Safety in the Home Care Environment of Families Caring for the Elderly

Abstract

Background: The family is the main provider of care for the elderly, which generates stress, with negative effects on the caregiver’s health. It is necessary to relieve the stress of caregivers for the safety of the caregiver and the dependent family member. Objective: To evaluate the effect of a nursing intervention based on a psychoeducational program for caregivers of elderly family members. Methods: This is a quasi-experimental study, with a sample of caregivers (n = 77), distributed between the intervention group (n = 37) and the control group (n = 40). The instruments comprised a questionnaire with the Zarit Burden scales and the Carers Management Assessment Index. The intervention group benefited from the psychoeducational program, and the control maintained the usual care. Results: The intervention group increased coping and decreased the burden compared to the control group. After six months, both groups decreased coping, but it was lower in the intervention group compared to the control group. The intervention group slightly decreased the burden while the control group increased it. Conclusions: The nursing intervention is a procedure that relieves the caregiver’s burden and increases the coping, contributing to reduce the impact of the damage caused by the provided care.

1. Introduction

In 2021, the global patient safety action plan 2021–2030 [1] was approved at the 74th World Health Assembly [1], continuing the process started in 2002, which anticipates the presentation of a report to monitor the implementation progress of this action plan at the 76th World Health Assembly in 2023 [2]. Patient safety is a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies, and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely, and reduce its impact when it does occur [1].

The topic of patient safety generates debates worldwide, aiming at defining the best practices in healthcare environments [3].

Many families provide care for dependent elderly people in the home environment, where there are many dangers. Providing care at home poses risks to the safety of families, who do not know how to organize themselves to provide safe care. Health professionals should assess the caregiver’s knowledge and skills, providing guidance on care to ensure that the patient receives safe, quality care and has access to community resources [4].

Clinical practices based on scientific evidence should be implemented to ensure quality on three fronts: improving the health of the individual patient, improving the quality of health care, and strengthening the overall health system [5].

This study aims to disclose the effect of a nursing intervention based on a psychoeducational program for family caregivers of the elderly aiming at reducing burden and improving coping. Caregivers must learn to be competent to manage their own safety and that of elderly family members.

Due to the increase in life expectancy, the last years of life are usually lived with a loss of physical or mental independence, so older people need help and care to perform the activities of daily living (ADL), with the family being the main caregiver [6]. It is inevitable to burden the family caregiver (FC) who transitions from an apparently healthy person to a sick one [7].

Family caregivers constitute a risk group, as they are more vulnerable to the development of physical and psychological morbidities [8], sleep disturbances, abuse, or abandonment of the person cared for. Caring for the elderly requires caregivers to use more health care resources and has inevitable implications for health systems and employing organizations [9].

Collaborating with the family, caregiver in the health system entails the creation of support networks and monitoring by health teams [10] with structured and contextualized interventions so that they can develop more appropriate coping strategies [11].

The dynamic process of caring over time allows the caregiver to learn how to care and acquire skills to perform tasks, care for, and mobilize resources, according to the evolution of the elderly’s comorbidities [12].

The model used in this study was the Neuman systems model [13], which contributed to understanding how variables influence a changing client system (consisting of the family caregiver and the dependent elderly). Nursing can help individuals and families maintain their well-being by providing interventions that reduce stressors and adverse conditions that affect the optimal functioning of the client system. Neuman’s systems model evaluates the interaction of five variables (physiological, psychological, sociocultural, spiritual, and developmental) in the constantly changing environment, caused by stress factors associated with care. The five client system variables can be located at different levels of the system from the center or core to the lines of resistance (LR) or lines of defense: Normal line of defense (NLD) and flexible line of defense (FLD) [13].

Stressors can arise in the internal or external environment of the family, which are stimuli or forces that create tension and can affect the client system to a greater or lesser degree, causing instability (Figure 1) [13].

Figure 1.

Neuman’s systems Modelan’s.

The nursing actions aim to improve, retain, achieve, or maintain the client’s health or well-being, using the three levels of prevention as interventions to keep the system stable. Community nursing cares for family caregivers of the elderly helps them to play their role, improve coping, learn new skills, and face the challenges of daily care [14].

There is evidence of the positive effects of a psychoeducational approach supported by programs for family caregivers in the home environment [15]. In psychoeducation, caregivers learn adaptive skills to deal with care demands and the stress, using a structured format that is usually taught in small groups, including time for teaching and practice. The addressed topics typically, include information about dementia, community resources and services, learning to take time to care for oneself, improving communication with family, and skills to manage problem behaviors, such as dealing with negative feelings by managing anger and anxiety, modifying one’s way of thinking, and learning to program enjoyable events [16].

This research is a quasi-experimental study, which was carried out based on a pilot study [17] and was based on the following research question: Does the nursing intervention focused on educational and support actions for the family caregiver have an effect on the client system variables (family caregiver and dependent elderly)?

2. Methods

2.1 Sampling and recruitment

The participants are family caregivers of elderly individuals who receive home care from a community health unit. This is an intentional sample and depended on the participants’ availability and willingness. The study was carried out from May 2015 to May 2017.

The inclusion criteria comprised adult family members responsible for care and with a score ≤16 on the screening scale for caregivers at risk of burden [18].

To facilitate access to the sample, the researcher joined the nursing team that provides care in the home context and knows the families well. Two groups were organized: the control group (CG), which received the usual care and did not adhere to the program and the intervention group (IG) in which the participants adhered to the intervention based on the psychoeducational stress management program [18]. According to Figure 1, after the screening, the sample of 77 participants was organized into two groups, 37 participants from the IG and 40 from the CG, preventing ethical issues since the decision was made by the participants.

The participants underwent a period of continuous assessment for eight months. The 1st evaluation was performed before the intervention (T1 – Baseline), the 2nd evaluation was performed two months after T1 (the intervention in the IG took place during this period) (T2 – post-intervention), and the 3^rd evaluation was performed six months after T2 (T3 – follow-up) (Figure 2).

Figure 2.

Participant recruitment and selection flowchart.

The variables of the two client systems were evaluated in three moments: T1, T2, and T3, according to the Neuman System Model, and the comparison between the two groups allowed us to assess the differences in the five variables and at the different levels of the system: core, lines of resistance (LR), and lines of defense (LD). The homogeneity of the results of the characterization variables of the two systems was verified.

2.2 Nursing intervention based on the psychoeducational stress management program.

In the control group (CG), the nurses performed unstructured activities to respond to the difficulties of family caregivers, as usual.

In the intervention group, the nursing team was trained by the researcher to implement the psychoeducational program of the stress management process [18]. They were supported by two documents: “The Caregiver’s Guidebook (Cartilha do Cuidador) and the “Nurse’s Manual” (Manual do Enfermeiro).

The stress management program for family caregivers at home aims to help caregivers to develop skills to manage difficult or stressful situations they experience in caring for the elderly at home. The program comprises five steps:

1. Step 1: Participants’ sensitization.

2. Step 2: Selection of a stressful situation and a goal to be achieved.

3. Step 3: Situation analysis: This analysis determines the choice of an adapted strategy to be put into practice in the next step.

4. Step 4: Selection of a strategy adapted to the situation and chosen action, following the presentation of several strategies that can help in the care setting.

5. Step 5: Evaluation: The final step allows a return to the second step to evaluate how the goal established in that step was achieved. If the goal is not achieved, the stress management process is resumed to allow the caregiver to try another action, which will be evaluated again to direct their thinking until the chosen goal is achieved.

2.3 Hypotheses

Hypothesis 1 – The client system intervention group (IG) shows better results in the variables when compared to the client system control group (CG) at T2 (post-intervention).

Hypothesis 2 – The client system intervention group (IG) shows better results in the variables between moments T2 and T3 when compared to the client system control group (CG).

2.4 Instruments

The data collection instrument was constituted by a questionnaire that includes scales translated and adapted to Portuguese with several parts.

Sociodemographic characterization of the family caregiver and the elderly regarding the following variables: sex, age, marital status, professional status, cohabitation, time of care provision, level of dependence on activities of daily living (ADL) [Basic (ADLB) and instrumental (ADLI)], coping with burden, and social support.

The ADL were assessed through questions, translated, and adapted to Portuguese [19], based on the original questionnaire.

The risk of caregiver burden was assessed by the Carers’ Risk Assessment Scale [18]. Caregiver burden was assessed using the Zarit Burden Interview Scale (ZBI). The burden scale values were: no burden (<46), light (47–55), and heavy (>56) [20].

The Caregiver’s Coping was assessed by the Carers’ Assessment of Management Index (CAMI) [21], translated and adapted to Portuguese [15].

2.5 Statistical analysis

The intervention and the control groups of the client system were compared, using a multiple set of variables, at the three study moments. Initially, descriptive statistics were used: mean, median, standard deviation, coefficient of variation (for quantitative variables, and count of columns and percentages (for qualitative variables), followed by inferential statistics, such as the chi-square test (for qualitative variables) and the comparison of the mean values of the “t-test” (for quantitative variables).

When the conditions for applying the chi-square test were not met for the qualitative variables, Fisher’s exact test was used.

The Mann–WhitneyU test was used for quantitative variables when there was no normality between the variables in the 2 groups. The nonparametric t-test was used if the normality of the variables in the 2 groups was verified, but their variance was not homogeneous (automatic SPSS procedure).

Both the Kolmogorov–Smirnov test and the Shapiro–Wilk test were used to test the normality of variables in the 2 groups. The significance level was set at 10% [22]. The statistical analysis was performed using the statistical package for the social sciences (SPSS), version 22 (SPSS Inc., Chicago, USA).

2.6 Ethical considerations

Authorization was obtained from the authors of the data collection instruments and the authors of the psychoeducational stress management program to apply them to the clients selected for the study.

The research protocol was approved by the clinical director of the grouping of health units, with favorable opinion n. 093/CES/INV/2014.

The participants were informed about the type of study and after clarification, all of them signed the free and informed consent form (ordinance 015/2013) [23]. The ethical principles of the declaration of Helsinki were considered throughout the process.

During the nursing intervention, ethical care was always ensured, while respecting the family caregiver’s availability, individualization of care, belief in their potentials and resources, and the avoidance of value judgments.

3. Results

The two groups were analyzed according to the model systems, regarding the physiological, psychological, sociocultural, and developmental variables in the core and the lines: LR and NLD (Table 1).

Level	Variables	Variable category	Statistical measures	IG; n = 32	CG; n = 32	Comparison of groups
Core	Physiological variables
	Family Caregiver (FC)
	Age		Average	62.97	63.59	Mann; Whitney; p =.930
			Median	66	66
			Standard deviation	15.64	13.36
			Minimum Maximum	24–86	31–86
	Sex	Female	n (%)	25 (78.1%)	23 (71.9%)	Fisher’s test; p =.774
		Male	n (%)	7 (21.9%)	9 (28.1%)
	Marital status	Married	n (%)	21 (65.6%)	18 (56.3%)	Chi-Square = 1.516 df = 3; p =.678
		Single	n (%)	7 (21.9%)	7 (21.9%)
		Widowed	n (%)	2 (6.3%)	2 (6.3%)
		Divorced/separated	n (%)	2 (6.3%)	5 (15.6%)
	Cohabitation	Yes	n (%)	28 (87.5%)	27 (84.4%)	Fisher’s test; p =1.000
		No	n (%)	4 (12.5%)	5 (15.6%)
	Elderly care
	Age		Average	81.69	80.34	Mann Whitney; p =.619
			Median	83.5	81.5
			Standard deviation	8.69	8.96
			Minimum Maximum	65–100	65–95
	Sex	Female	n (%)	15 (46.9%)	17 (53.1%)	Fisher’s test; p =.803
		Male	n (%)	17 (53.1%)	15 (46.9%)
	Marital status	Married	n (%)	18 (56.3%)	14 (43.8%)	Chi-Square = 3.667 df = 3; p = .300
		Single	n (%)	5 (15.6%)	3 (9.4%)
		Widowed	n (%)	7 (21.9%)	14 (43.9%)
		Divorced / separated	n (%)	2 (6.3%)	1 (3.1%)
	Psychological variables
	Degree of kinship	Spouse	n (%)	14 (43.8%)	12 (37%)	Chi-Square = .627 df = 2; p =.731
		Son / daughter	n (%)	15 (46.9%)	18 (56.3%)
		Other	n (%)	3 (9.4%)	2 (6.3%)
	Sociocultural variables
	Family Caregiver (FC)
	Work situation	Employed	n (%)	7 (21.9%)	9 (28.1%)	Chi-Square = .355; df = 3 p = .949
		Unemployed	n (%)	4 (12.5%)	4 (12.5%)
		Retired	n (%)	20 (62.5%)	18 (56.3%)
		Other	n (%)	1 (3.1%)	1 (3.1%)
	Schooling	Can read and write	n (%)	0	2 (6.3%)	Chi-Square = 4.836 df = 4 p = .305
		Elementary	n (%)	9 (28.1%)	12 (37.5%)
		Middle School	n (%)	7 (21.9%)	3 (9.4%)
		High school	n (%)	5 (15.6%)	7 (21.9%)
		Higher education	n (%)	11 (34.4%)	8 (25.0%)
	Elderly
	Schooling	Illiterate	n (%)	4 (12.5%)	4 (12.5%)	Chi-Square = 8.673; df = 6; p = .193
		Can read and write	n (%)	2 (6.3%)	3 (9.4%)
		Elementary	n (%)	14 (43.8%)	15 (46.9%)
		Midlle School	n (%)	4 (12.5%)	4 (12.5%)
		High school	n (%)	2 (6.3%)	5; (15.6%)
		Higher education	n (%)	6 (18.8%)	1 (3.1%)
	Developmental variables
	Elderly
	Dependence in activities of daily living (ADL)
	ADLB		Average	3.1	2.8	Mann Whitney; p = .178
			Median	3.4	2.8
			Standard deviation	0.9	0.9
			Minimum Maximum	1–4	1–4
	ADLI		Average	3.5	3.2	Mann Whitney; p = .347
			Median	3.9	3.4
			Standard deviation	0.7	0.7
			Minimum Maximum	1–4	1–4
	ADL (total)		Average	46	41.9	Mann Whitney; p = .203
Normal line of defense (NLD)	Physiological variables
	Family Caregiver (FC)
	Degree of risk of burden		Average	11.3	11.6	Mann Whitney; p = .542
			Median	11.5	12
			Standard deviation	2.2	2.1
			Minimum – Maximum	8–15	8–15
	How long has the elderly been cared; (in years)	Less than 6 months	n (%)	8 (25.0%)	Chi-Square; p =.877	Chi-Square = 1.792; df = 5; p = .877
		6 months to 1 year	n (%)	3 (9.4%)	5 (15.6%)
		Between 1 and 3 years	n (%)	9 (28.1%)	8 (25.0%)
		Between 3 and 5 years	n (%)	2 (6.3%)	4 (12.5%)
		Between 5 and 10 years	n (%)	5 (15.6%)	3 (9.4%)
		More than 10 years	n (%)	5 (15.6%)	5 (15.6%)

Table 1.

Participants’ characterization at baseline (T1).

Statistical homogeneity was verified in the two groups at T1, and the differences observed later can be attributed to the effect of the intervention in the group (IG).

4. Evaluation of the systems in the three evaluation moments

Dependence of the elderly during activities of daily living (ADL).

In the core, the Mann–Whitney test shows a significant difference (p = 0.089) between the IG and CG regarding the ADL at T3. The difference in medians increased at T3 to 0.8, with the CG showing a significantly lower value than the IG. There is a difference in the total ADL, with a relevant variation in the medians at T3: the median in the IG increases from 47 at T2 to 53 at T3, and the CG median decreases from 43 to 24; it was verified that the level of dependence in the CG decreased from very dependent to little dependent.

4.1 Social support

In the LR, the support hours received by the participants increased with time in the IG and decreased in the CG, but there are no statistically significant differences. The IG shows a positive progression of the medians: from 6.5 to 7, between T1 and T3; the CG shows a negative progression of the medians: from 6 to 5, between T1 and T3.

The chi-square test shows statistically significant differences (p = 0.077) between the IG and CG at T3 regarding “who receives support,” with the IG receiving more home support. The percentage of support received by caregivers is higher in the IG at the different moments of T1, T2, and T3.

Over time, support hours received by the participants increased in the IG and decreased in the CG. The support provided by the home support center increased for the IG and decreased for the CG. The activity that needs the most support is hygiene care, which increased for the IG and remained the same for the CG throughout the study.

The percentage of caregivers who pay for the support received is lower in all cases in the CG and decreased at T3 in both groups.

4.2 Daily time dedicated to care

Statistically significant differences (P = 0.071) were observed in the NLD with the chi-square test, in the physiological variable at time T2, in the number of hours of care per day, with the IG showing differences when compared to the CG regarding the caregivers who provide care for more than five hours a day.

4.3 Burden

At T1, statistically significant differences in the tests applied to total burden. At T1, the IG and CG groups showed the greatest difference in the median (59 and 51 respectively), with statistically significant differences. The initial differences decrease at T2 and T3, subsequently converging. While the IG decreased the burden between T1 and T2 and maintained the value at T3, the CG results remained the same between T1–T2 and increased at T3. The intervention group had more evident differences, but these differences decreased over the course of the study.

At T1, there were statistically significant differences in the “Expectations of care” category, whose initial values ​​were higher in the IG, and the burden was higher in the IG. However, this initial difference decreased over time (T2 and T3). Nevertheless, it should be noted that over time (T1–T3) they decreased in the IG, while they increased over the same period in the CG. Perceived self-efficacy remained the same at T2 in the IG and decreased in the CG. Over time, it decreased more in the CG than in the IG.

4.4 Coping

Table 2 shows an increase in the coping value (CAMI scale) in the IG when compared to the CG (differences of 5.4 and 4.2 respectively) between moments T1 and T2, meaning that there was an increase in coping after the intervention. At T3, the differences were statistically significant between the two groups after a decrease in the 2 groups. However, this decrease was more prominent in the CG (differences of 14.1 between T2 and T3 in the CG and 6.5 in the IG).

NLD; Sociocultural Variable	Statistical measures	T1			T2			T3
		IG	CG	Statistical; test	IG	CG	Statistical; test	IG	CG	Statistical; Test
Coping problem solving	Average; Median; S. deviation; Min-Max	3; 3; 0.5; 2–4	3; 3; 0.4; 2–4	Mann; Whitney p = .707	3.1; 3.2; 0.5; 2–4	3.1; 2.9; 1; 2–8	Mann Whitney; p = .124	3; 3.3; 0.7; 1–4	2.7; 2.8; 0.6; 1–4	Mann Whitney; p = .104
Coping - alternate perception of situation	Average; Median; S. deviation; Min-Max	2.9; 2.9; 0.4; 2–4	2.9; 2.8; 0.5; 2–4	Mann; Whitney p = .925	3; 2.9; 0.6; 2–4	3; 1.1; 2.8; 2–8	Mann; Whitney p = .506	2.8; 2.9; 0.5; 2–3	2.7; 2.7; 0.6; 1–4	t = .647; p = .522
Coping - dealing with stress symptoms	Average; Median; S. deviation; Min-Max	2.1; 2.1; 0.6; 1–3	2; 1.9; 0.5; 1–3	t = .724; p = .472	2.3; 2.4; 0.7; 1–4	2.3; 2; 1.3; 1–8	Mann; Whitney p = .199	2.1; 2; 0.5; 1–3	1.9; 1.7; 0.7; 1–4	t = .918; p = .364
Coping; (full scale)	Average; Median; S. deviation; Min–Max	103.3; 105; 15.3; 63–137	102.8; 103; 13.7; 73–123	Mann; Whitney; p = .773	108.7; 111.5; 16.7; 63–141	107; 103.5; 43.6; 0–304	Mann Whitney; p = .105	102.2; 106.5; 16.3; 70–125	92.9; 95.5; 28.2; 3–140	Mann Whitney; p = .099

Table 2.

Differences in the two client systems at the three evaluation moments (CAMI scale).

The results show that the intervention group (IG) increased coping and decreased burden compared to the control group (CG). After six months, both groups had decreased coping, but its reduction was lower in the intervention group compared to the control group, with statistically significant differences. The intervention group slightly decreased the burden, while the control group increased it.

5. Discussion

The profile of family caregivers was defined in both groups, with the mode being female (72% and 78%). The mean age is close to 63 years, a result similar to other studies [7, 24, 25, 26]. Most are married women and daughters who live with their parents, as other studies have shown [7, 27, 28, 29].

The mean age of caregivers justifies the higher frequency of retired participants. Most are female, which explains the traditional role of women in the family in western society that is associated with caregiver roles. Caregiver daughters are predominant [26]. The fact of being “married” is in accordance with the characteristics of the Portuguese population [30].

In both groups, the elderly have a mean age of 80.3 years, which corresponds to advanced age. Elderly widows in the CG are twice the number found in the IG, which is explained by the predominance of elderly women in the control group, as the average life expectancy of women is higher than that of men [31].

The elderly caregiver in the IG is more dependent regarding the activities of daily living when compared to the elderly in the CG. In both groups, dependence is at the “highly dependent” level, which means that the caregiver takes responsibility for care to support the ADL [24].

There is a similar level of burden risk between the two client systems, with a predominance of moderate risk [31].

In terms of duration of care, most have been caregivers for one to three years. This value is lower than that found in other studies, in which the care duration was more than five years.

Regarding the “daily hours dedicated to care” in the two client systems, the most frequent category is “more than 10 hours a day,” which is identical to what was found in other studies [24, 26].

In the present study, at the same evaluation period (T1) we found statistically significant differences in both groups, specifically in the normal line of defense variables of “total burden” (physiological variable) and “caring expectations” (sociocultural variable). The results obtained for these variables in the intervention group show its disadvantage when compared to the control group, but the data also reveal that the elderly were older in the intervention group and were more dependent regarding the activities of daily living.

During the follow-up (T3) the IG client system showed a better assessment of the “global burden”, which varied from intense to moderate, while the burden remained moderate in the CG, considering that this change results from the intervention [31].

Also during the follow-up (T3) the study showed the effect of the nursing intervention on coping strategies with statistically significant differences in the IG client system. The intervention facilitated the process that allowed caregivers to find coping strategies with the available resources, focusing on the most effective ones to meet their needs. The intervention allowed the caregivers in the intervention group to focus on the sources from which they received support, when compared to the CG client system. The results show that in the period after the intervention, the intervention group used coping strategies related to the search for support [31].

The greater dependence regarding the ADL in the IG explains the increase in the time spent by the caregiver, when compared to the CG. These differences are statistically significant. The results confirm that the increased ADL dependence by the elderly increases the time of care provision [32].

Due to psychoeducational interventions, caregivers in the intervention group were more empowered, improved social skills, sought support, and disclosed more knowledge of the available resources, which reduces feelings of isolation and stigma [33].

Informal support provided to caregivers declines over time. Nursing guidance is needed to mobilize the community resources and help the system to prevent disruptions and maintain homeostasis [13].

The economic costs of dependent elderly people have increased and the families need help. In the LR at the post-intervention moment (T2), the IG client system increased the percentages of “received support,” “payment for received support,” “hours of received support,” and “home support” in relation to the CG. The increase in these categories occurred over the eight months of the research and is related to the increase in the dependence of the elderly, which has costs associated with care [32].

It is necessary to have policies to support family caregivers. Law N. 100/2019 approves the informal caregiver statute, which regulates the rights and duties of caregivers in Portugal [34].

The health system understands that the family caregiver is a resource, but it is necessary to change the paradigm and understand this is a vulnerable group who needs to be taken care of. The literature refers to the tendency of health professionals to abandon care for less empowered families [34].

At T3, the IG showed the best coping when compared to the CG, with statistically significant differences, which is verified in other studies in which the psychoeducational program was applied [31]. The caregivers must be taught to associate a stressful situation with a coping strategy, making them more effective in the management of difficulties [27].

6. Conclusion

For the caregiver, the responsibility of caring for a dependent elderly family member at home is a stressful situation in the internal and external environment of the client system. Playing the role of caregiver can affect the client system to a greater or lesser degree [17], requiring a different type of intervention by health professionals than is currently provided.

The nursing intervention based on the psychoeducational program is easy, well-structured, and proposes steps to help the caregiver to develop coping strategies that are appropriate to deal with stress factors, promotes the learning of new skills to face the challenges of the care process, helps build confidence to play the role of caregiver, and promotes stability of the client system on the path to well-being.

The present study suggests the advantage of adopting the training program for family caregivers, aiming to minimize the impact of the damage caused by the provided care.

The implementation of the intervention is in line with the strategic objectives of the Global Action Plan on Patient Safety 2021–2030: in objective 1, which aims to reduce avoidable harm to patients to zero; and objective 4, which aims to involve and empower patients and families to help and support them on a safer health care path and contribute to achieve health and well-being goals [3]. The situation experienced at the micro level in the home environment of each family requires health policies and resources organized at the macro level, to reduce the harmful effects for families with dependent members and members who have assumed the role of caregivers.

Conflicts of interest

The authors declare no conflicts of interest.