Family caregivers' experience with healthcare and social care professionals and their participation in health checkups: A cross sectional study in Japan

Abstract Background For family caregivers, who are generally regarded as a vulnerable population, having regular checkups is a desirable health behavior. This study examined family caregivers' habit of having regular checkups prior to becoming involved with professionals who care for patients, and whether they had had recent checkups. We then examined the association between family caregivers' experience with professionals and their participation in checkups after adjusting for the past habit. Methods We conducted a cross sectional survey in Japan between November and December 2020. We recruited family caregivers who were aged 40–74 years and caring for community‐dwelling adult patients. The outcome variable was whether family caregivers had undergone any health checkups since April 2019. We assessed family caregivers' experience using the Japanese version of the Caregivers' Experience Instrument (J‐IEXPAC CAREGIVERS). Results Of the 1091 recruited family caregivers, 629 were included in the analysis. Of these, 358 had previously undergone regular checkups, and 158 had no checkups or selected the option “unknown.” Outcome rates in each group were 74.6% and 43.0%, respectively, and 62.0% for all 629 caregivers. Multivariate modified Poisson regression analysis revealed that among the J‐IEXPAC CAREGIVERS scores, only the domain score for attention for the caregiver was significantly associated with family caregivers' participation in checkups (adjusted prevalence ratio per 1 SD increase = 1.07; 95% CI 1.01–1.14). Conclusions Among family caregivers' experience with professionals, the factor that focused on caregivers themselves was significantly associated with their participation in checkups. This finding underscores the significance of caregiver‐focused care.


| INTRODUC TI ON
The rapidly aging world population and increasing incidence of chronic diseases is leading to a rise in the roles and needs of family caregivers as elderly patients (care recipients) increasingly rely on family members to support their daily activities. 1 Previous studies have reported that family caregivers have more problems with their psychological or physical health than noncaregivers. 2,3 Family caregivers are also reported to underutilize needed healthcare services, 4 and to tend to subordinate their own health needs to those of others. 5 Therefore, family caregivers are a population that warrants a strategic public health approach. Indeed, the Centers for Disease Control and Prevention (CDC) has released several calls to action in support of family caregivers. 6 These include encouraging family caregivers to have regular health checkups. 6 Having regular health checkups is a desirable health behavior for family caregivers. 7,8 Although the effectiveness of checkups in the general population is controversial, [9][10][11] checkups have been associated with controlling risk factors, incorporating preventive services, and improving patient-reported outcomes, 12 and are therefore considered particularly appropriate for vulnerable populations, such as those with low self-rated health and poor connection to primary care. 12 Family caregivers represent such a vulnerable group, [2][3][4][5] and having regular checkups is therefore a desirable health behavior. In countries like Japan and South Korea, where the government already recommends regular checkups for the general population, special attention is considered necessary to encourage family caregivers to undergo health checkups. 13,14 A recent examination of health checkups among family caregivers found that family caregivers who had more positive experiences with healthcare and social care professionals -in other words, positive interactions between the caregiver and the professionals who care for patients -were more likely to participate in health checkups. 15 This concept of experience has attracted attention as a means of evaluating the quality of professional care from the caregiver's perspective. 16,17 The authors suggested 15 that family caregivers with more positive experiences received more emotional support for their own health and well-being from professionals, and as a result may have paid more attention to their own health and tended to participate in checkups; to our knowledge, the study is the first to suggest an association between family caregiver experience with professionals who care for patients and their participation in health checkups.
Nevertheless, it has some limitations. First, the study was a secondary analysis of data from scale development, and the sample size was small. Second, there were potential unmeasured confounders. In particular, the study did not consider family caregivers' habit of having regular checkups prior to becoming involved with professionals who care for patients. Because such past habits may have a significant impact on participation in current checkups, we believe that adjusting for a past habit may lead to a more robust examination.
In this study, we first examined family caregivers' habit of having regular checkups prior to becoming involved with professionals who care for patients with chronic conditions, and whether they had had recent checkups. We then examined the association between family caregivers' experience with these professionals and their participation in health checkups after adjusting for possible confounders, including a past habit of having regular checkups.  18 The researchers instructed the care managers to recruit family caregivers consecutively, in order of their original appointments with patients and family caregivers. To be eligible, family caregivers were required to be caring for patients who were suffering from "chronic conditions." 19 All data on family caregivers were collected using a selfadministered questionnaire. The family caregivers provided informed consent via the questionnaires and directly returned the questionnaires by mail to the office of our university.

| Inclusion criteria
Study participants were eligible for this study if they were aged 40-74 years and had been using LTCI for ≥1 year. The Japanese government places particular emphasis on health checkups for people aged 40-74 years. 20

| Exclusion criteria
Family caregivers were excluded from the study if they answered ≥2 questionnaires per person, because caregivers caring for two or more people were instructed to limit their responses to the care of the most dependent patient; provided care with a frequency of "once or less in several days," 21 because family caregivers who provide less frequent care are reported to have limited contact with professionals 17 ; or had undergone any health checkups since April 2019 but before starting LTCI use, because the time at which family caregivers began engaging with professionals was chosen to represent the time of the first LTCI use.

| Outcome variable: Participation in health checkups
The outcome variable was whether family caregivers had un-  24 Because the CCM places importance on the systematization of primary care, 25 IEXPAC scales were designed to evaluate a range of professionals, rather than any specific one.
J-IEXPAC CAREGIVERS evaluates professionals such as primary care physicians, nurses and care managers from the family caregiver's perspective. This scale consists of two dimensions-attention for the patient and attention for the caregiver. The former dimension captures the process by which professionals work with caregivers to provide care for patients and the latter captures the process by which professionals provide care to family caregivers as co-clients.
Each item is rated on a five-point Likert scale ranging from 1 (Never) to 5 (Always). A scale score is calculated by simply summing the scores for each of 12 items, with total scores ranging from 12 to 60.
A higher total score indicates higher quality of integrated care from the caregiver's perspective. The internal consistency (Cronbach's alpha) determined in the J-IEXPAC CAREGIVERS development study was 0.92. 23

| Covariates
Based on studies that examined factors that affect participation in disease screening or health promotion behaviors among family caregivers, 14,26,27 we included the following as possible confounders in the association between family caregivers' experience and their participation in health checkups: age, gender, relationship with care recipient, self-rated health, type of insurance, educational attainment, annual household income, municipality of residence, caregiving time, caregivers' experience as patients (caregivers' PX), social support by relatives or acquaintances and participation behavior in health checkups before starting LTCI use. Caregiving time was determined using a question based on the CSLC questionnaire. 21 Because daily caregiving time strongly reflects patient deficiencies in activities of daily living, 28 we did not include the patients' functional status as a covariate in the present study. Caregivers' PX was measured using the Japanese version of Primary Care Assessment Tool Short Form (JPCAT-SF). 29 We first assessed whether the subject had a usual source of care and, if so, measured PX in primary care with the overall JPCAT-SF score. To determine social support by relatives or acquaintances, we measured emotional support, which has in particular been shown to be associated with preventive health behaviors. 30,31 Because the breadth of our questionnaire was limited, we used the following item to determine emotional support based on previous research 32 : "I have relatives or acquaintances who listen to my worries and fears (other than the professionals who care for me and my loved ones)." Participants chose from responses ranging from 1 (Disagree) to 5 (Agree).

| Statistical analysis
We reported the characteristics of family caregivers and the distribution of the J-IEXPAC CAREGIVERS score. We also described information about participation in health checkups before and whether they had had recent checkups. A robust (modified) Poisson regression model was used to determine whether the J-IEXPAC CAREGIVERS total score and each domain score were positively associated with participation in health checkups. We analyzed the unadjusted association between J-IEXPAC CAREGIVERS scores and outcome by calculating the crude prevalence ratio in bivariate regression.
In the multivariate regression, the variables described in "Covariates" were included as possible confounders. All variables except J-IEXPAC CAREGIVERS score and age were divided into multiple categorical variables. Municipality of residence was categorized into two groups (Appendix S1). Caregivers' PX was categorized into four groups: no usual source of care or unknown, and tertiles of JPCAT-SF total score. Social support by relatives or acquaintances was categorized into three groups: disagree or partly disagree, neither agree nor disagree, and partly agree or agree, based on a previous study. 31 Participation behavior in health checkups before starting LTCI use was categorized into the following three groups by combining the "no participation" and "unknown" options into one category: regular participation, occasional participation, and no participation or unknown. We included each J-IEXPAC CAREGIVERS score separately in the model and interpreted the results without Bonferroni correction. Participants with missing data were excluded from all analyses. Since the use of logistic regression analysis was planned during the study planning stage, the sample size setting and the results of logistic regression analysis are presented as a supplement (Appendix S2). Statistical analyses were conducted using SPSS Statistics version 28 (IBM Corp.).

| Participants' characteristics and descriptive analysis of the J-IEXPAC CAREGIVERS score
Of the 1091 recruited family caregivers, 887 (81.3%) responded to the questionnaire. Figure 1 shows a flow chart of the study participants, with 629 (57.7% of 1091) ultimately included in the analysis. Table 1 shows the characteristics of the 629 family caregivers.
Median age was 62 years, and the majority were women (74.7%). Table 2 shows the mean and standard deviation (SD) of the J-IEXPAC CAREGIVERS total score and the proportion of family caregivers who responded "always" or "almost always" to each J-IEXPAC  Table 3 Table 4 shows the results of bivariate and multivariate modified Poisson regression analyses of the association of J-IEXPAC CAREGIVERS scores with family caregivers' participation in health checkups. In bivariate (unadjusted) models, the J-IEXPAC CAREGIVERS total score and the domain score for attention for the caregiver were significantly associated with family caregivers' participation in health checkups.

| Associations of J-IEXPAC CAREGIVERS score with family caregiver participation in health checkups
After adjusting for possible confounders, only the domain score for attention for the caregiver was positively associated with family caregivers' participation in health checkups (adjusted prevalence ratio per 1 SD increase = 1.07; 95% CI 1.01-1.14).

| DISCUSS ION
We first examined family caregivers' habit of having regular checkups prior to becoming involved with professionals who care for patients, and whether they had had recent checkups. We found that Attention for the caregiver (items 9, 10, 11, and 12)

Always/almost always responses (%)
1. They respect the lifestyle of the person I care for 72.7 2. They are coordinated to offer us good care 52.9 3. They help me become informed via the Internet 12. TA B L E 2 Japanese version of the Caregivers' experience instrument (J-IEXPAC CAREGIVERS) score and the proportion of family caregivers who selected "always" or "almost always" to each J-IEXPAC CAREGIVERS item (N = 629).
significantly associated with participation in health checkups was attention for the caregiver. This differs from the results of a previous preliminary analysis, in which all scores were significantly associated with participation in health checkups. 15 The significance of the domain score for attention for the caregiver was common in both studies, which is theoretically understandable because the main construct of this domain is the family caregiver's perception of whether the caregiver has professional care support for his or her own health and well-being, and to obtain information to help acquire such support.
Interpersonal relationships in facilitating and preserving well-being prevents and buffers stress; increases connectedness, control and self-esteem; and consequently promotes health behaviors. 37  we collected time-sensitive data on the timing of family caregivers' engagement with professionals and the occurrence of outcomes after this engagement, we believe that reverse causality is unlikely.

| CON CLUS ION
We found that one-quarter of family caregivers who had been in

PATI ENT CO N S ENT S TATEM ENT
All participants were volunteers and checked the box on the questionnaire indicating their intention to participate.

CLI N I C A L TR I A L R EG I S TR ATI O N
None.

CO N FLI C T O F I NTE R E S T
The authors have stated explicitly that there are no conflicts of interest in connection with this article.