International Journal of

Environmental Research
and Public Health

Article
Effectiveness of the Online “Dialogue Circles” Nursing
Intervention to Increase Positive Mental Health and Reduce the
Burden of Caregivers of Patients with Complex Chronic
Conditions. Randomized Clinical Trial
Jose Manuel Tinoco-Camarena 1,2 , Montserrat Puig-Llobet 2, * , María Teresa Lluch-Canut 2 ,
Juan Roldan-Merino 3 , Mari Carmen Moreno-Arroyo 4,5 , Antonio Moreno-Poyato 2 , Judith Balaguer-Sancho 2,6 ,
Zaida Agüera 2,7,8 , Maria Aurelia Sánchez-Ortega 9 and Miguel Ángel Hidalgo-Blanco 4,5

1 Center of Cornellà Specialists, Consorci Sanitari Integral, 08940 Barcelona, Spain

2 Department of Public Health, Mental Health and Maternal-Child Nursing, School of Nursing, University of
Barcelona, Health Sciences Campus Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
3 Department of Mental Health, Campus Docent Sant Joan de Déu School of Nursing, University of Barcelona,
Sant Boi de Llobregat, 08830 Barcelona, Spain
4 Department of Nursing, Fundamental and Medical-Surgical, School of Nursing, Faculty of Medicine and
Health Sciences, University of Barcelona, 08907 Barcelona, Spain
5 Department of Nursing Research Group (GRIN), Bellvitge Biomedical Research Institute (IDIBELL),
L’Hospitalet de Llobregat, 08908 Barcelona, Spain
6 Hospital de la Santa Creu I Sant Pau, 08041 Barcelona, Spain
7 Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Programme, Bellvitge
Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
Citation: Tinoco-Camarena, J.M.; 8 CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto Salud Carlos III, 28015 Madrid, Spain
Puig-Llobet, M.; Lluch-Canut, M.T.; 9 University School of Nursing and Occupational Therapy of Terrassa (EUIT), Universitat Autònoma de
Roldan-Merino, J.; Moreno-Arroyo, Barcelona, 08221 Terrassa, Spain
M.C.; Moreno-Poyato, A.; * Correspondence: [email protected]
Balaguer-Sancho, J.; Agüera, Z.;
Sánchez-Ortega, M.A.; Abstract: The personal demands involved in caring for a chronically ill person can lead to emotional
Hidalgo-Blanco, M.Á. Effectiveness and physical exhaustion in caregivers. The aim of this study was to evaluate the effectiveness of
of the Online “Dialogue Circles” an online nursing intervention called “dialogue circles” designed to reduce caregiver overload and
Nursing Intervention to Increase enhance positive mental health (PMH) in family caregivers. We used a pre-post design. The sample
Positive Mental Health and Reduce consisted of 86 family caregivers of patients with complex chronic conditions, randomly assigned to
the Burden of Caregivers of Patients
the intervention group (n = 43) or the control group (n = 43). All participants completed the Zarit scale
with Complex Chronic Conditions.
and the Positive Mental Health Questionnaire 15 days before starting the intervention and 30 days
Randomized Clinical Trial. Int. J.
after its completion. Comparison of the post-test changes revealed statistically significant differences
Environ. Res. Public Health 2023, 20,
between the two groups in PMH and overload, with the intervention group showing greater positive
644. https://doi.org/10.3390/
ijerph20010644
changes in all dimensions of PMH after the intervention and lower scores on overload. In conclusion,
the results suggest that incorporating dialogue circles as an online nursing intervention in the
Academic Editor: Paul B. Tchounwou
caregivers of patients with complex chronic conditions can enhance PMH and decrease caregiver
Received: 1 December 2022 overload, especially in settings where face-to-face encounters are not possible.
Revised: 20 December 2022
Accepted: 27 December 2022 Keywords: chronic disease; nursing intervention; clinical trial; dialogue circle; positive mental health;
Published: 30 December 2022 caregiver overload

Copyright: © 2022 by the authors.

1. Introduction
Licensee MDPI, Basel, Switzerland.
This article is an open access article Chronic diseases are becoming increasingly prevalent, as is the coexistence of several
distributed under the terms and of such diseases in the same person [1]. These diseases often reduce functional capacity
conditions of the Creative Commons and lead to a high risk of cognitive decline, making affected individuals dependent for
Attribution (CC BY) license (https:// activities of daily living [2,3].
creativecommons.org/licenses/by/ Patients with complex needs can be defined as those who are vulnerable, frail, with
4.0/). multiple comorbidities, difficult-to-control symptoms, a high risk of exacerbations, and

Int. J. Environ. Res. Public Health 2023, 20, 644. https://doi.org/10.3390/ijerph20010644 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023, 20, 644 2 of 13

taking multiple medications requiring integrated care to improve their quality of life.
Equally, these patients require multiple healthcare resources and strong support from their
families and a multidisciplinary healthcare team to ameliorate the suffering caused by the
disease process [4].
The main resource in the care of dependent persons is the family [5]. Family carers
often provide home care, with no specific training for this activity [6]. Continuous provision
of this task and the lack of social and professional care often negatively affect principal
carers [7] and increase their psychosocial burden [8–10]. Both caregivers and dependent
persons may experience negative physical and psychological effects [11,12].
There is consensus-based evidence that persons carrying out the role of informal
caregiving for a prolonged period perform multiple and complex tasks. The lack of training
for the management of these tasks often provokes demoralization and stress [13,14], with
negative effects such as depression, anxiety, sleep disturbance, and fatigue [15,16]. These
difficulties form part of a process that constantly tests caregivers’ physical limits and mental
health, often leading to overload and/or burnout. This, in turn, can negatively affect the
relationship between caregiver and patient [16–18]. Moreover, recent studies also report
that caregiver overload can reduce emotional wellbeing and positive mental health (PMH).
Because of the time devoted to caregiving, these individuals often neglect their own needs,
losing contact with their families and friends, which in turn leads to a pessimistic view of
the future [19].
Several studies evaluating the role of the carers of persons with chronic diseases
have concluded that the interventions needed should focus on empowering caregivers to
perform their role, while maintaining optimal self-care [20–22], as well as on enhancing
their wellbeing and PMH [23].
Various systematic reviews and meta-analyses concur on the difficulty of assessing
the results on the effectiveness of interventions aimed at informal caregivers. This could be
due to several factors such as the diversity of methods employed and the distinct designs
and interventions used, as well as focus on a specific disease [24–29].
In this regard, some studies have used different types of intervention in carers, such as
those combining self-help programs with psycho-educational programs [30], those based on
the use of information and communication technology (ICT) [31–33], and those encouraging
physical activity [34]. Among all these studies, some authors believe that psychotherapeutic
interventions produce a greater benefit than psychoeducational interventions [35] and that
multi-component group programs are more efficient in reducing carer overload [36,37].
Several authors have made proposals that include the use of ICTs in interventions
aimed at informal caregivers [38,39]. Of note, one study used ICTs to enhance PMH in infor-
mal caregivers through the support of virtual platforms: (a) “Cuidadores 2.0” [Carers 2.0]
through self-care resources [40] and (b) a program to encourage PMH through an app
called “Cuidadoras crónicos” [Chronic carers]. This smartphone app-based intervention
offered a different activity every day for 4 weeks. After the end of the intervention, the
3-month follow-up results showed an improvement in PMH [41].
Various studies have used new technologies to carry out nursing interventions in
distinct populations [42–44], with favorable results.
A novel intervention, which has not yet been explored in the health setting, is the
use of dialogue circles; this intervention aims to offer carers support, advice, protection,
and accompaniment during the process of change, in which they adjust to a life with the
limitations imposed by caring for a patient with complex and chronic needs and with a
chronic disease in an advanced stage. These circles are essentially spaces in which carers can
share their feelings with other persons with similar preoccupations and fears; this provides
an opportunity to normalize some thoughts and concerns as carers realize they are shared
by other people in a similar situation. In addition, members of the group share strategies
and information they have found useful in their role as caregivers [45]. Consequently, this
intervention could be useful to enhance PMH and reduce caregiver overload.
Int. J. Environ. Res. Public Health 2023, 20, 644 3 of 13

We found no previous studies applying this intervention in caregivers, although a

similar online intervention, called “virtual culture circles” was used in families in Brazil to
offer a space to encourage health promotion in coping with COVID-19 [46].
Given the gaps in the literature, the main objective of this study was to evaluate the
efficacy of the “dialogue circles” nursing intervention to decrease caregiving overload
and increase the PMH of primary caregivers of patients with complex chronic needs and
advanced chronic disease.

2. Materials and Methods

2.1. Study Design
This study was designed as a randomized controlled trial with simple masking.
The study was registered in ClinicalTrials (ID: NCT04993248). The CONSORT checklist
was used.

2.2. Setting and Participant Selection

The study was conducted in primary health centers in Catalonia (Spain) administered
by the publicly funded health system.
The sample was composed of the family carers of patients identified as having chronic
complex disease or a chronic disease at an advanced stage, and who were found to have
overload on the short-form version of the Zarit Burden Interview (ZBI-7) [47]. This ques-
tionnaire, derived from the ZBI [48], contains seven items on overload.
Participants were identified by nurse case managers. These nurses identified, among
patients assigned to their services portfolio, the family caregivers who could be included in
the study during routine nurse consultations in the health center or home.
The inclusion criteria were as follows: (a) age > 18 years, (b) being a caregiver for
6 months or more, (c) experiencing caregiver overload according to the ZBI-7, (d) having
internet access, and (e) not being involved in any type of individual or group psycho-
logical intervention during the performance of the intervention. Exclusion criteria were
(a) being an occasional caregiver, (b) not having computer skills, and/or (c) not having the
resources/media to connect to the online sessions.
A total of 100 persons were invited to participate, of which 14 were excluded, mostly
due to their own refusal (n = 10) or due to their inability to complete the intervention
because of the health status of the person they cared for (n = 4).

2.3. Randomization and Masking

Participants who met the inclusion criteria were contacted by telephone or in person
during the medical visit to inform them of the study. Those who agreed to participate were
randomly assigned to the control group (CG) or intervention group (IG) using the OxMaR
software [49]. After assigning them to each group, they were given by hand or by e-mail a
document containing the study information, self-reported questionnaires, and the informed
consent document to be signed. Figure 1 shows a flow diagram of the distribution of the
participants, following the CONSORT statement. The caregivers were unaware of their
group assignment, which was performed using the single-blind technique.

2.4. Instruments
Data were collected through self-reported questionnaires sent through e-mail.
An ad-hoc sheet was used to collect participants’ sociodemographic variables (age,
sex, time since starting caregiving, educational level, marital status, number of children,
employment situation, family relationship to the patient, whether living with the patient or
not, and, if so, whether the patient received dependency benefits).
Int. J.
Int. J. Environ.
Environ. Res.
Res. Public
Public Health 2023, 20,
Health 2023, 20, 644
x FOR PEER REVIEW 44 of 14
of 13

Figure 1.
Figure 1. Flow
Flowdiagram
diagramshowing
showing participants’ progress
participants’ through
progress the the
through phases of the
phases ofrandomized two-
the randomized
arm parallel group clinical trial.
two-arm parallel group clinical trial.

2.4. Instruments
The variable PMH was assessed through the Positive Mental Health Questionnaire
(PMHQ; DataLluch,
were 1999) [50].through
collected This instrument contains
self-reported 39 items with
questionnaires sentanthrough
unequale-mail.
distribution
between the 6 factors
An ad-hoc sheetdefining
was used thetoconstruct: F1-Personal sociodemographic
collect participants’ satisfaction (8 items), F2-Prosocial
variables (age,
attitude (5 items), F3-Self-control (5 items), F4-Autonomy (5 items), F5-Problem
sex, time since starting caregiving, educational level, marital status, number of children, solving
and self-actualization
employment situation,(9 family
items), relationship
and F6-Interpersonal relationship
to the patient, whether skills (7 items).
living with the Thepatient
items
take the form of positive or negative statements that participants
or not, and, if so, whether the patient received dependency benefits). mark on a scale of 1 to 4,
depending on the frequency with which they occur: always or almost
The variable PMH was assessed through the Positive Mental Health Questionnaire always, fairly often,
always
(PMHQ;orLluch,
always, sometimes,
1999) [50]. Thisnever or notcontains
instrument often. The questionnaire
39 items providesdistribution
with an unequal an overall
PMH score (the sum of the scores of the elements), as well as specific scores
between the 6 factors defining the construct: F1-Personal satisfaction (8 items), F2-Proso- for each factor.
The overall PMH score ranges from 39 points (low PMH) to 156 points
cial attitude (5 items), F3-Self-control (5 items), F4-Autonomy (5 items), F5-Problem solv- (high PMH). The
minimum and maximum scores for each factor are as follows: 8–32 (factor
ing and self-actualization (9 items), and F6-Interpersonal relationship skills (7 items). TheF1), 5–20 (factors
F2,
itemsF3,take
and the
F4),form
9–36of(factor F5),or
positive and 7–28 (factor
negative F6). that participants mark on a scale of
statements
The questionnaire has been validated by
1 to 4, depending on the frequency with which they occur:several studies, obtaining
always a Cronbach’s
or almost always, alpha
fairly
between 0.89 and 0.90 and a test-retest correlation of 0.85 [51,52]. Based on the validation of
often, always or always, sometimes, never or not often. The questionnaire provides an
this questionnaire, a decalogue of recommendations to promote PMH was developed [53].
overall PMH score (the sum of the scores of the elements), as well as specific scores for
The ZBI-7, validated by Regueiro et al. (2007) [47], consists of 7 items related to
each factor. The overall PMH score ranges from 39 points (low PMH) to 156 points (high
overload and uses a Likert-like scale to obtain scores ranging from 7 to 35. In line with the
PMH). The minimum and maximum scores for each factor are as follows: 8–32 (factor F1),
literature, scores of 17 or more were considered to indicate intense overload. The questions
5–20 (factors F2, F3, and F4), 9–36 (factor F5), and 7–28 (factor F6).
focus on important areas such as caregiver health, psychological wellbeing, finances, social
The questionnaire has been validated by several studies, obtaining a Cronbach’s al-
life, and the relationship between carer and patient [54].
pha between 0.89 and 0.90 and a test-retest correlation of 0.85 [51,52]. Based on the vali-
The level of satisfaction in the IG was assessed using a satisfaction survey consisting
dation of this questionnaire, a decalogue of recommendations to promote PMH was de-
of the following four questions with yes/no answers: (a) I felt understood, (b) I consider
veloped [53].
Int. J. Environ. Res. Public Health 2023, 20, 644 5 of 13

that the intervention has helped me to decrease overload, (c) I think all caregivers should
undergo the intervention, and (d) I felt helped by listening to people in a similar situation.

2.5. Intervention
The intervention was performed between July 2021 and February 2022. Carers in the
control group (CG) were provided with routine care and they were referred to social work
to receive information on the help they could request.
The IG (IC) underwent the dialogue circles intervention. This intervention aimed
to increase PMH and reduce overload through the creation of safe spaces (circles) that
allow participants to be protagonists and experience the trust necessary to voice problems,
difficulties, and feelings surrounding their role as carers.
The overall intervention consisted of conducting three dialogue circles per group.
There were five groups: two composed of eight participants and three composed of nine
participants and a facilitator, who was always the principal investigator of the study. Each
circle lasted approximately 90 min, with a 15-day interval between each.
In the first circle, the facilitator explained the methodology and dynamics of the circles.
The use of the item was explained: the item is a material object indicating whose turn it is
to speak at that time and that the others are to pay attention. The object is passed around
the circle by hand among the participants, providing each with an opportunity to share
their thoughts and feelings if they wish.
Receiving the object is an invitation to share with the group. The object helps to ensure
that each participant in the circle has the opportunity to collaborate in their own time and
way without being interrupted while they speak. Participants share what they want or
remain silent during their turn, passing the object to the person next to them, from one
participant to another, until the circle is closed. None of the circles has an established script
and the themes to be discussed arise spontaneously among the participants. The facilitator
intervenes if a participant monopolizes the circle.
After this detailed explanation by the facilitator, the first circle starts with each partici-
pant introducing themselves, one after the other, applying the above-mentioned method
and dynamics. The two remaining circles follow the same methodology and dynamics as
the first.
The circles were carried out online, through a video call using the Zoom platform.
Consequently, the item was the raised hand icon.
Caregivers’ PMH and overload were measured in each group, 15 days before the
start of the intervention and 30 days after its end, with measurements being performed
at the same time in both groups. The IG was also administered a satisfaction survey on
the intervention.

2.6. Statistical Analysis

The R.4.1.2 program was used for the statistical analysis. The baseline characteristics
and outcomes (cross-sectionally and their change) of the IG and CG were compared using
the chi-square test for categorical variables and the Student’s t-test, Fisher’s exact test,
or Mann–Whitney U-test for quantitative variables. PMH was analyzed globally and by
factors with direct scoring.
A repeated measures analysis of variance was performed to study the variation in the
PMH and Zarit scales between the two study groups. An analysis of covariance with the
independent variables age, educational level, and marital status was also performed.
The descriptive variables used were absolute and relative frequency for categorical
variables, and median and interquartile range for continuous variables.
To evaluate the effect of the intervention on the change in pre-post intervention scores
on the Zarit and PMH scales, regression models were fitted to explain the change in scores
based on the intervention, age (with quadratic relationship), sex, baseline score, and the
2-sided interactions between the exposure group and the variables age, sex, and baseline
Int. J. Environ. Res. Public Health 2023, 20, 644 6 of 13

score. A variable selection process based on Akaike information criterion was applied to
obtain the final models.

3. Results
3.1. Sociodemographic Data
Overall, no differences were observed between the two groups at the baseline, except
for age, education level, and marital status, with the IG being older and more frequently
single and having a higher educational level than the CG (Table 1). For numerical vari-
ables, the median and interquartile range (Q1 and Q3, which contain 50% of the sample)
are described, and for categorical variables, the absolute and relative frequency of each
category. The p-value of the test of equal distribution of the variable between the control
and intervention groups is presented: Wilcoxon if the variable is numerical, Fisher’s exact
test for categorical variables.

3.2. Levels of Overload and Positive Mental Health at Baseline

At the baseline assessment of the scales (Table 2), the IG scored significantly higher on
caregiver overload (assessed with the Zarit scale). There were no statistically significant
differences in PMH in the overall PMHQ score between the two groups (Table 2).

Table 1. Baseline characteristics of the sample, overall and by group.

Items Overall Control Intervention p-Value

Age 56.00 [49.25, 63.00] 60.00 [54.50, 65.00] 53.00 [46.50, 59.00] 0.002
Caregiver months 26.50 [16.25, 48.00] 30.00 [18.00, 48.00] 24.00 [14.00, 48.00] 0.267
Gender 0.102
Men 17 (19.77%) 12 (27.91%) 5 (11.63%)
Women 69 (80.23%) 31 (72.09%) 38 (88.37%)
Educational level <0.001
No studies 1 (1.16%) 1 (2.33%) 0 (0.00%)
Primary education 21 (24.42%) 17 (39.53%) 4 (9.30%)
Intermediate level
14 (16.28%) 2 (4.65%) 12 (27.91%)
training cycle
Baccalaureate or
23 (26.74%) 11 (25.58%) 12 (27.91%)
higher education
University education 27 (31.40%) 12 (27.91%) 15 (34.88%)
Marital status 0.030
Single 12 (13.95%) 3 (6.98%) 9 (20.93%)
Domestic partner 6 (6.98%) 1 (2.33%) 5 (11.63%)
Married 56 (65.12%) 34 (79.07%) 22 (51.16%)
Divorced 12 (13.95%) 5 (11.63%) 7 (16.28%)
Number of
0.171
children
0 23 (26.74%) 10 (23.26%) 13 (30.23%)
1 19 (22.09%) 7 (16.28%) 12 (27.91%)
2 38 (44.19%) 24 (55.81%) 14 (32.56%)
3 6 (6.98%) 2 (4.65%) 4 (9.30%)
Employment
0.244
status
Unemployed 15 (17.44%) 8 (18.60%) 7 (16.28%)
Part-time work 5 (5.81%) 2 (4.65%) 3 (6.98%)
Employed 44 (51.16%) 18 (41.86%) 26 (60.47%)
Self-employed 6 (6.98%) 5 (11.63%) 1 (2.33%)
Retired 16 (18.60%) 10 (23.26%) 6 (13.95%)
Int. J. Environ. Res. Public Health 2023, 20, 644 7 of 13

Table 1. Cont.

Items Overall Control Intervention p-Value

Family
0.277
relationship
Spouse 17 (19.77%) 11 (25.58%) 6 (13.95%)
Son/daugher 67 (77.91%) 32 (74.42%) 35 (81.40%)
Son-in-law/
1 (1.16%) 0 (0.00%) 1 (2.33%)
daugher-in-law
Others 1 (1.16%) 0 (0.00%) 1 (2.33%)
Living together 0.459
No 22 (25.58%) 13 (30.23%) 9 (20.93%)
Yes 64 (74.42%) 30 (69.77%) 34 (79.07%)
Receives financial
1.000
benefits
No 65 (75.58%) 33 (76.74%) 32 (74.42%)
Yes 21 (24.42%) 10 (23.26%) 11 (25.58%)

Table 2. Direct scores and by levels on baseline scales in the overall sample and in the control and
intervention groups.

Items Overall Control Intervention p-Value

ZBI-7 Total score 24.00 [21.00, 27.00] 22.00 [20.00, 25.00] 26.00 [24.00, 28.00] <0.001
Burden 86 (100.00%) 43 (100.00%) 43 (100.00%) 1.000
PMH total score 93.00 [89.25, 96.00] 93.00 [90.50, 96.50] 91.00 [89.00, 95.50] 0.467
F1: Personal satisfaction 15.00 [13.00, 18.00] 15.00 [13.00, 18.00] 16.00 [14.00, 19.00] 0.252
F2: Prosocial attitude 14.00 [13.00, 15.00] 14.00 [13.00, 14.50] 14.00 [13.00, 15.00] 0.446
F3: Self-control 13.00 [11.00, 14.00] 14.00 [12.00, 14.50] 11.00 [10.00, 13.00] <0.001
F4: Autonomy 8.50 [7.00, 11.00] 8.00 [7.00, 10.00] 9.00 [7.00, 11.00] 0.238
F5: Problem solving and self-actualization 26.50 [23.00, 30.00] 28.00 [23.50, 31.00] 26.00 [22.00, 28.50] 0.029
F6: Interpersonal
15.00 [13.00, 16.00] 14.00 [13.00, 15.00] 15.00 [14.00, 17.00] 0.005
relationship skills
PMH: positive mental health; ZBI-7: 7-item Zarit Caregiver Burden.

After categorization of the factors of the PMH, significant differences were found only
in F3-self-control and F6-interpersonal relationship skills.

3.3. Post-Intervention Levels of Overload and Positive Mental Health

In the post-intervention assessment (Table 3), statistically significant differences were
found between the CG and the IG, with the IG scoring higher in all factors of the PMHQ
and overall and scoring lower on the ZBI-7 than the CG.

Table 3. Follow-up scores for the overall sample and for the control and intervention group.

Items Overall Control Intervention p-Value

ZBI-7 Total score 23.00 [20.00, 26.00] 25.00 [22.00, 27.00] 20.00 [18.00, 24.00] <0.001
Burden 80 (93.02%) 43 (100.00%) 37 (86.05%) 0.034
PMH total score 98.00 [89.25, 112.00] 89.00 [83.00, 93.00] 112.00 [105.50, 118.00] <0.001
F1: Personal satisfaction 17.50 [14.00, 21.00] 14.00 [12.00, 18.00] 20.00 [17.00, 22.50] <0.001
F2: Prosocial attitude 15.00 [13.00, 16.00] 13.00 [12.00, 14.00] 16.00 [16.00, 17.00] <0.001
F3: Self-Control 13.00 [12.00, 15.00] 13.00 [11.00, 14.00] 15.00 [13.00, 16.00] <0.001
F4: Autonomy 10.00 [8.00, 12.00] 8.00 [6.00, 10.00] 12.00 [9.00, 14.00] <0.001
F5: Problem solving and self-actualization 28.50 [24.00, 32.00] 25.00 [19.50, 29.00] 32.00 [28.00, 33.50] <0.001
F6: Interpersonal relationship skills 16.00 [14.00, 19.00] 14.00 [13.00, 15.00] 19.00 [18.00, 21.00] <0.001
PMH: positive mental health; ZBI-7: 7-item Zarit Caregiver Burden.
Int. J. Environ. Res. Public Health 2023, 20, 644 8 of 13

3.4. Post-Intervention Changes

Table 4 shows changes in the baseline and post-intervention scores. ZBI-7 scores
significantly worsened by a median of 2 points in the CG and significantly improved by a
median of 5 points in the IG. Overall PMH worsened in the CG but improved by a median
of 18 points in the IG. Unlike the CG, the IG showed improvement in all factors at follow-up.
This difference between the two groups was statistically significant (p < 0.001) (Table 4).

Table 4. Changes between baseline and post-intervention scores.

Items Control Intervention p-Value

ZBI-7 total score 2.00 [1.00, 3.00] −5.00 [−6.00, −4.00] <0.001
PMH total score −4.00 [−8.50, −1.50] 18.00 [14.00, 25.50] <0.001
F1: Personal satisfaction 0.00 [−1.00, 0.50] 3.00 [2.00, 4.50] <0.001
F2: Prosocial attitude −1.00 [−1.00, 0.00] 2.00 [1.00, 3.00] <0.001
F3: Self-control −1.00 [−2.00, 0.00] 2.00 [1.50, 4.00] <0.001
F4: Autonomy 0.00 [−0.50, 1.00] 2.00 [1.00, 3.00] <0.001
F5: Problem solving and self-actualization −2.00 [−4.50, 0.00] 5.00 [3.00, 8.00] <0.001
F6: Interpersonal relationship skills 0.00 [−1.00, 1.00] 4.00 [3.00, 5.00] <0.001
PMH: positive mental health; ZBI-7: 7-item Zarit Caregiver Burden.

4. Discussion
Informal caregivers often have high levels of psychological distress and dissatisfaction
in terms of meeting their own needs. Consequently, they require support and constant
guidance by nurses [55], who can offer interventions that help to prevent complications
in caregivers and reduce the risk of overload or ameliorate its effects [56]. Bearing in
mind this premise, we performed this study to analyze the impact of the online “dialogue
circles” nursing intervention on caregiver overload and PMH. As described, the main result
revealed that this intervention produced positive changes in the dimensions of PMH and
reduced the general level of overload reported by the family caregivers themselves.
The sociodemographic profile of the main caregivers in this study was in line with
previous studies reporting that the typical profile of these individuals has the following
characteristics: mainly middle-aged women, a first-degree relative of the patient (daughter
or wife), with low to secondary level education, living with the patient, and with an average
of two children [57–63]. In terms of the employment situation of the study population, most
caregivers in this study had a paid job. This result is similar to that reported in another
study [63], but contrasts with those of other authors [25,64] indicating that carers do not
have paid work. Those results may be due to the large amount of time that carers spend in
the care of older adults, limiting the time available to perform paid work. In this study, we
did not examine whether the main caregivers received some form of financial aid to carry
out their task (from other family members or some form of benefit), which could explain
these discrepancies.
The results on the changes produced after the intervention show enhanced PMH
and lower perceived overload in the IG. These results agree with those of another type of
intervention in carers previously reported in the literature. A study by Ferré-Grau et al.
(2021) [65] found that designing and implementing an ICT-based nursing intervention
reduced overload and increased PMH in informal caregivers, with an increase in the
global score of the PMH scale in the IG. The improvement in the PMH scores in the IG,
both overall and in its different categories, was highly favorable and encouraging, since
previous research had shown that PMH was correlated with self-care and, therefore, directly
affected caregivers’ health and indirectly the quality of care provided to the patient [51,52].
Therefore, the present study demonstrates that the dialogue circles nursing intervention
may benefit not only carers but also patients.
To our knowledge, no previous studies have analyzed the efficacy of a dialogue circles
nursing intervention in informal caregivers. However, there have been previous reports
Int. J. Environ. Res. Public Health 2023, 20, 644 9 of 13

of a similar technique in other study populations. For example, a study by Silva et al.
(2019) [66] implemented the culture circles created by Freire (1987) [67] in teachers, while
Souza et al. (2021) [46] used them in a nursing intervention in the families of patients
with COVID-19, showing that these tools encourage the ability to reflect on participants’
behavior by allowing them to be the protagonists of their own health/disease story, thus
enhancing their quality of life. Although dialogue circles have not been previously used
as a nursing intervention, Souza et al. (2021) [46] showed that culture circles can help
to reduce the overload perceived by the main carers of patients with complex chronic
needs and with advanced-stage disease, by offering a space in which they can share their
experiences and feelings, which in turn encourages empathy as participants feel identified
with others while listening to them describe their own similar situations. Therefore, this
type of intervention may be beneficial for other carers.
Satisfaction with the dialogue circles nursing intervention was high, with all partici-
pants reporting they were satisfied, since they indicated that they had felt understood and
that the experience had helped them to reduce their feeling of overload. Moreover, they felt
that the intervention should be extended to all family caregivers. These results are similar
to those reported by Lleixà-Fortuño et al. (2015) [40], who designed a web 2.0 website
for the carers of patients with chronic problems and who found that user satisfaction was
higher than 93% and that a similar percentage of carers would recommend the website to
other caregivers. Likewise, Ferré-Grau et al. (2021) [65] found that satisfaction with their
app-based intervention was high among users, who stated that they would recommend it
to other carers. A large proportion of the users agreed that increasing the duration of the
program would be beneficial.

Limitations and Strengths

This study should be considered in the context of several limitations. First, all outcome
variables (i.e., perceived overload, PMH, and satisfaction) were assessed using self-reported
measures. Although all the questionnaires used have been validated and have good
psychometric properties [6,26,50], we have to point out that self-reported measures may
also have biases that can affect the results, such as social desirability bias. Secondly, the
effectiveness of the intervention has not been assessed in terms of objective variables, such
as the reduction in the number of hospital readmissions and the number of emergency visits
of affected family members, as well as the improvement in the physical health or economic
situation of caregivers. These limitations should be addressed in future studies, and longer-
term follow-ups would be useful to assess the consistency of the reported improvements.
Despite these limitations, the study also presents several noteworthy strengths. To
our knowledge, this is the first study exploring the effectiveness of the dialogue circles
nursing intervention. It is a novel intervention delivered online and useful for reducing
family caregiver overload and improving their PMH by creating a space for social support
and an opportunity for group reflection.

5. Conclusions
The results of this study suggest that nursing intervention in online dialogue circles
improves PMH and reduces the perception of caregiver overload. It offers satisfaction to
caregivers, as it makes them visible and allows them to interact with other people who
are going through the same situation. Likewise, the use of new technologies to carry out
nursing interventions favors the participation of caregivers, avoiding displacements and
saving them time.
Our study is, to our knowledge, the first to evaluate the nursing intervention of
dialogue circles. It is a novel intervention—all the more so because it is conducted online—
that appears to be effective in reducing family caregiver overload. The intervention may
also help to improve their PMH by creating a space that provides social support and an
opportunity for reflection in this group.
Int. J. Environ. Res. Public Health 2023, 20, 644 10 of 13

However, further studies are needed to determine whether this type of interven-
tion, whether face-to-face or online, can contribute to improving the care of patients with
chronic diseases and their families and thus respond to the current situation of social and
health care.

Author Contributions: Conceptualization, J.M.T.-C., M.P.-L., M.Á.H.-B. and M.T.L.-C.; methodology,

J.M.T.-C., M.P.-L., M.Á.H.-B., J.B.-S. and M.T.L.-C.; investigation, J.M.T.-C.; data curation, J.M.T.-C.,
J.R.-M., Z.A. and M.P.-L.; resources, M.C.M.-A., A.M.-P., M.A.S.-O. and J.B.-S.; formal analysis,
J.R.-M., Z.A. and J.M.T.-C.; writing—original draft preparation, J.M.T.-C.; writing—review and
editing, J.M.T.-C., M.P.-L., M.Á.H.-B., M.T.L.-C., M.C.M.-A., A.M.-P., J.B.-S., Z.A., M.A.S.-O. and
M.Á.H.-B.; supervision, J.M.T.-C., M.P.-L., M.Á.H.-B. and M.T.L.-C. visualization, J.M.T.-C., M.P.-L.,
M.Á.H.-B., Z.A. and M.T.L.-C.; project administration, J.M.T.-C.; funding acquisition, J.M.T.-C. All
authors have read and agreed to the published version of the manuscript.
Funding: This work was supported by the Fundació Infermeria I Societat, Grant Numbers (PR/1998).
This project received a grant for the translation and publication of this paper.
Institutional Review Board Statement: In accordance with the Declaration of Helsinki, the present
study was approved by the Ethics Committee of the authors’ institution [Clinical Research Ethics
Committee of the Jordi Gol Primary Care Research Institute (reference 20/112-PCV)]. All participants
signed the informed consent form. The study was registered at ClinicalTrials.gov (ID:NCT04993248).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data that support the findings of this study are available from the
corresponding author [M.P.-L.], upon reasonable request.
Acknowledgments: The authors thank their colleagues from the Unit for their support, especially
Paula Campresiós, Daniel Garcia, Iris Lumillo, and Jesus Vaquero del Baix Llobregat Center. The
authors thank all the nurses from the participating primary healthcare centers. The authors also
thank all the caregivers and patients for their contribution to this research.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or
in the decision to publish the results.

References
1. World Health Organization-WHO. Noncommunicable Diseases Country Profiles. 2018. Available online: https://apps.who.int/
iris/handle/10665/274512 (accessed on 18 October 2022).
2. Díez-Manglano, J. La Pluripatología, Un Reto Para Los Sistemas Sanitarios. Rev. Clin. Esp. 2017, 217, 207. [CrossRef] [PubMed]
3. Gual, N.; Yuste Font, A.; Enfedaque Montes, B.; Blay Pueyo, C.; Martín Álvarez, R.; Inzitari, M. Profile and Evolution of Chronic
Complex Patients in a Subacute Unit. Aten. Primaria 2017, 49, 510–517. [CrossRef] [PubMed]
4. Prat Martínez, M.; Bleda Garcia, S.; Edo Gual, M.; Pineda-Herrero, P. Learning Outcomes of Nursing Skills Related to Decision
Making in the Context of Care of the Chronic Patient with Complex Needs. Educ. Med. 2021, 22, 466–472. [CrossRef]
5. Wright, L.M.; Leahey, M. Nurses and Families A Guide to Family Assessment and Intervention, 6th ed.; References Scientific Research
Publishing; FA Davis Company: Philadelphia, PA, USA, 2013. Available online: https://www.scirp.org/(S(lz5mqp453edsnp5
5rrgjct55))/reference/ReferencesPapers.aspx?ReferenceID=1875806 (accessed on 18 October 2022).
6. Tartaglini, M.F.; Feldberg, C.; Hermida, P.D.; Heisecke, S.L.; Dillon, C.; Ofman, S.D.; Nuñez, M.L.; Somale, V. Escala de Sobrecarga
Del Cuidador de Zarit: Análisis de Sus Propiedades Psicométricas En Cuidadores Familiares Residentes En Buenos Aires,
Argentina. Neurol. Argent. 2020, 12, 27–35. [CrossRef]
7. Farquhar, M. Assessing Carer Needs in Chronic Obstructive Pulmonary Disease. Chronic. Respir. Dis. 2017, 15, 26–35. [CrossRef]
[PubMed]
8. Hsiao, C.Y.; Tsai, Y.F. Factors of Caregiver Burden and Family Functioning among Taiwanese Family Caregivers Living with
Schizophrenia. J. Clin. Nurs. 2015, 24, 1546–1556. [CrossRef]
9. Morais Duarte Miranda, G.; da Cruz Gouveia Mendes, A.; Lucia Andrade da Silva, A.; Oswaldo Cruz, F.; Gabriella Morais
Duarte Miranda, C. Population Aging in Brazil: Current and Future Social Challenges and Consequences. Rev. Bras. De Geriatr. E
Gerontol. 2016, 19, 507–519. [CrossRef]
10. Roth, D.L.; Fredman, L.; Haley, W.E. Informal Caregiving and Its Impact on Health: A Reappraisal from Population-Based Studies.
Gerontologist 2015, 55, 309–319. [CrossRef]
11. Guerra-Martín, M.D.; Amador-Marín, B.; Martínez-Montilla, J.M. Health Problems of Family Caregivers of People over 65
Suffering from Chronic Renal Failure: A Systematic Review. An. Del Sist. Sanit. De Navar. 2015, 38, 425–438. [CrossRef]
Int. J. Environ. Res. Public Health 2023, 20, 644 11 of 13

12. Moriarty, H.; Winter, L.; Short, T.H.; True, G. Exploration of Factors Related to Depressive Symptomatology in Family Members
of Military Veterans with Traumatic Brain Injury. J. Fam. Nurs. 2018, 24, 184–216. [CrossRef]
13. Ngangana, P.C.; Davis, B.L.; Burns, D.P.; McGee, Z.T.; Montgomery, A.J. Intra-Family Stressors among Adult Siblings Sharing
Caregiving for Parents. J. Adv. Nurs. 2016, 72, 3169–3181. [CrossRef] [PubMed]
14. Bove, D.G.; Zakrisson, A.B.; Midtgaard, J.; Lomborg, K.; Overgaard, D. Undefined and Unpredictable Responsibility: A Focus
Group Study of the Experiences of Informal Caregiver Spouses of Patients with Severe COPD. J. Clin. Nurs. 2016, 25, 483–493.
[CrossRef] [PubMed]
15. Rodrigues, A.M.; Ferré-Grau, C.; Ferreira, P.L. Being an Informal Caregiver of a Person with a Pressure Ulcer in the Azores
Islands. Adv. Skin. Wound Care 2015, 28, 452–459. [CrossRef] [PubMed]
16. Deek, H.; Hamilton, S.; Brown, N.; Inglis, S.C.; Digiacomo, M.; Newton, P.J.; Noureddine, S.; Macdonald, P.S.; Davidson, P.M.
Family-Centred Approaches to Healthcare Interventions in Chronic Diseases in Adults: A Quantitative Systematic Review. J. Adv.
Nurs. 2016, 72, 968–979. [CrossRef] [PubMed]
17. Pucciarelli, G.; Ausili, D.; Galbussera, A.A.; Rebora, P.; Savini, S.; Simeone, S.; Alvaro, R.; Vellone, E. Quality of Life, Anxiety,
Depression and Burden among Stroke Caregivers: A Longitudinal, Observational Multicentre Study. J. Adv. Nurs. 2018, 74,
1875–1887. [CrossRef]
18. Rossinot, H.; Marquestaut, O.; de Stampa, M. The Experience of Patients and Family Caregivers during Hospital-at-Home in
France. BMC Health Serv. Res. 2019, 19, 470. [CrossRef]
19. Síndrome de Sobrecarga Del Cuidador. Available online: https://www.gerontologica.com/articulo-interes/sindrome-de-
sobrecarga-del-cuidador (accessed on 18 October 2022).
20. Corry, M.; While, A.; Neenan, K.; Smith, V. A Systematic Review of Systematic Reviews on Interventions for Caregivers of People
with Chronic Conditions. J. Adv. Nurs. 2015, 71, 718–734. [CrossRef]
21. Thomas, S.; Dalton, J.; Harden, M.; Eastwood, A.; Parker, G. Updated Meta-Review of Evidence on Support for Carers. Health
Serv. Deliv. Res. 2017, 5, 1–132. [CrossRef]
22. Faronbi, J.O.; Faronbi, G.O.; Ayamolowo, S.J.; Olaogun, A.A. Caring for the Seniors with Chronic Illness: The Lived Experience of
Caregivers of Older Adults. Arch. Gerontol. Geriatr. 2019, 82, 8–14. [CrossRef]
23. Ferré-Bergadà, M.; Valls, A.; Raigal-Aran, L.; Lorca-Cabrera, J.; Albacar-Riobóo, N.; Lluch-Canut, T.; Ferré-Grau, C. A Method to
Determine a Personalized Set of Online Exercises for Improving the Positive Mental Health of a Caregiver of a Chronically Ill
Patient. BMC Med. Inform. Decis. Mak. 2021, 21, 74. [CrossRef]
24. Bustillo, M.L.; Gómez-Gutiérrez, M.; Guillén, A.I. Informal Caregivers for Dependent Elderly People: A Revision of Psychological
Interventions over the Last Ten Years. Clin. Salud. 2018, 29, 89–100. [CrossRef]
25. Ferré-Grau, C.; Sevilla-Casado, M.; Lleixá-Fortuño, M.; Aparicio-Casals, M.R.; Cid-Buera, D.; Rodero-Sanchez, V.; Vives-Relats, C.
Effectiveness of Problem-Solving Technique in Caring for Family Caregivers: A Clinical Trial Study in an Urban Area of Catalonia
(Spain). J. Clin. Nurs. 2014, 23, 288–295. [CrossRef] [PubMed]
26. Parra-Vidales, E.; Soto-Pérez, F.; Perea-Bartolomé, M.; Franco-Martín, M.; Muñoz-Sánchez, J. Intervenciones Online Para
Cuidadores de Personas Con Demencia: Revisión Sistemática. Actas. Esp. Psiquiatr. 2017, 45, 116–126. [PubMed]
27. Corry, M.; Neenan, K.; Brabyn, S.; Sheaf, G.; Smith, V. Telephone Interventions, Delivered by Healthcare Professionals, for
Providing Education and Psychosocial Support for Informal Caregivers of Adults with Diagnosed Illnesses. Cochrane Database
Syst. Rev. 2019, 2019, CD012533. [CrossRef]
28. Liu, Z.; Sun, Y.-Y.; Zhong, B. Mindfulness-Based Stress Reduction for Family Carers of People with Dementia. Cochrane Database
Syst. Rev. 2018, 2018, CD012791. [CrossRef]
29. Treanor, C.J.; Santin, O.; Prue, G.; Coleman, H.; Cardwell, C.R.; O’halloran, P.; Donnelly, M. Psychosocial Interventions for
Informal Caregivers of People Living with Cancer. Cochrane Database Syst. Rev. 2019, 2019, CD009912. [CrossRef]
30. Mittelman, M.S.; Roth, D.L.; Coon, D.W.; Haley, W.E. Sustained Benefit of Supportive Intervention for Depressive Symptoms in
Caregivers of Patients with Alzheimer’s Disease. Am. J. Psychiatry 2004, 161, 850–856. [CrossRef]
31. Bakas, T.; Austin, J.K.; Habermann, B.; Jessup, N.M.; McLennon, S.M.; Mitchell, P.H.; Morrison, G.; Yang, Z.; Stump, T.E.; Weaver,
M.T. Telephone Assessment and Skill-Building Kit for Stroke Caregivers: A Randomized Controlled Clinical Trial. Stroke 2015, 46,
3478–3487. [CrossRef]
32. Moskowitz, J.T.; Cheung, E.O.; Snowberg, K.E.; Verstaen, A.; Merrilees, J.; Salsman, J.M.; Dowling, G.A. Randomized Controlled
Trial of a Facilitated Online Positive Emotion Regulation Intervention for Dementia Caregivers. Health Psychol. 2019, 38, 391–402.
[CrossRef]
33. Pfeiffer, K.; Beische, D.; Hautzinger, M.; Berry, J.W.; Wengert, J.; Hoffrichter, R.; Becker, C.; van Schayck, R.; Elliott, T.R. Telephone-
Based Problem-Solving Intervention for Family Caregivers of Stroke Survivors: A Randomized Controlled Trial. J. Consult. Clin.
Psychol. 2014, 82, 628–643. [CrossRef]
34. Cuthbert, C.A.; King-Shier, K.M.; Ruether, J.D.; Tapp, D.M.; Wytsma-Fisher, K.; Fung, T.S.; Nicole Culos-Reed, S. The Effects of
Exercise on Physical and Psychological Outcomes in Cancer Caregivers: Results From the RECHARGE Randomized Controlled
Trial. Ann. Behav. Med. 2018, 52, 645–661. [CrossRef] [PubMed]
35. Gómez, Á.M.O. Programa de Intervención Cognoscitivo Conductual En La Calidad de Sueño de Cuidadores Familiares. Rev.
Colomb. De Enfermería 2012, 7, 75–85. [CrossRef]
Int. J. Environ. Res. Public Health 2023, 20, 644 12 of 13

36. Javier, L.; Instituto de Mayores y Servicios Sociales (Espanya). El Apoyo a Los Cuidadores de Familiares Mayores
Dependientes En El Hogar: Desarrollo Del Programa “Cómo Mantener Su Bienestar”. 2007. Available online: https:
//www.academia.edu/39265058/El_apoyo_a_los_cuidadores_de_familiares_mayores_dependientes_en_el_hogar_desarrollo_
del_programa_C%C3%B3mo_mantener_su_bienestar_ (accessed on 17 November 2022).
37. Zabalegui Yárnoz, A.; Navarro Díez, M.; Cabrera Torres, E.; Fernández-Puebla, A.G.; Bardallo Porras, D.; Rodríguez Higueras, E.;
Gual García, P.; Fernández Capo, M.; Argemí Remon, J. Eficacia de Las Intervenciones Dirigidas a Cuidadores Principales de
Personas Dependientes Mayores de 65 Años. Una Revisión Sistemática. Rev. Esp. Geriatr. Gerontol. 2008, 43, 157–166. [CrossRef]
[PubMed]
38. Blom, M.M.; Bosmans, J.E.; Cuijpers, P.; Zarit, S.H.; Pot, A.M. Effectiveness and Cost-Effectiveness of an Internet Intervention for
Family Caregivers of People with Dementia: Design of a Randomized Controlled Trial. BMC Psychiatry 2013, 13, 17. [CrossRef]
[PubMed]
39. Cristancho-Lacroix, V.; Moulin, F.; Wrobel, J.; Batrancourt, B.; Plichart, M.; de Rotrou, J.; Cantegreil-Kallen, I.; Rigaud, A.-S. A
Web-Based Program for Informal Caregivers of Persons with Alzheimer’s Disease: An Iterative User-Centered Design. JMIR Res.
Protoc. 2014, 3, e46. [CrossRef]
40. Mar, D.; Fortuño, L.; Montserrat, D.; Martínez, G.; Maria, D.; Canut, T.L.; Merino, J.R.; Cinta, D.; Vidal, E.; Carme, D.; et al. Diseño
de Una Web 2.0 Para Cuidadoras de Personas Con Problemas Crónicos de Salud. Pixel-Bit. Rev. De Medios Y Educ. 2015, 47,
149–161. [CrossRef]
41. Ferré-Grau, C.; Raigal-Aran, L.; Lorca-Cabrera, J.; Ferré-Bergadá, M.; Lleixà-Fortuño, M.; Lluch-Canut, M.T.; Puig-Llobet, M.;
Albacar-Riobóo, N. A Multi-Centre, Randomized, 3-Month Study to Evaluate the Efficacy of a Smartphone App to Increase
Caregiver’s Positive Mental Health. BMC Public Health 2019, 19, 888. [CrossRef]
42. Fuller-Tyszkiewicz, M.; Richardson, B.; Little, K.; Teague, S.; Hartley-Clark, L.; Capic, T.; Khor, S.; Cummins, R.A.; Olsson, C.A.;
Hutchinson, D. Efficacy of a Smartphone App Intervention for Reducing Caregiver Stress: Randomized Controlled Trial. JMIR
Ment. Health 2020, 7, e17541. [CrossRef]
43. Sweet, C.M.C.; Li, E.J.; Sagui-Henson, S.; Chamberlain, C.E.W.; Altman, M. Impact of Online Group Psychoeducation and Support
Sessions on Receptivity Towards Digital Mental Health Care During the COVID-19 Pandemic: A Pilot Study. J. Technol. Behav. Sci.
2022, 1–9. [CrossRef]
44. Ghanbari, E.; Yektatalab, S.; Mehrabi, M. Effects of Psychoeducational Interventions Using Mobile Apps and Mobile-Based
Online Group Discussions on Anxiety and Self-Esteem in Women with Breast Cancer: Randomized Controlled Trial. MIR Mhealth
Uhealth 2021, 9, e19262. [CrossRef]
45. Camarena, J.M.T.; Cruzado, J.V.; Llobet, M.P.; Blanco, M.Á.H.; Canut, M.T.L.; Arroyo, M.C.M. Intervención Enfermera “Círculos de
Diálogo” Para La Disminución Del Nivel de Sobrecarga de Cuidadores de Pacientes Crónico Complejos y Con Enfermedad Crónica
Avanzada. 2021. Available online: https://dialnet.unirioja.es/servlet/articulo?codigo=7843709 (accessed on 17 November 2022).
46. De Souza, J.B.; Heidemann, I.T.S.B.; Massaroli, A.; Geremia, D.S. Health Promotion in Coping with COVID-19: A Virtual Culture
Circle Experience. Rev. Bras. Enferm. 2021, 74, e20200602. [CrossRef] [PubMed]
47. Regueiro Martínez, A.Á.; Pérez-Vázquez, A.; Gómara Villabona, S.M.; Ferreiro Cruz, M.C. Escala de Zarit Reducida Para La
Sobrecarga Del Cuidador En Atención Primaria. Aten. Primaria 2007, 39, 185–188. [CrossRef] [PubMed]
48. Zarit, S.H.; Reever, K.E.; Bach-Peterson, J. Relatives of the Impaired Elderly: Correlates of Feelings of Burden. Gerontologist 1980,
20, 649–655. [CrossRef] [PubMed]
49. O’callaghan, C.A. OxMaR: Open Source Free Software for Online Minimization and Randomization for Clinical Trials. PLoS ONE
2014, 9, e110761. [CrossRef]
50. Lluch, M.T. Construcción de Una Escala Para Evaluar la Salud Mental Positiva. Ph.D. Thesis, Universidad de Barcelona, Barcelona,
Spain, 1999. Available online: https://www.tdx.cat/handle/10803/2366 (accessed on 17 November 2022).
51. Lluch-Canut, T.; Puig-Llobet, M.; Sánchez-Ortega, A.; Roldán-Merino, J.; Ferré-Grau, C.; Albacar, N.; Broncano, M.; Falcó-
Pegueroles, A.; Gelabert, S.; Lleixà, M.M.; et al. Assessing Positive Mental Health in People with Chronic Physical Health
Problems: Correlations with Socio-Demographic Variables and Physical Health Status. BMC Public Health 2013, 13, 928. [CrossRef]
52. Puig Llobet, M.; Sánchez Ortega, M.; Lluch-Canut, M.; Moreno-Arroyo, M.; Hidalgo Blanco, M.À.; Roldán-Merino, J. Positive
Mental Health and Self-Care in Patients with Chronic Physical Health Problems: Implications for Evidence-Based Practice.
Worldviews Evid. Based Nurs. 2020, 17, 293–300. [CrossRef]
53. Lluch, M.T. Decálogo de Salud Mental Positiva; Impresión Digital de la Universidad de Barcelona: Barcelona, Spain, 2011. Available
online: http://diposit.ub.edu/dspace/handle/2445/20062 (accessed on 17 November 2022).
54. Rodríguez-González, A.M.; Rodríguez-Míguez, E.; Duarte-Pérez, A.; Díaz-Sanisidro, E.; Barbosa-Álvarez, Á.; Clavería, A. Estudio
Observacional Transversal de La Sobrecarga En Cuidadoras Informales y Los Determinantes Relacionados Con La Atención a Las
Personas Dependientes. Aten. Primaria 2017, 49, 156–165. [CrossRef]
55. Shah, S.; Vanclay, F.; Cooper, B. Improving the Sensitivity of the Barthel Index for Stroke Rehabilitation. J. Clin. Epidemiol. 1989,
42, 703–709. [CrossRef]
56. Tulia Sánchez Martínez, R.; Milena, E.; Cardona, M.; Rocío Gómez-Ortega, O. Intervenciones de Enfermería Para Disminuir La
Sobrecarga En Cuidadores: Un Estudio Piloto. Rev. Cuid. 2016, 7, 1171–1184. [CrossRef]
57. Álvarez-Tello, M.; Casado-Mejía, R.; Ortega-Calvo, M.; Ruiz-Arias, E. Sobrecarga Sentida En Personas Cuidadoras Informales de
Pacientes Pluripatológicos En Una Zona Urbana. Enferm. Clin. 2012, 22, 286–292. [CrossRef]
Int. J. Environ. Res. Public Health 2023, 20, 644 13 of 13

58. Arango-Lasprilla, J.C.; Nicholls, E.; Cabrera, T.V.; Drew, A.; Jimenez-Maldonado, M.; Martinez-Cortes, M.L. Health-Related
Quality of Life in Caregivers of Individuals with Traumatic Brain Injury from Guadalajara, Mexico. J. Rehabil. Med. 2011, 43,
983–986. [CrossRef] [PubMed]
59. Arechabala, M.C.; Catoni, M.I.; Palma, E.; Barrios, S. Depresión y Autopercepción de La Carga Del Cuidado En Pacientes En
Hemodiálisis y Sus Cuidadores. Rev. Panam. De Salud Pública 2011, 30, 74–79. [CrossRef]
60. Minué-Lorenzo, S.; Fernández-Aguilar, C. Visión Crítica y Argumentación Sobre Los Programas de Atención de La Cronicidad
En Atención Primaria y Comunitaria. Aten. Primaria 2018, 50, 114–129. [CrossRef] [PubMed]
61. Ramón-Arbués, E.; Martínez-Abadía, B.; Martín-Gómez, S. Factores Determinantes de La Sobrecarga Del Cuidador. Estudio de
Las Diferencias de Género. Aten. Primaria 2017, 49, 308–309. [CrossRef] [PubMed]
62. Rubio Fernández, E.; Martínez Momblan, M.A.; Rosino Bosch, A.; Manresa Domínguez, J.M.; Ramos Fernández, A.; Torres
Quintana, A. Carga del cuidador principal informal del paciente crónico complejo y paciente crónico avanzado en dos centros de
urgencia de atención primaria de la provincia de Barcelona. Rev. Rol. Enferm. 2020, 43, 290–296.
63. Toffoletto, M.C.; Reynaldos-Grandón, K.L. Determinantes Sociales de Salud, Sobrecarga Familiar y Calidad de Vida de Cuidadores
Familiares de Pacientes Oncológicos En Cuidados Paliativos. Rev. De Salud Pública 2019, 21, 154–160. [CrossRef]
64. Elizabeth Flores, G.; Edith Rivas, R.; Fredy Seguel, P. burden level in performing the role of family caregivers of elderly with
severe dependence. Cienc. Y Enfermería 2012, 18, 29–41. [CrossRef]
65. Ferré-Grau, C.; Raigal-Aran, L.; Lorca-Cabrera, J.; Lluch-Canut, T.; Ferré-Bergadà, M.; Lleixá-Fortuño, M.; Puig-Llobet, M.;
Miguel-Ruiz, M.D.; Albacar-Riobóo, N. A Mobile App–Based Intervention Program for Nonprofessional Caregivers to Promote
Positive Mental Health: Randomized Controlled Trial. JMIR Mhealth Uhealth 2021, 9, e21708. [CrossRef]
66. Lopes Da Silva, M.C.; De, R.; Almeida, O.; Lopes Da, M.C.; Rosemary, S. Círculos de Diálogo: A Perspectiva Das Emoções Com
Os Professores. Perspectiva 2021, 39, 1–19. [CrossRef]
67. Freire, P. Pedagogia da Esperança: Um Reencontro com a Pedagogia do Oprimido. Editora Paz e Terra. 1987. Available online:
https://books.google.com.au/books?hl=en&lr=&id=I73NAgAAQBAJ&oi=fnd&pg=PT4&dq=%3DFreire,+P.+Pedagogia+da+
esperan%C3%A7a:+um+reencontro+com+a+pedagogia+do+oprimido.+Editora+Paz+e+Terra,+1987.&ots=q0b2z0S6nw&sig=
VeMEcSWpp86nNyHOntFzm9fZShw&redir_esc=y#v=onepage&q&f=false (accessed on 17 November 2022).

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.