Acute pesticide poisoning is a major public health concern. The relationship between family function and depression in caregivers of patients with acute pesticide poisoning is unclear. Therefore, this study aimed to explore the relationship between family function, coping style, and depression among caregivers of patients with acute pesticide poisoning and to provide a theoretical basis and intervention targets for future research.

A cross-sectional study was conducted among caregivers of patients with acute pesticide poisoning in the Department of Toxicology and Occupational Disease of a Grade A hospital in Jinan, Shandong Province, from November 2022 to June 2023. A general data questionnaire, family caring index scale, simple coping style questionnaire, and health questionnaire depression symptom group scale were used to collect the data. Pearson correlation and a structural equation model were used for data analysis.

The average depression score of the caregivers was 5.66 ± 4.291, and the incidence of depression was 54.7%. The family function may directly or indirectly affect depression in caregivers through coping styles.

Future health education and interventions should focus on improving the family functioning of caregivers and encouraging positive coping mechanisms.

Acute pesticide poisoning is defined as any illness or adverse health effect resulting from suspected or confirmed exposure to a pesticide within 48 h. This condition can be classified into unintentional and intentional acute pesticide poisoning [1]. Approximately 385 million cases of unintentional pesticide poisoning are reported annually worldwide, with approximately 11,000 deaths [2]. However, most cases are intentional poisonings [3]. Since the 1960s, 14 million people have died by pesticide suicide [4], highlighting the severity of acute pesticide poisoning as a major public health concern. Studies have shown that patients with acute pesticide poisoning experience severe illness and high mortality [5, 6]. Long-term, intensive, and stressful caregiving responsibilities not only affect the physical and mental health of caregivers but also affect the quality of care they provide. However, caregivers often pay more attention to the needs and disease conditions of their patients and neglect their own health needs. Studies have demonstrated that caregivers of patients with acute pesticide poisoning are more likely to suffer from depression, which significantly affects their quality of life and care [7,8,9,10]. Therefore, in the context of family-centered nursing, health professionals should also pay attention to the mental health of caregivers of patients with acute pesticide poisoning, identify factors influencing depression, and provide appropriate interventions.

Many variables influence depression, especially the family environment and personal characteristics. In the caregiver adaptation model, the American scholar Kramer pointed out that in addition to the characteristics of patients and caregivers and the caregiving context, the resources available to caregivers in the caring process also affect how well they adapt to their caregiving role and the emotions they experience during the process. These resources usually include external (family support, external assets, etc.) and internal (coping styles, self-efficacy, etc.) resources [11]. The family is the most important and basic unit in human life, providing not only material guarantees for the survival and development of the individual but also important psychological and emotional support. Family function not only reflects the ability of the family as a whole to meet the needs of all family members but also refers to the care and support among family members [12]. Family function is closely related to the health status of family members and the occurrence and prognosis of various conditions, such as depression. Many studies have shown that good family function can alleviate depression in individuals, whereas poor family function leads to higher levels of depression [13,14,15]. Therefore, family function may be a protective factor against depression in caregivers of patients with acute pesticide poisoning. However, the relationship and mechanism between family function and depression in caregivers of patients with acute pesticide poisoning have not been discussed.

Coping style refers to the methods or strategies people adopt to survive their internal and external environments and related emotional distress. It can be divided into positive and negative coping strategies. Coping plays an important mediating role between stress and mental health [16]. Research shows [17, 18] that caregivers’ coping style is an intrinsic personal trait and is closely related to their mental health status. Positive coping styles can significantly reduce depression levels, whereas negative coping styles can aggravate it. The buffering effect model of social support points out that when an individual is under stress, social support can reduce the negative impact of stressful events by affecting the individual’s cognitive evaluation and coping style of stressful events [19]. A study of young adults whose parents had lung cancer indicated that good family function increases the likelihood that the individual would adopt a positive coping style [20]. It can be seen that family function, as a social resource available to caregivers, affects their coping styles. Combining theories and existing studies, we speculate that coping styles may play a mediating role in the relationship between family functioning and depression among caregivers of patients with acute pesticide poisoning.

The study combined the caregiver adaptation model and social support buffer effect model to explore the relationship between family function, coping style, and depression in caregivers of patients with acute pesticide poisoning for the first time, which will provide a theoretical basis and intervention targets for subsequent research.

In this cross-sectional study, convenience sampling was used to recruit caregivers of patients with acute pesticide poisoning as the study participants. The sampling was conducted in the Department of Poisoning and Occupational Disease of a grade A hospital in Jinan, Shandong Province, from November 2022 to June 2023. The inclusion criteria were as follows: (1) primary caregivers of patients with acute pesticide poisoning; (2) age ≥ 18 years and voluntary participation; (3) ability to read, write, and communicate; and (4) patients who stayed in the hospital for more than 3 days. Exclusion criteria were as follows: (1) participants with mental disorders; (2) care workers or a family member who is paid to care for a patient; (3) caregivers who previously participated in similar research; and (4) caregivers who experienced other major traumatic events (such as surgery, car accident, and natural disaster) in the past 6 months.

To sum up, with a large sample size, we need to issue at least 223 questionnaires.

Case reviews and field questionnaire surveys were conducted. The investigators selected the list of study participants from the department’s case system, and relevant information was verified from the participants. The investigators explained the purpose of the survey and the precautions to be taken while completing the questionnaires. The questionnaires were designed to assess the caregivers’ knowledge and understanding of the subject matter. Patients with a poisoning severity score (PSS) of 1–3 and a hospital stay of 3–7 days were selected to send questionnaires to their caregivers, which were completed and recovered immediately after the examination.

General information obtained from the questionnaire for patients and caregivers

The general information obtained through the questionnaire included age, sex, ethnicity, only child, religious belief, education level, occupation, marital status, family location, chronic disease history, monthly per capita household income, and relationship with the patient. Chronic diseases are short for chronic noncommunicable diseases. It refers to diseases that occur due to the gradual accumulation of genetic inheritance, personality traits, exposure to external pollutants, unhealthy lifestyles and habits, long-term mental fatigue, and mental imbalance [23].

Disease-related data

Disease-related data that were obtained included pesticide type, poisoning method, PSS score, payment method, mental illness history, and suicide attempt history.

Family APGAR

This scale was developed by Smilkstein in 1978 and is based on characteristics of family function [12]. The scale includes five components: family fitness, cooperation, growth, emotion, and intimacy, with each item scoring 0–2 points. A total score of 7–10 indicates good family function, a score of 4–6 indicates moderate impairment of family function, and a score of 0–3 indicates severe impairment of family function. The outcomes of employing the APGAR scale by both the authors and foreign researchers showed the correlation coefficient of retest reliability to be 0.80–0.83 [24]. In this section, Cronbach’s α was 0.726.

Simplified coping style questionnaire (SCSQ)

This questionnaire was adapted by Yaning Xieon, based on the coping style questionnaire compiled by Folkman and Lazarus [25]. This questionnaire was used to assess individuals’ coping styles in the face of stressful events, including the two strategies of positive and negative coping. There were 20 items in total, and the 4-point Likert scoring system was adopted. The scale has good reliability and validity; Cronbach’s α coefficient was 0.90, and Cronbach’s α coefficients for the positive and negative strategies were 0.89 and 0.78, respectively. In the study, the Cronbach’s α coefficient of this scale was 0.704, and Cronbach’s α coefficients for the positive and negative strategies were 0.808 and 0.710, respectively.

Patient health questionnaire 9-item scale (PHQ-9)

In 1999, Spitzer et al. compiled a set of nine items based on the diagnostic criteria of the fourth edition of the American Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). These items were used to screen for depressive disorders and evaluate the severity of symptoms [26]. The 4-point Likert scale was used, with the total score ranging from 0 to 27 points. A total score greater than 4 points indicated the presence of depressive symptoms; 5–9, 10–14, 15–19, and 20–27 indicated mild, moderate, moderately severe, and severe depression, respectively. The reliability and validity of the scale were good, and Cronbach’s α coefficient was 0.833. In the study, Cronbach’s α was 0.822.

The data were recorded in Microsoft Excel and analyzed using SPSS Statistics version 26.0 (IBM Corp., Armonk, N.Y., USA) and Amos 26.0 (IBM Corp.) software. Statistical significance was set at P < 0.05. Common method bias was analyzed using the Harman single-factor test. General demographic data were described using frequency and composition ratios. The scores of each variable were tested for normality. In cases where the data did not conform to a normal distribution, M (P25 and P75) was used to represent the data. When a normal distribution was exhibited, it was described as mean ± standard deviation (x ± s). Depression scores for different demographic groups were compared. Based on the results of the normality test, an independent sample t-test and one-way ANOVA were performed if a normal distribution was exhibited, and a nonparametric test was performed when a non-normal distribution was exhibited. Pearson’s correlation analysis or Spearman’s correlation analysis was used to explore correlations among variables. Amos 26.0 (IBM Corp.) was used to construct a structural equation model to verify the relationship between family function, coping style, and depression among caregivers of patients with acute pesticide poisoning. The mediation effect was tested using the bootstrapping method, with 5000 sampling iterations. A statistically significant mediation effect was indicated by the 95% confidence interval (CI) of the effect value excluding zero.

Since all data were collected using self-report questionnaires simultaneously, the Harman single-factor test was used before data analysis to analyze common method bias. Nine factors with feature roots greater than one were extracted from the results of the unrotated exploratory factor analysis. The maximum explanatory factor variance was 20.99% (below the critical value of 40%), indicating no significant common method bias.

In this study, 250 questionnaires were sent, of which 16 were incomplete and not included in the result analysis (response rate, 93.6%). The average age of the 234 patients with acute pesticide poisoning was 40.62 ± 18.59 years, and 109 (46.6%) of these patients were men. The patients mainly lived in rural areas (65.8%), and most were farmers (30.8%) or students (16.2%). The average age of caregivers of patients with acute pesticide poisoning was 40.04 ± 10.51 years, and there were slightly more female caregivers than male caregivers (Table 1).

The main sources of acute pesticide poisoning were diquat (30.3%) and paraquat (23.1%), and the major poisoning mode was nonproductive self-administration of pesticides (88.5%), as shown in Table 2.

The average depression score and incidence of depression among the caregivers were 5.66 ± 4.291 and 54.7%, respectively. Most caregivers were mildly depressed (83.1%). As shown in Table 3, the average scores of positive and negative coping mechanisms were 20.90 ± 6.294 and 10.41 ± 4.520, respectively, and the average score of family function was 6.95 ± 2.187. Correlation analysis showed that the caregivers’ family function and positive and negative coping strategies significantly correlated with depression (P < 0.001), and family function significantly correlated with positive and negative coping strategies (P < 0.05). However, no significant correlation was observed between the caregivers’ positive and negative coping strategies (P = 0.128), as shown in Tables 3 and 4.

The results of single factor analysis showed that there was no significant difference in depression scores among the patient’s demographic data (Table 5). In the disease-related data, the depression score of caregivers had a statistically significant difference in PSS score (P = 0.004) (Table 6). In the demographic data of caregivers, the depression scores of caregivers were statistically significant in four aspects: religious belief (P = 0.021), educational level (P = 0.001), monthly family income (P = 0.002), and chronic medical history (P = 0.006) (Table 7).

Amos software was used to construct the structural equation images, as shown in Fig. 1. The model had a good fit [χ² = 31.682, df = 18, χ²/df = 1.760, P = 0.024; root mean square error of approximation (RMSEA) = 0.057, 90% CI= (0.021–0.089), P = 0.328; goodness-of-fit index (GFI) = 0.966; adjusted goodness-of-fit index (AGFI) = 0.932; comparative fit index (CFI) = 0.964; Tucker–Lewis index (TLI) = 0.944]. The results of the bootstrapping test showed that the CI of the mediator variable was (-0.288, -0.114), with zero excluded, indicating that the mediation effect was significant. The total effect value of family function on depression was − 0.481, and the direct effect value was − 0.284 (59.04%). The indirect effect value was − 0.197 (40.96%), further indicating that coping style partially mediated the relationship between family function and depression (Table 8).

Mediation model. All coefficients in the figure were standardized. *P < 0.05, **P < 0.001

Full size image

In this study, more than half of caregivers (54.7%) reported depressive symptoms, indicating a need for attention and intervention regarding the well-being of caregivers in relation to such symptoms. The incidence of depression in this study was lower than in family members of suicidal patients who took oral organophosphorus pesticides (69%), which may be due to the fact that the patients in this study utilized more types of pesticides and poisoning modes [8]. Furthermore, the proportion of nonproductive self-administered pesticides in this study was remarkably high, reaching 88.5%, suggesting that intentional pesticide poisoning continues to be the main cause of acute pesticide poisoning.

The higher the patient’s PSS score, the higher the caregiver’s depression score, indicating that the sicker the patient, the more prone the caregiver to depression. The mortality rate of acute pesticide poisoning is relatively high, and the prognosis of patients is difficult to predict. However, caregivers pay great attention to the severity and prognosis of patients, which makes them prone to negative emotions. The results showed that religious caregivers had lower depression scores. In many multi-ethnic countries, religious belief as a form of spiritual sustenance has been shown to improve caregivers’ depression [27]. Education level is a protective factor for caregivers’ depression, and caregivers with higher education levels have lower depression scores, which is consistent with the results of Monahan [28]. When in a strange hospital environment, caregivers with high education levels have advantages in acquiring disease-related knowledge and making medical decisions and can better cope with emergencies. Caregivers with low monthly family income had higher depression scores, consistent with findings among caregivers of visually impaired children [29]. A good economic foundation can enhance the family’s ability to cope with diseases and reduce the psychological burden of caregivers. Good physical condition is also a protective factor for caregiver depression. Caregivers with chronic diseases may develop negative emotions such as self-blame, anxiety, and depression due to their inability to provide quality care to patients.

The family function of caregivers negatively correlated with depression; that is, the better the family function of caregivers was, the lower the level of depression. This finding is consistent with the findings of studies on caregivers of children with epilepsy, caregivers of patients with heart failure, and families of patients with acute stroke [15, 30, 31]. The buffering effect theory of social support states that social support during stress can cushion the negative impact of stressful events on an individual’s physical and mental state, thus protecting their physical and mental health [19]. As a crucial aspect of social support, good family function promotes mutual support and effective communication among family members. Conversely, poor family function reflects a lack of good communication among family members, often resulting in conflicts. When caregivers live in close, harmonious, and caring families, they take the initiative to obtain family and social resources. Simultaneously, they feel that their contributions are understood and recognized, enabling caregivers to solve problems independently and reduce negative emotions. In addition, family members of patients with suicidal thoughts often find it difficult to disclose the reasons for the patient’s hospitalization, fearing the stigmatization associated with the spread of such information. This makes it difficult for caregivers to obtain external support, and support provided between family members is particularly important at this time [32]. Thus, good family function is a protective factor against depression among caregivers of patients with acute pesticide poisoning.

Individuals inadequately equipped to deal with stressful events are at higher risk of adverse mental and psychological outcomes. Among caregivers of patients with acute pesticide poisoning, positive coping was negatively correlated with depression, whereas negative coping was positively correlated with depression. This finding is consistent with the findings of studies on caregivers of patients with cancer and children with cystic fibrosis; that is, positive coping styles can alleviate depression in caregivers, whereas negative coping styles can aggravate depression in caregivers [18, 33]. When encountering problems, caregivers who adopt a positive coping style will take the initiative to seek help from family and friends, obtain external resources, and improve their caregiving skills to better cope with the role transition and have a sense of achievement brought about by the caregiver role. This promotes overall positive feelings. In contrast, caregivers who adopt negative coping styles, mainly avoidance and fantasy, will not only provide a compromised quality of care but also experience physical and mental exhaustion and increased negative emotions [34].

To the best of our knowledge, this study is the first to explore the relationship between family function, coping styles, and depression among caregivers of patients with acute pesticide poisoning. Coping style was found to play a partial mediating role in the relationship between family function and depression. Coping style, as a behavioral strategy, can effectively relieve the psychological pressure on caregivers [33]. A study on caregivers of patients with dementia indicated that family function may influence post-traumatic growth through positive coping strategies [35]. Family members support each other and resist difficulties together. This positive support mechanism aligns with the findings of this study. In instances where caregivers of patients with acute pesticide poisoning encounter the stressful event of pesticide poisoning in their relatives, their initial response is to seek help from other family members. Caregivers with good family function feel the care and love of family members, have a positive perception of difficult situations, and encourage them to adopt more positive ways to solve difficulties and cope with pressure, thus reducing depression.

This study has several limitations. First of all, this is a cross-sectional study, and we did not assess the mental health status of caregivers before the patient was admitted to the hospital. In the future, we will consider longitudinal studies to further observe the changing trend of the mental health status of caregivers. Second, the study used a self-report questionnaire, which may lead to recall bias. Third, this study was a single-center study, and future research should focus on multicenter studies and employ large sample sizes.

AGFI:

Adjusted goodness-of-fit index

ANOVA:

Analysis of variance

CFI:

Comparative fit index

DSM-IV:

Diagnostic and statistical manual of mental disorders

GFI:

Goodness-of-fit index

PHQ-9:

Patient health questionnaire 9-item scale

PSS:

Poisoning severity score

RMSEA:

Root mean square error of approximation

SCSQ:

Simplified coping style questionnaire

SD:

Standard deviation

SPSS:

Statistical package for social sciences

TLI:

Tucker–Lewis index

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WZX, ZYX, SJ, JXD and KBT designed of the work; WZX, ZYX, SJ, ZYY, JTZ collected, analyzed, interpreted of data; WZX drafted the manuscript; JXD and KBT substantively revised it. All authors have read and agreed to the published version of the manuscript.

Correspondence to Xiangdong Jian or Baotian Kan.

This study was approved by the Ethics Committee of the School of Nursing and Rehabilitation at Shandong University (2022-R-124). All participants voluntarily participated in the study and provided informed consent. This survey was conducted in accordance with the principles of the Declaration of Helsinki.

All authors read and approved the manuscript and agree to be accountable for all aspects of the research to ensure that the accuracy or integrity of any part of the work is appropriately investigated and resolved.

The authors declare no competing interests.

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