PCS and MCS scores is approximately 50, with a standard deviation of approximately 10. High values indicate high QOL, whereas scores below 50 indicate poorer QOL than that of the national general population.

Demographic data (age, sex, relationship with patients, living with patients or not, work, highest educational status, secondary caregivers, caregiving experience, and physical function) of family caregivers were obtained from medical records and through questionnaire assessments. Physical function was assessed using the Motor Fitness Scale (MFS).[14] The MFS comprised 14 questions that measured motor function, muscle strength, and balancing abilities. The scores ranged between 0 and 14, with high scores indicating high levels of physical function. In addition, demographic data (age, sex, primary disease, comorbidity, onset to hospitalization period, and length of hospital stay) and Functional Independence Measure (FIM) scores of the patients were obtained from medical records. FIM scores at admission and discharge in the patients were assessed by a physical or occupational therapist. Subsequently, motor, cognitive, and total FIM scores were calculated.

2.4. Statistical analysis

The analysis was conducted after addressing missing variables through a single imputation with regression. We compared baseline characteristics and outcomes between the ICT and control groups using chi-square, unpaired t tests, and Mann–Whitney U tests. To mitigate the confounding effects of nonrandom assignment on the psychological outcomes of family caregivers, we computed propensity scores. These scores were based on the presence of ICT intervention as the dependent variable, with covariates including caregiver age, caregiver–patient relationship, caregivers’ highest education level, SF-8 (MCS) score at admission, and patients’ total FIM scores at admission. Propensity-score matching, conducted without replacement using nearest-neighbor matching, created matched study groups with a 0.2 caliper width.

After propensity-score matching, median differences in primary and secondary outcomes were calculated as Δhospitalization (score at admission − score at discharge) and Δafter discharge (score at discharge − score at 1 month after discharge) values. The matched ICT and control groups were compared for each variable by chi-square and Mann–Whitney U tests. Additionally, Hodges–Lehmann (H–L) median differences and corresponding 95% confidence intervals (CIs) were calculated. Finally, to verify the relationship between intervention frequency and its effectiveness, Spearman correlation coefficient was used. All statistical analyses were performed using IBM SPSS Statistics for Windows version 29 (IBM Corp., Armonk, NY, USA). Statistical significance was set at P < .05.

3. Results

Figure 2 shows the flowchart of this study. A total of 176 patients and their family caregivers were enrolled. Initially, 83 and 93 patients were assigned to the ICT and control groups, respectively. Before the discharge assessment, a total of 38 patients were excluded because they were discharged to places other than their homes or transferred to another hospital. Fifty-five participants dropped out between the discharge and follow-up period (22 in the ICT group and 33 in the control group). The only reason for dropout was not responding to the questionnaire. Finally, 83 participants completed the follow-up assessment (43 in the ICT group and 40 in the control group). Significant differences existed between family caregivers who did not respond to the questionnaire and those who completed the study. Family caregivers who were older (P < .01), unemployed (P < .01), and living with the patients (P = .04) were more likely to complete the study. However, there were no significant differences in the dropout rate between the ICT and control groups (P = .25). There were no adverse events, such as information leakage, observed in the conduct of the IRIS program.

Figure 2. Participants flow and follow-up.

Primary diseases in the overall cohort of 83 patients included neurological diseases (total, n = 31; stroke, n = 26; spinal cord disease, n = 5), musculoskeletal diseases (total, n = 45; upper and lower extremity fractures and replacements, n = 36; spinal column and pelvic fractures, n = 8; musculoskeletal instability, n = 1), and disuse syndrome (n = 7). Descriptive data of the patients are summarized in Table 1. The length of hospital stays and FIM (total and motor) scores in the patients significantly differed between the 2 groups. After propensity-score matching, the baseline data of matched ICT and control groups did not differ significantly.

Table 1 Patients’ descriptive data of overall and propensity score-matched cohorts.

	Overall cohort	Propensity-score-matched cohort	
ICT group	Control group	P value	ICT group	Control group	P value	
(n = 43)	(n = 40)	(n = 20)	(n = 20)	
Age (yr), mean ± SD	81.3 ± 11.4	79.1 ± 8.3	.31	85.1 ± 7.6	80.1 ± 8.7	.06	
Sex, female, n (%)	22 (51.2)	15 (37.5)	.21	11 (55.0)	7 (35.0)	.20	
Primary disease, n (%)	
 Neurological disease	17 (39.5)	14 (35.0)	.67	8 (40.0)	6 (30.0)	.51	
 Musculoskeletal disease	22 (51.2)	23 (57.5)	.56	10 (50.0)	12 (60.0)	.53	
 Disuse syndrome	4 (9.3)	3 (7.5)	.77	2 (10.0)	2 (10.0)	>.99	
Comorbidity, n (%)	
 Hypertension	26 (60.5)	22 (55.0)	.61	12 (60.0)	14 (70.0)	.51	
 Orthopedic disease	17 (40.5)	20 (50.0)	.39	9 (45.0)	11 (55.0)	.75	
 Heart disease	11 (25.6)	9 (22.5)	.74	5 (25.0)	5 (25.0)	>.99	
 Diabetes	8 (18.6)	12 (30.0)	.23	3 (15.0)	5 (25.0)	.70	
 Kidney disease	10 (23.3)	3 (7.5)	.07	5 (25.0)	2 (10.0)	.41	
 Lung disease	9 (20.9)	4 (10.0)	.23	5 (25.0)	1 (5.0)	.18	
 Stroke	5 (11.6)	5 (12.5)	>.99	2 (10.0)	2 (10.0)	>.99	
 Visual disability	1 (2.3)	2 (5.0)	.61	1 (5.0)	1 (5.0)	>.99	
Onset to hospitalization (days), mean ± SD	22.4 ± 12.6	25.9 ± 10.4	.17	23.1 ± 13.2	26.7 ± 11.9	.38	
Length of hospital stay (days), mean ± SD	63.5 ± 28.1	50.6 ± 26.3	.03	58.7 ± 21.6	58.1 ± 26.4	.94	
Total FIM (score), mean ± SD	
 Admission	70.3 ± 18.3	83.5 ± 17.2	.01	80.0 ± 16.3	76.3 ± 14.7	.45	
 Discharge	103.1 ± 19.0	112.3 ± 16.0	.02	106.6 ± 18.9	111.4 ± 14.1	.37	
Motor FIM (score), mean ± SD	
 Admission	44.1 ± 14.0	54.9 ± 14.2	<.01	51.4 ± 12.8	50.4 ± 11.4	.81	
 Discharge	73.4 ± 16.0	80.6 ± 13.9	.03	76.0 ± 15.5	80.6 ± 11.0	.29	
Cognitive FIM (score), mean ± SD	
 Admission	26.2 ± 6.7	28.6 ± 6.2	.10	28.7 ± 5.8	25.9 ± 6.7	.17	
 Discharge	29.7 ± 4.6	31.8 ± 5.0	.06	30.6 ± 4.6	30.8 ± 6.0	.91	
Chi-square test, unpaired t test.

FIM = Functional Independence Measure, ICT = Internet and Communication Technology.

In the overall cohort, the 83 family caregivers who participated were spouses (39.8%), daughters (33.7%), sons (13.3%), daughters-in-law (4.8%), and other relatives (8.4%). Descriptive data of family caregivers are listed in Table 2. Significant differences in age, relationship with the patient, employment status, highest educational degree, and SF-8 (MCS) score were present between the groups. The median MCS score was 44.9 (interquartile range [IQR]: 38.4–50.2) in the ICT group and 48.9 (IQR: 43.0–52.7) in the control group. Other family-related primary and secondary outcomes did not differ. After propensity-score matching, no differences in baseline data were found between the 2 groups.

Table 2 Caregivers’ descriptive data of overall and propensity-score-matched cohorts.

	Overall cohort	Propensity-score-matched cohort	
ICT group	Control group	P value	ICT group	Control group	P value	
(n = 43)	(n = 40)	(n = 20)	(n = 20)	
Age (yr), mean ± SD	59.4 ± 12.0	67.2 ± 9.3	.01	66.1 ± 9.7	64.4 ± 9.8	.57	
Sex, female, n (%)	35 (81.4)	27 (67.5)	.15	15 (75.0)	15 (75.0)	>.99	
Relationship with patients, n (%)	
 Spouse	12 (27.9)	21 (52.5)	.02	8 (40.0)	8 (40.0)	>.99	
 Daughter	20 (46.5)	8 (20.0)	.01	6 (30.0)	4 (20.0)	.47	
 Son	6 (14.0)	5 (12.5)	.85	3 (15.0)	4 (20.0)	.68	
 Daughter in law	3 (7.0)	1 (2.5)	.62	2 (10.0)	1 (5.0)	.55	
 Other relative	2 (4.7)	5 (12.5)	.25	1 (5.0)	3 (15.0)	.29	
Living with patient, n (%)	33 (76.7)	24 (60.0)	.10	16 (80.0)	11 (55.0)	.09	
Employment status, n (%)	
 Employment full time	14 (32.6)	9 (22.5)	.31	5 (25.0)	4 (20.0)	.71	
 Employment part time	10 (23.3)	7 (17.5)	.52	2 (10.0)	5 (25.0)	.22	
 Unemployed	7 (16.3)	15 (37.5)	.03	4 (20.0)	6 (30.0)	.47	
 Homemaker	11 (25.6)	9 (22.5)	.74	8 (40.0)	5 (25.0)	.31	
 Other	1 (2.3)	0 (0.0)	>.99	1 (5.0)	0 (0.0)	>.99	
Highest educational status, n (%)	
 ≥Professional or academic university	26 (60.5)	15 (37.5)	.04	10 (50.0)	7 (35.0)	.34	
Secondary caregiver, n (%)	19 (44.2)	12 (30.0)	.18	8 (40.0)	8 (40.0)	>.99	
Care experience, n (%)	16 (37.2)	14 (35.0)	.83	8 (40.0)	5 (25.0)	.31	
MFS (score), median (IQR)	13.0 (10.0, 14.0)	11.0 (7.0, 14.0)	.06	12.5 (7.5, 14.0)	12.5 (7.0, 14.0)	.51	
Chi-square test, unpaired t test, Mann–Whitney U test.

ICT = Internet and Communication Technology, MFS = Motor Fitness Scale.

Median HADS and SF-8 scores of the propensity-score-matched cohort are presented in Table 3. In family caregivers, no significant differences in primary and secondary outcomes at admission, discharge, and 1 month after patient discharge were present. Although no significant intergroup differences in QOL (PCS and MCS scores) were found, the matched control group experienced a slight decrease in QOL (MCS score) compared with the matched ICT group.

Table 3 Primary and secondary outcome scores of propensity-score-matched cohorts of the caregivers.

	Propensity-score-matched cohort	
ICT group	Control group	H–L estimate	P value	
(n = 20)	(n = 20)	(95%CI)	
HADS (anxiety), median (IQR)	
 Admission	6.0	(2.3, 8.8)	6.0	(2.3, 8.8)	0.00 (−3.00, 2.00)	.86	
 Discharge	5.0	(1.3, 8.8)	5.0	(2.3, 7.8)	0.00 (−3.00, 2.00)	.95	
 One month after discharge	4.5	(2.0, 7.0)	6.0	(3.3, 9.0)	1.00 (−1.00, 4.00)	.31	
HADS (depression), median (IQR)	
 Admission	5.5	(2.0, 9.8)	4.0	(2.3, 7.5)	0.00 (−3.00, 2.00)	.70	
 Discharge	5.0	(4.0, 8.8)	6.5	(4.0, 10.0)	1.00 (−1.00, 3.00)	.41	
 One month after discharge	7.0	(3.0, 10.8)	8.0	(5.3, 10.8)	1.00 (−1.00, 4.00)	.34	
SF-8 (PCS), median (IQR)	
 Admission	50.3	(43.9, 55.1)	50.4	(44.3, 57.2)	0.79 (−5.06, 4.70)	.78	
 Discharge	52.7	(47.1, 58.0)	52.5	(43.5, 56.3)	−0.56 (−5.76, 4.28)	.78	
 One month after discharge	50.8	(44.9, 56.3)	50.0	(44.5, 53.0)	−1.28 (−5.92, 3.35)	.55	
SF-8 (MCS), median (IQR)	
 Admission	48.6	(42.1, 53.1)	48.9	(43.0, 52.2)	0.70 (−3.24, 4.58)	.78	
 Discharge	50.1	(43.0, 52.7)	46.2	(41.3, 53.4)	−2.16 (−7.34, 3.40)	.45	
 One month after discharge	48.2	(43.2, 52.3)	45.0	(39.5, 52.2)	−1.86 (−6.72, 3.04)	.46	
Mann–Whitney U test.

CI = confidence interval, HADS = Hospital Anxiety and Depression Scale, H–L = Hodges–Lehmann, ICT = Internet and Communication Technology, IQR = interquartile range, MCS = Mental Component Summary, PCS = Physical Component Summary.

Median differences in anxiety (Δafter discharge) and depression (Δhospitalization) scores were confirmed to be significantly different (Table 4). The median difference in anxiety scores (Δafter discharge) was −1.0 (IQR: −2.0 to 0.8) in the matched ICT group and 1.0 (IQR: −1.0 to 2.0) in the matched control group. The matched ICT group exhibited a significant reduction in anxiety compared with the matched control group after discharge. Median depression score differences during hospitalization (Δhospitalization) were 0.5 (IQR: −1.0 to 2.8) in the matched ICT group and 2.0 (IQR: 1.0–3.8) in the control group, indicating a significantly lower increase in depression in the matched ICT group.

Table 4 Median differences in the outcomes of propensity-score-matched cohorts of caregivers.

	Propensity-score-matched cohort	
ICT group	Control group	H–L estimate	P value	
(n = 20)	(n = 20)	(95%CI)	
HADS (anxiety), median (IQR)	
 Δhospitalization	−1.0	(−2.0, 0.8)	−0.5	(−3.8, 1.0)	0.00 (−3.00, 2.00)	>.99	
 Δafter discharge	−1.0	(−2.0, 0.8)	1.0	(−1.0, 2.0)	2.00 (0.00, 3.00)	.03	
HADS (depression), median (IQR)	
 Δhospitalization	0.5	(−1.0, 2.8)	2.0	(1.0, 3.8)	2.00 (0.00, 3.00)	.049	
 Δafter discharge	0.0	(−1.0, 3.0)	0.0	(−1.0, 4.8)	1.00 (−1.00, 2.00)	.51	
SF-8 (PCS), median (IQR)	
 Δhospitalization	1.9	(−1.6, 5.8)	−0.1	(−5.8, 4.5)	−1.92 (−6.09, 2.57)	.36	
 Δafter discharge	0.0	(−4.7, 2.7)	−2.5	(−6.1, 2.1)	−1.90 (−5.47, 1.89)	.27	
SF-8 (MCS), median (IQR)	
 Δhospitalization	0.0	(−4.3, 4.8)	−0.7	(−8.5, 3.5)	−2.59 (−7.39, 3.05)	.37	
 Δafter discharge	0.0	(−5.0, 3.6)	0.1	(−5.4, 3.5)	0.17 (−4.71, 5.42)	.88	
Mann-Whitney U test.

CI = confidence interval, HADS = Hospital Anxiety and Depression Scale, H–L = Hodges–Lehmann, ICT = Internet and Communication Technology, IQR = interquartile range, MCS = Mental Component Summary, PCS = Physical Component Summary.

Δhospitalization: admission – discharge, Δafter discharge: discharge – 1 month after discharge.

The IRIS program’s information delivery frequency after matching averaged 8.6 ± 2.9 times (range: 3–13), varying with patients’ length of hospital stay. Subsequent correlation analysis between the information frequency provided by the IRIS program and median outcome change revealed no significant correlation with anxiety (Δafter discharge) at  r = 0.21 (P = .37) and depression (Δhospitalization) at  r = 0.06 (P = .79), suggesting no link between intervention frequency and changes in family anxiety and depression.

4. Discussion

This study examined the effects of the IRIS program on family caregivers’ stress. The results showed that the ICT group had significantly reduced anxiety after discharge compared with the control group. Furthermore, the IRIS program prevented the progression of depressive symptoms in caregivers during the hospitalization period.

Most previous ICT intervention studies involved families of patients after discharge, with limited involvement of rehabilitation professionals during hospitalization. The novelty of the present study was providing families with information on the progress of the rehabilitation in inpatients via ICT. Given that the family caregivers were in their 50s and 60s,[15] many of whom were working, and that visitations were limited owing to the coronavirus disease 19 (COVID-19) pandemic, this study’s approach using ICT was expected to be of great clinical significance.

We found no significant correlation between the IRIS program intervention frequency and changes in family anxiety/depression. Despite variability based on patient hospital stay duration, the program consistently facilitated information sharing at least weekly. This regular engagement with rehabilitation professionals likely mitigated the psychological stress in family caregivers.

The IRIS program was shown to reduce the anxiety in caregivers after the discharge of patients and prevent the progression of depressive symptoms in caregivers during the hospitalization period. Our intervention included weekly reporting of rehabilitation progress via photos and videos and answering questions from family caregivers during hospitalization. In contrast, an intervention study by Vloothuis et al[16] used ICT once a week for 8 weeks to educate family caregivers of patients with stroke regarding exercise therapy to be performed during hospitalization and after discharge. Moreover, these patients and their families exercised 5 days per week. In the present study, the intervention group showed an increase in the HADS depression score by approximately 0.5 points, whereas the previous study showed a decrease of approximately 0.7 points. In both studies, the control groups showed a similar increase in the HADS score (approximately 2 points). This indicates that in the present study, sharing rehabilitation information during hospitalization alone reduced depression in caregivers despite the low intervention frequency and family burden. Considering the cost-effectiveness of the intervention, the IRIS program seems to be a feasible intervention to reduce family caregivers’ stress.

Anxiety-related and depression-related factors have been studied extensively among family caregivers providing care at home and include the caregivers’ age, educational level, social support, and anxiety/depression symptoms.[17–19] Additionally, caregivers’ mastery[20] and coping styles[21] have been reported as factors associated with anxiety and depression. Previous studies have implemented interventions that could provide telephone support and information to family caregivers based on patients’ recovery status, reporting improvements in caregiver mastery.[22] The IRIS program was unique in that it also provided photos and videos of the rehabilitation progress and suggestions for assistive equipment and assistance methods required after discharge. The IRIS program usage might have improved the family caregivers’ mastery.

The study’s limitations are outlined as follows: first, its design as a single-center, non-randomized study with a small sample size might introduce the possibility of selection bias, challenging the generalizability of the results. To address these issues, future studies could benefit from a multicenter, randomized trial design. Second, the inconsistent frequency of the intervention, limited to the hospitalization period, suggests that although the efficacy of the IRIS program may stem more from the connection with rehabilitation professionals than with the intervention frequency, standardizing both the quantity and content of interventions could enhance their generalizability. Future efforts should aim to customize the IRIS program to suit specific disease characteristics and standardize intervention volumes. Third, during the study period, visits were restricted owing to the COVID-19 pandemic; the intervention effects after the pandemic should have been further examined. Fourth, the long-term effects of this program could not be elucidated since the maximum observation period was 1 month after discharge from the hospital. However, it is appropriate to observe the intervention effects up to 1 month after discharge because home care after discharge from the hospital is often provided by long-term care insurance services, such as home nursing and home care services. Finally, the analysis did not adequately account for potential confounding factors influencing the primary outcomes of anxiety and depression, such as the economic status of the caregiver, burden, mastery, and social resources.

In conclusion, the present study was conducted to identify the effect of the IRIS program on family caregivers’ stress. The study revealed that the IRIS program reduced the anxiety in the caregivers after the discharge of patients and prevented the progression of depressive symptoms of caregivers during hospitalization. The results suggest that sharing the progress of the rehabilitation process can positively affect the mental state of family caregivers, which is an environmental factor affecting patient care. Since this is a clinically meaningful intervention that improves the living environment of patients, we suggest that information on rehabilitation should be actively provided to family caregivers during hospitalization.

Acknowledgments

We would like to sincerely express our gratitude to all the staff in the Tezukayama Rehabilitation Hospital and the patients and family caregivers who participated in this study.

Author contributions

Conceptualization: Wataru Kozuki, Yumi Higuchi, Tetsuya Ueda, Tatsunori Murakami, Aki Gen.

Data curation: Wataru Kozuki.

Formal analysis: Wataru Kozuki, Yumi Higuchi.

Investigation: Wataru Kozuki.

Methodology: Wataru Kozuki, Yumi Higuchi, Tetsuya Ueda, Tatsunori Murakami, Aki Gen.

Project administration: Wataru Kozuki.

Visualization: Wataru Kozuki, Yumi Higuchi, Tetsuya Ueda, Tatsunori Murakami, Aki Gen.

Writing – original draft: Wataru Kozuki, Yumi Higuchi, Tetsuya Ueda.

Writing – review & editing: Wataru Kozuki, Yumi Higuchi, Tetsuya Ueda, Tatsunori Murakami, Aki Gen.

Supervision: Yumi Higuchi.

Abbreviations:

ADL activities of daily living

CIs confidence intervals

COVID-19 coronavirus disease 19

FIM Functional Independence Measure

HADS Hospital Anxiety and Depression Scale

H–L Hodges–Lehmann

ICT Internet and Communication Technology

IQR interquartile range

IRIS Internet-based rehabilitation information sharing

MCS Mental Component Summary

MFS Motor Fitness Scale

PCS Physical Component Summary

QOL quality of life.

The authors have no funding and conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

How to cite this article: Kozuki W, Higuchi Y, Ueda T, Murakami T, Gen A. Effects of the Internet-based rehabilitation information sharing program on psychological stress of family caregivers of inpatients: A non-randomized controlled study. Medicine 2024;103:29(e38910).
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