Introduction

Over the last few decades, psychological distress (PD) among caregivers of individuals with neurological, neurosurgical, and mental disorders has been well documented in the literature. Long-term hospital stay, poor knowledge about illness, illiteracy, and poverty could be some of the other reasons. Studies suggest that impact of caregiving for someone with illness brings the risks of mental ill health to the carer in the form of emotional stress, depressive symptoms, or clinical depression.1 2 Because of high burden and responsibilities, caregivers experience poorer self-reported health and lower life satisfaction and engage in fewer health promotion activities.1 In case of caregiving for spouses, the stress is interpersonal in nature and focus must be encouraged on the positive aspects of the caregiver’s relationship to mitigate stress.3 Early identification of the vulnerable caregivers is required to target effective health promotion.4 More tailored approach to understanding the needs of caregivers is required, particularly in terms of time since diagnosis and care recipient, to provide more effective support.5 6

A study was conducted by Jagannathan et al about the needs of caregivers of inpatients who have schizophrenia, wherein about 5 focus group discussions (FGDs) from 30 caregivers were recorded and transcribed, and similar needs were grouped and ranked according to their order of importance. The main needs that emerged were needs regarding managing the behavior of patients (29%), managing sociovocational problems of patients (21%), health issues of caregivers (18%), education about schizophrenia (15%), rehabilitation (13%), and managing sexual and marital problems of patients (5%). The authors advocated a pyramid of needs in which all needs are to be addressed, and FGDs revealed that caregivers required assistance to manage all their needs and expressed their willingness to participate in any training that would address their needs.7 Intervention should include attention to the mental health and recovery of the caregivers in addition to the patient’s recovery.8 Interventions may also include cognitive and psychological supportive therapies, supportive strategies such as rapport building and establishing buy-in and communication,9 behavioral management, daily functional activities, stress management, self-efficacy techniques,10 and competency-based caregivers’ training.11 Early interventions for caregivers ensure low initial level of burden, which may have a positive effect on social support, depression, and anxiety.12 Stress management is also one of the proven interventions that help the caregiver to cope up with the distress.13

Extensive research done in the field of yoga supports the evidence that certain practices of yoga have impact on physical and mental components, for example, reducing heart rate and systolic and diastolic blood pressure; managing stress, anxiety, and depression; and improving the sense of emotional, social, and spiritual well-being.14 15 Various studies have been conducted to assess the effect of yoga among caregivers of patients with neurological and neurosurgical disorders,16 17 oncological disorder,18 and psychiatric disorder19 in acute care settings. Models have already been developed earlier. However, the problems and the distress faced by the patients of neurorehabilitation wards may be more severe as most of the neurological disorders are chronic in nature and require longterm care. Hence, in this study, researchers have tried to adopt the same caregivers’ module that was used earlier, to the caregivers of patients admitted to neurorehabilitation wards. In addition, till date, there are no Indian studies that explored the effect of yoga on mental well-being (MWB) and PD among caregivers attending chronically ill patients of neurorehabilitation wards. Thus, the study aims to assess the effect of caregivers’ yoga module (CYM) on the mentioned variables.

Materials and Methods

The study adopted the true experimental pretest–posttest design. The investigator used the principles of experimental design by using multiphase randomization of assigning patients to control and experimental groups (EGs) and withholding the intervention of CYM to the waitlisted group till the data for the study were collected.

Caregivers of patients admitted to neurological rehabilitation wards were invited to participate in the study on the basis of the following inclusion criteria: (a) both genders, (b) caregivers of patients admitted to neurorehabilitation wards for at least 2 weeks, (c) caregivers’ age: 18 to 60 years, and (d) languages known by caregivers: Kannada/Hindi/ English. Caregivers who reported to have severe psychiatric, neurological, or orthopaedic disorders or who were practicing yoga/relaxation techniques/physical exercise regularly for the past 1 month were excluded from the study.

The study was approved by the institute’s ethics committee. The nature and purpose of the study were explained to the participants, and they were told that they had the right to withdraw the consent during the study. Consenting participants were informed in detail about the assessments, CYM, and follow-up. Permission was also obtained from the treating consultants that patients will be randomized and followed up for assessments in the next 1 month. Written informed consent was taken from the participants. A total of 37 healthy consented caregivers were randomly allocated to the EG and waitlisted control group (WCG) in a multiphase manner.

Results

To verify the homogeneity of the sociodemographic characteristics of the participants between control and EGs, independent t test and chi-squared test were used. The Fisher’s exact test was used for variables that were categorical in nature with 2 × 2 tables. Both EG and control groups were homogeneous in relation to their sociodemographic variables (Table 2) and physical and physiological variables (Table 3) as p-value was not statistically significant.

Both EG and control groups were homogeneous in relation to their patient profile as p-value was not statistically significant (Table 4). There was no statistically significant difference in pretest MWB scores between EG and control groups (p = 0.582, t =-0.556). There was also no statistically significant difference in pretest PD between EG and control groups (p = 0.591, t = 0.591). Thus, before intervention, both the EG and control groups with regard to MWB and PD were homogeneous in nature.

CYM had a significant effect within groups (F = 17.78, p < 0.001) and between groups (F = 15.87, p < 0.001) on PD. Pairwise comparison showed that there was a significant difference between pretest–posttest and pretest–follow-up at p < 0.01, suggesting that CYM was found to be effective among caregivers of neurorehabilitation wards. There was no significant difference found between posttest and follow-up. CYM had a significant effect within groups (F = 5.48, p < 0.03 and between groups (F = 15.87, p < 0.01) on MWB. Pairwise comparison showed that there was a significant difference between pretest and posttest although no significant difference was found between pretest–follow-up and posttest–follow- up (Table 5).

It was found that there was a statistically significant negative correlation between caregivers’ pretest MWB and pretest PD (r =–0.579, p < 0.01), implying that the increase in MWB was associated with the lower level of PD.

Table 6 shows significant association between MWB and PDs with the selected sociodemographic variables. Marital status of caregivers was significantly associated with pretest PD (p = 0.03). Married individuals were found to have more distress than the unmarried ones. Illness improvement of the patient was significantly associated with caregivers’ PD. There was statistically significantly (p = 0.49) higher PD among caregivers whose patients had poor improvement. However, no other statistically significant association was found between MWB and PDs with the selected sociodemographic variables of caregivers or their patients.

Discussion

The study provides preliminary findings on the effectiveness of CYM in lowering the PD and improving the MWB. At the baseline, both EG and control groups were homogeneous in relation to their sociodemographic profile, patient profile, and baseline PD and MWB as p-value was not statistically significant (Tables 2 3 4).

All the three participants who dropped out of the study were females. It may be due to more responsibilities or lack of interest. The National Alliance for Caregiving24 found that female caregivers spend more time providing care than male caregivers. A stepwise multiple regression analysis conducted by Osayomi and Adegboye25 identified that male gender was found to be a significant risk factor for PD.25 However, in the current study, men outnumbered women in both control and EGs to participate in the study.

It was observed that participants belonging to Islam and Christianity had consented and enthusiastically participated in the study. It may be attributed to the fact that although yoga is an activity that is traditionally and culturally associated with the Hindu community, it has got wider acceptability in other religions also.

The majority of the participants in the EG (52.9%) and the control group (58.8%) had an annual income of up to INR 20,000, reflecting that National Institute of Mental Health and Neuro Sciences (NIMHANS), being the tertiary care public service institution, provides services to the poor in an affordable manner. Previous literature found socioeconomic status to be a contributing factor in PD. Firdaus26 found that people in lower income group are at greater risk of becoming distressed, but higher income is not always the guarantor of psychological well-being.

In this study, the mean pretest PD was under the category of moderate PD, and the mean pretest score of MWB in EG was 54.82 (SD = 8.8) and in control group was 53.06 (SD = 9.64). Similar findings were noticed in a population survey (n = 7,020) conducted in England, where the mean score for MWB was 51.61 (SD = 8.71).27

The present study findings report that CYM was effective in reducing PD and improving MWB among caregivers of neurorehabilitation wards (Table 6), which is in line with prior studies. In a randomized controlled study, EG who received yoga intervention for ~30 minutes per day, 5 days per week, for 1 month, showed significant reduction (32.90%, p < 0.001) in PD, whereas the control group did not show any significant decrease in PD (p = 0.103).28 Knobben,29 in a meta-analysis on 32 studies on the effect of yoga on mental health outcomes, found positive results and effect on MWB, emotional wellbeing (EWB), and social well-being (SWB) (overall g = 0.62, EWB g = 0.56, MWB g = 0.53, and SWB g = 0.42). Similarly, one more meta-analysis showed significantly greater improvements in PD (p = 0.003).30 Statler et al31 found improvement in psychological indices such as improvement in concentration, decreased trait anxiety, and improved motivation at p < 0.001 following 10 weeks’ practice of yoga.

About four caregivers whose PD scores were maintained more than 30 even after intervention were referred to a liaison psychiatrist associated with neurorehabilitation wards for further evaluation.

The findings showed that the increase in MWB was associated with lower level of PD. Similar to the current findings, an epidemiological descriptive study (n = 516) found that participants with a higher level of psychological well-being had a lower level of psychopathological symptoms.32 Another study (n = 1,933) found that variables that were positively associated with MWB were negatively associated with PD and vice versa, which supports the evidence of this study.33

The findings also showed significant association between marital status of caregivers and PD (p = 0.03), whereas no other sociodemographic variables had significant association with PD. The finding that illness improvement of patient was significantly associated with the MWB of caregiver may be due to the positive or negative outcome of treatment received by the patient. The findings were supported and contradicted by previous studies.34 35 36 Urban living, employment, education, and being married were associated with higher level of MWB.36 Occupation35 and income34 were associated with PD. Job insecurity was positively associated with PD, and lower income groups had 7.14% of higher PD than that of the normal population. Previous studies also did not find any significant association with age and gender.

This study has several strengths. First, it is the first study to explore the effect of yoga on PD among caregivers of patients admitted to neurorehabilitation wards. Second, this study was a randomized controlled study, and last yoga was used as an adjunctive therapy for caregivers to cope up with PD and improve their MWB. This study was not an exception to certain limitations such as the study was not blinded and small sample size, which makes it difficult to generalize the findings. The researchers included the following clinical variables of the patient: diagnosis, illness improvement, and dependency on ADL, whereas morbidity and disability also could have directly affected the stress and MWB of their caregivers. Similarly, the study dealt with two prominent variables, PD and MWB, whereas other variables such as depression, anxiety, or other mood condition should be assessed in future research with a larger sample size. In this study, the participants in the EG continued the module for 3 weeks, without monitoring, which has a possibility to change the nature and quality of the intervention. Hence, the authors recommend regular, may be weekly once, practices with the expert to maintain the evenness of the sessions.

Conclusion

This study provides the baseline data regarding the effectiveness of CYM on PD and MWB among caregivers of the patients admitted to neurorehabilitation wards. Similar studies with a larger sample size could be an eye-opener for mental health professionals for implementing suitable and affordable interventions for their country and local community and generalizing the findings for persons with mental illness.