Caregiving Appraisal and Social Support: Key Determinants of Quality of Life Among Caregivers of Individuals with Alcohol Use Disorder

Abstract

Background

Caregivers of individuals with alcohol use disorder (AUD) face unique challenges, including stigma and social isolation, that affect their emotional, physical and psychological well-being. According to Szmukler et al. (1996) stress-coping model, the Experience of Caregiving (EoC) and social support (SS) are crucial resources that help caregivers manage stress. This study examines how caregiving appraisals (positive: ECIP; negative: ECIN) and SS influence the quality of life (QoL) of caregivers.

Purpose

To explore the relationships between QoL, ECIP, ECIN and SS among caregivers of individuals with AUD and assess their collective impact on QoL.

Methods

Using purposive sampling, 128 family caregivers (18 males and 110 females) providing care to a male family member diagnosed with AUD were recruited from two psychiatric hospitals in Amritsar, Punjab. The mean age of the participants was 43.05 years (SD = 13.02). Participants completed the World Health Organisation Quality of Life–Brief Version (WHOQOL-BREF), Experience of Caregiving Inventory (ECI) and the Post Graduate Institute (PGI) Social Support Questionnaire (PGI-SSQ). Data were analysed using Pearson’s product–moment correlation and multiple regression analysis to identify predictors of QoL.

Results

Pearson’s product–moment correlation analysis revealed that QoL was significantly positively correlated with ECIP (r = 0.714, p < .01) and SS (r = 0.641, p < .01) and negatively correlated with ECIN (r = −0.679, p < .01). Multiple regression analysis indicated that ECIP, ECIN and SS together explained 64% of the variance in QoL, with ECIP emerging as the strongest predictor (β = 0.383).

Conclusion

QoL among AUD caregivers is significantly shaped by their caregiving appraisals and perceptions of SS. Interventions aimed at fostering positive appraisals and strengthening support systems are essential for improving caregiver well-being. Integrating caregiver-focused psychosocial interventions within routine addiction treatment services may further enhance long-term outcomes for both caregivers and patients.

Keywords

Stress and coping/stress management health and well-being family psychology substance abuse/addictions counselling

Alcohol dependence, also referred to as alcoholism or alcohol use disorder (AUD), is a chronic and often progressive medical condition marked by an individual’s inability to regulate their alcohol intake despite negative impacts on their physical, mental and social well-being.¹ According to the World Health Organisation, approximately 400 million individuals aged 15 years and older worldwide suffer from AUD, with around 209 million experiencing alcohol dependence.² In India, too, alcohol dependence is a significant concern, with 14.6% (160 million) of individuals aged 10–75 years consuming alcohol, including 29 million dependent users.³

AUD not only impacts the individual but also profoundly affects the family, making it a complex biopsychosocial phenomenon. Family members often serve as a crucial support system in the treatment and recovery process for those with substance dependence. However, supporting a loved one struggling with AUD can be deeply distressing for family caregivers, which in turn can negatively impact their quality of life (QoL). This disruption often makes family caregivers more vulnerable to developing mental health issues. Studies have shown that family caregivers of AUD patients experience higher levels of stress, lower well-being, increased depressive symptoms, poor sleep quality and an overall decline in QoL compared to non-caregivers.^{4, 5}

Early caregiving research primarily focused on the negative aspects of caregiving, especially caregiver burden.⁶ This concept, however, has been criticised for blaming all negative effects in a caregiver’s life on the patient’s illness, while ignoring factors such as life transitions, caregiver personality and social circumstances.⁷ Importantly, caregiving is not always seen as burdensome.⁸ Recent findings highlight that caregivers may experience positive aspects, such as increased sensitivity to others, re-evaluation of life priorities and inner strength.⁹ This has led to the development of the concept of caregiving appraisal, which assesses caregiving demands, considering both stressors and available resources, resulting in positive, negative or neutral perceptions.^{10, 11} Szmukler et al. (1996) stress-coping model describes the experience of caregiving (EoC) as an appraisal of both perceived threats and positive aspects of caregiving.¹² Studies have found that positive psychological appraisals are consistently linked to higher well-being among informal caregivers.¹³ Additionally, positive aspects of caregiving in dementia caregivers are associated with reduced depressive symptoms, burden and improved mental health, QoL, life satisfaction and self-efficacy.¹⁴ Furthermore, research has shown that stress appraisals influence both caregivers’ and patients’ QoL, with caregiver burden being a strong predictor of caregivers’ own QoL.¹⁵

Another key factor influencing caregivers’ QoL is social support (SS), defined as the presence or availability of individuals who provide care, value and love and on whom others can rely.¹⁶ Studies have identified a lack of SS as a key factor contributing to depressive symptoms among caregivers, with evidence showing that SS moderates the relationship between burden and anxiety.¹⁷ Similarly, it was found that while friend support directly reduced caregiver burden, it had little impact on patient QoL.¹⁸ Additionally, it was highlighted that SS strongly mediated the negative effects of psychological distress on QoL.¹⁹

Lazarus and Folkman’s (1984) stress and coping theory²⁰ provides a useful framework for examining the QoL among caregivers of individuals with AUD. Szmukler et al. (1996)¹² extended this framework to caregiving situations, conceptualising the EoC as an appraisal of both the threatening and positive aspects of the caregiving role. Caregivers can have a positive Experience of Caregiving Inventory–Positive (ECIP), a negative Experience of Caregiving Inventory–Negative (ECIN) or both, depending on the balance of stressors and resources in their caregiving context. According to the model, SS is a key factor that influences this appraisal, potentially impacting the caregiver’s overall well-being.

While existing research has extensively examined caregiving burden and the negative impacts on caregivers’ QoL, it has largely centred on caregivers of dementia and other chronic illnesses, with limited focus on those caring for individuals with AUD. Additionally, frameworks such as Szmukler et al. (1996) stress-coping model highlight the importance of positive and negative appraisals, yet there is a lack of targeted research exploring how these appraisals interact within the unique context of AUD caregiving, where factors such as stigma, social isolation and specific caregiving stressors may further exacerbate the caregiving experience. Moreover, despite substantial evidence that SS plays a crucial role in enhancing QoL for caregivers across various contexts, its specific impact on AUD caregivers is underexplored. Existing literature often overlooks how SS might interact with caregiving appraisals to influence the well-being of caregivers within the stigmatised and demanding environment of AUD caregiving.

The present study aimed to address this gap in the literature. Its objective was to examine the relationship between QoL and EoC as well as SS perception among caregivers of individuals with AUD. Additionally, the study sought to explore whether QoL can be predicted by EoC and SS. The proposed conceptual model depicting the predictive relationships of the positive and negative dimensions of EoC and SS with QoL is illustrated in Figure 1.

Hypotheses

QoL of caregivers will have a significant relationship with EoC and SS perception.

QoL of caregivers will have significant and positive relationships with ECIP and SS perception.

QoL of caregivers will have a significant and negative relationship with ECIN.

QoL in caregivers will be significantly predicted by EoC and SS perception.

QoL in caregivers will be significantly and positively predicted by ECIP and SS perception in caregivers.

QoL in caregivers will be significantly and negatively predicted by ECIN in caregivers.

Figure 1.

Proposed Conceptual Model Depicting the Predictive Relationships of Positive and Negative Dimensions of EoC and SS with QoL Among AUD Caregivers.

Method

Participants

The cross-sectional study was conducted as part of a comprehensive doctoral research project. The study was approved by the Institutional Ethics Committee of the university (Approval No. 1088/HG) and utilised a purposive sampling technique to gather data from 128 family caregivers, consisting of 18 males and 110 females, responsible for the care of a male family member with AUD. Written informed consent was obtained from all the participants. Data was collected from two psychiatric hospitals located in the city of Amritsar, Punjab. The recruitment phase spanned from August 2022 to January 2023. The average age of the participants was 43.05 years, with a standard deviation of 13.02 years. Potential participants underwent initial evaluations to confirm their alignment with specific inclusion and exclusion criteria.

Inclusion Criteria

Caregivers who were responsible for the care of a male family member aged between 20 and 65 years who had been diagnosed with AUD in accordance with the International Classification of Diseases (ICD)-11.

Male and female caregivers who were 18 years of age or older.

Exclusion Criteria

Caregivers who were providing care to a male family member with a dependency on substances other than alcohol (excluding nicotine) or who had any coexisting physical or psychiatric conditions.

Family members who were providing care to another family member diagnosed with a chronic physical illness or psychiatric disorder, apart from the patients themselves.

Caregivers who themselves were coping with a chronic physical ailment or a diagnosed mental health condition.

A family caregiver was operationally defined as an individual cohabiting with the patient and actively participating in the patient’s care for a duration of at least 1 year. In cases where more than one family caregiver met the outlined criteria, priority was granted to the individual who demonstrated a higher degree of involvement in the patient’s care.

Measures

World Health Organisation Quality of Life–Brief Version (WHOQOL-BREF)²¹: The QoL of caregivers was evaluated using the English version of WHOQOL-BREF, which is a condensed 26-item variant of the WHOQOL-100. This assessment tool measures four key domains: Physical capacity (seven items), psychological well-being (six items), social relationships (three items) and environmental health (eight items). The first two items assess the overall QoL and health, respectively. Responses were rated on a five-point Likert-type scale (1–5), with higher scores indicating a more positive perception of QoL. The split-half reliability analysis of the WHOQOL-BREF yielded a Spearman–Brown coefficient of 0.935, signifying excellent internal consistency.

Experience of Caregiving Inventory (ECI)¹²: The ECI is a self-report instrument comprising 66 items designed to assess the appraisal of caregiving situations for individuals providing care to individuals with severe mental illness. The ECI identifies 10 distinct dimensions in relatives’ appraisal of caregiving, encompassing eight negative dimensions and two positive dimensions. These negative and positive measures yield two overall scores: ECIN and ECIP. Respondents are required to indicate the frequency of specific thoughts over the past month, using a rating scale from zero (never) to four (nearly always). Higher scores on the ECIN subscale indicate more substantial negative appraisals, while elevated scores on the ECIP subscale denote heightened positive appraisals. In the present study, the positive and negative dimensions of the ECI scale showed strong reliability, with Spearman–Brown coefficients of 0.844 and 0.890, respectively.

PGI Social Support Questionnaire (PGI-SSQ)²²: The perception of SS in caregivers was assessed using the PGI-SSQ. This questionnaire consists of 18 items, each offering four response options ranging from fully agree to not agree. The cumulative total score obtained from the questionnaire serves as an indicator of the individual’s perceived level of SS, with higher scores indicating greater perceived support. The Spearman–Brown coefficient for the split-half reliability of the PGI-SSQ was calculated to be 0.743, indicating satisfactory internal consistency.

Procedure

Two psychiatric hospitals in Amritsar, Punjab, were approached for the process of data collection. Written approval was obtained from the authorities of the hospitals before the data collection began. Caregivers of male family members suffering from AUD were approached, briefed about the study’s objectives and their roles in the study and invited to participate. Efforts were made to establish rapport with the participants and confidentiality was assured. The diagnosis of AUD in patients was carried out by the psychiatrists/doctors of the respective hospitals. Caregivers who agreed to take part in the study were then assessed based on pre-established inclusion and exclusion criteria. Those who met the criteria were asked to provide written consent for their participation. Participants had the freedom to withdraw from the study at any point without facing any consequences. The assessment tools were individually administered to consenting participants with clear instructions provided according to the respective tests’ manuals.

Statistical Analysis

After collecting the data, the scoring of the questionnaires was done according to the instructions provided in the user manuals of the respective questionnaires. Subsequently, the data were analysed using the Statistical Package for the Social Sciences for Windows, version 21 (released in 2012, based in Armonk, New York). The study utilised descriptive statistics to characterise variables. The data distribution was assessed, with skewness and kurtosis both falling within the range of ±2, meeting the parametric limits. Pearson’s product–moment correlation was used to evaluate relationships between variables and QoL, followed by multiple regression analysis to determine predictors of caregivers’ QoL.

Results

The demographic details of patients and caregivers, including age, education, occupation, marital status and caregiving roles, have been reported in detail in previous work.23 Briefly, the patients’ ages ranged from 20 to 65 years, with a mean age of 41 years, while caregivers’ ages ranged from 18 to 80 years, with a mean age of 43.05 years. Most patients were engaged in clerical/shop owner/farmer roles and the majority of caregivers were homemakers. Spouses constituted 65.63% of caregivers, emphasising the critical role of spousal caregiving in managing AUD. The duration of caregiving varied, with a significant proportion providing care for 1–2 years.

Table 1 presents the descriptive statistics for the variables under study (N = 128). The skewness and kurtosis values for all variables were within acceptable ranges, suggesting that the data approximates a normal distribution, making it suitable for parametric analysis. Similarly, Table 2 illustrates the results of the correlation analysis, showing strong positive correlations of ECIP (r = 0.714) and SS (r = 0.641) with QoL, indicating that positive caregiving appraisals and better perceived SS are linked to higher QoL. Conversely, ECIN had a strong negative correlation with QoL (r = −0.679), suggesting that negative caregiving appraisals are associated with lower QoL.

Table 1.

Showing the Frequency Distributions of Means, Standard Deviations, Skewness and Kurtosis for all Variables Under Study (N = 128).

Variables	Mean	SD	Skewness	Kurtosis
Quality of life	84.13	18.7	−0.127	−0.497
Experience of Caregiving Inventory–Positive	33.804	13.56	−0.081	−1.116
Experience of Caregiving Inventory–Negative	90.07	46.45	−0.233	−0.846
Social support	50.88	9.45	−0.526	0.150

Table 2.

Showing Correlation Coefficients of Predictor Variables with Quality of Life (N = 128).

Predictor Variables	Quality of Life
Experience of Caregiving Inventory–Positive	0.714*
Experience of Caregiving Inventory–Negative	−0.679*
Social support	0.641*

Note: *p < .01 (two-tailed).

Furthermore, Table 3 presents the results of multiple regression analysis, with QoL as the criterion variable and ECIP, ECIN and SS as predictor variables. The analysis revealed that 64.3% of the variance in QoL was explained by the combination of positive and negative caregiving appraisals and perceived SS. Among these predictors, ECIP was the most significant contributor to QoL (β = 0.383), followed by SS (β = 0.318). ECIN also significantly impacted QoL but in a negative direction (β = −0.245). This suggests that enhancing positive caregiving appraisal and perception of SS could substantially improve caregivers’ QoL, while mitigating negative appraisal is equally crucial.

Table 3.

Summary Table Showing Results of Multiple Regression Analysis.

Criterion	Predictor	t	B	p Value
Quality of life	Experience of Caregiving Inventory–Positive	4.997	0.383	<.001
	Experience of Caregiving Inventory–Negative	−3.155	−0.245	.002
	Social support	4.916	0.318	<.001
R	0.802
R square	0.643

Note: F = 74.569, p < .001.

In summary, the results from the correlation and regression analyses support the hypotheses 1a, 1b, 2a and 2b, confirming the significant impact of caregiving appraisals and SS on the QoL of family caregivers of individuals with AUD. These findings emphasise the complex interplay between the positive and negative aspects of caregiving appraisal and the critical role of SS in shaping caregivers’ well-being.

Discussion

The main objective of this study was to explore the connection between the QoL of caregivers and their appraisal of caregiving situations and SS. The findings clearly show that positive caregiving appraisals and strong SS are linked to higher QoL, while negative caregiving appraisals are associated with lower QoL. Over 64% of the variance in QoL was explained by the combination of ECIP, ECIN and SS, emphasising the critical role these factors play in caregiver well-being.

The finding that positive appraisals of caregiving significantly contribute to the well-being of caregivers is consistent with previous studies.^{8, 24} Within the Indian sociocultural context, caregiving is deeply embedded in familial obligation, moral duty (dharma) and collectivistic values, where caring for an ill family member—particularly within close kinship networks—is often viewed as a normative and expected role rather than a discretionary choice. Positive caregiving appraisals in such contexts may stem not only from personal satisfaction but also from culturally reinforced meanings attached to caregiving, such as fulfilling responsibility, maintaining family honour and upholding interdependence within the family system.

According to equity theory, maintaining balance in the caregiver-care receiver relationship is crucial for satisfaction.²⁵ However, in Indian family structures, where hierarchical and role-based expectations are common, the notion of equity may be interpreted differently compared to Western individualistic settings. Caregivers may continue to provide care despite perceived imbalance, driven by long-standing emotional bonds, cultural norms of sacrifice and the prioritisation of family needs over individual well-being. The onset of AUD often disrupts this balance, leading to emotional challenges for the caregiver.²⁶ However, McPherson et al. (2011) argue that while balance is typically vital, its significance may diminish when one party is in need.²⁷ This perspective aligns with findings from Indian caregiving contexts, where caregivers may derive meaning and emotional fulfilment from caregiving despite substantial burden, particularly when the relationship with the care recipient is strong and enduring.⁷ Such culturally embedded interpretations of caregiving may partly explain the strong positive association between ECIP and QoL observed in the present study.

Conversely, negative caregiving appraisals emerged as a significant negative predictor of QoL. Caregivers who evaluate caregiving negatively experience lower QoL, which aligns with past studies that identified negative caregiver appraisal as a key factor in psychological morbidity.^{13, 28} In India, caregiving for individuals with AUD is often compounded by pronounced stigma surrounding substance use disorders, which extends beyond the individual to the family unit.²⁹ Caregiving stressors such as managing substance use, aggression, mood instability and interpersonal conflicts further contribute to emotional exhaustion, anxiety and helplessness, thereby reducing overall QoL.^{30, 31} These stressors may be particularly salient in Indian households, where limited access to formal caregiving services places the primary caregiving burden almost exclusively on family members.

Similarly, SS emerged as a substantial positive predictor of QoL. The findings reinforce previous evidence highlighting SS as a critical determinant of caregiver well-being.^{32, 33} In the Indian context, SS is often derived from extended family networks, neighbours and community ties, which can play a compensatory role in the absence of formal mental health and caregiving services. SS among caregivers of individuals with AUD may manifest in various forms, such as in the form of instrumental support, informational support and emotional support. Instrumental support provides practical help, reducing the caregiver’s workload and stress.³⁴ Informational support helps caregivers access vital information, making it easier to manage caregiving responsibilities.³⁵ Last, emotional support offers a buffer against the challenges of caregiving, reducing feelings of loneliness and distress.³⁶ As caregiving continues over time, the importance of emotional support increases, fostering resilience and improving psychological well-being.³⁷ The strong predictive role of SS observed in this study highlights the protective function of culturally embedded social networks in India.

Overall, the study underscores the critical role of both caregiving appraisals and SS in shaping the QoL of caregivers of individuals with AUD. Positive caregiving appraisals and strong SS networks significantly enhance caregivers’ QoL, while negative appraisals detract from it. The findings suggest that improving caregivers’ perspectives on caregiving and strengthening their SS can significantly improve their well-being.

In clinical practice, mental health professionals should focus on helping caregivers recognise and cultivate positive aspects of caregiving, as well as providing them with the necessary support networks. Policies should be developed to provide comprehensive caregiver support services, such as respite care and community resources and integrate caregiver support into healthcare systems. Financial assistance and insurance coverage for caregiving expenses should be prioritised to alleviate the financial burden on caregivers.

Despite its contributions, the study has several limitations. The cross-sectional design restricts the ability to establish causality and the reliance on self-report measures may introduce biases. Future research should focus on longitudinal studies to explore the long-term effects of caregiving appraisals and SS on caregivers’ QoL. Additionally, mixed-method designs could provide more comprehensive insights into caregivers’ experiences.

Conclusion

In conclusion, this study highlights the significant factors influencing the QoL among caregivers of individuals with AUD, emphasising the critical roles of caregiving appraisals and SS. Positive caregiving appraisals were found to significantly enhance caregivers’ QoL, while negative appraisals were shown to diminish it. Additionally, SS emerged as a key determinant in improving caregivers’ well-being. The findings suggest that interventions aimed at fostering positive caregiving experiences and strengthening SS systems can substantially improve the QoL of caregivers in this population. This study also addresses an important gap in the literature by focusing on caregiving experiences in the context of AUD, a group often overlooked in research on caregiving dynamics. Future research should continue to explore these relationships, with an emphasis on longitudinal studies, mixed method designs and cultural considerations, to develop more tailored interventions and support strategies for AUD caregivers.

Footnotes

Abbreviations

AUD: alcohol use disorder

QoL: Quality of life

SS: Social support

ECIP: Experience of Caregiving Inventory–Positive

ECIN: Experience of Caregiving Inventory–Negative

Acknowledgements

The authors wish to extend their heartfelt gratitude to Prof. NS Tung (Retd.) and Dr Jeshtha Angrish for their invaluable support with the statistical analysis. Their expert guidance significantly enhanced the rigour and precision of this research.

Authors’ Contribution

HK and ST contributed to the concepts, design, definition of intellectual content, literature search, and data acquisition. HK, RD, and ST were involved in data analysis and statistical analysis. HK and RD prepared and edited the manuscript, while ST performed the manuscript review. HK serves as the guarantor.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

ICMJE Statement

The authors of this manuscript adhere to the authorship criteria established by the International Committee of Medical Journal Editors (ICMJE). They take public responsibility for the content and any discrepancies are resolved in accordance with ICMJE guidelines.

Statement of Ethics

Institutional Ethics Committee of Guru Nanak Dev University, Amritsar, Punjab, before the commencement of the study. Written informed consent was obtained from all participants before their involvement.

Informed Consent

Written informed consent was obtained from all participants prior to their inclusion in the study. Participants were briefed on the voluntary nature of their participation and the strict confidentiality of their responses. No financial or material incentives were provided for participation.

ORCID iD

Hunny Kalra

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