The estimated number of caregivers in the U.S. exceeded 50 million in 2020, and the majority were relatives (89 %) who provided unpaid care for adults.1 Unpaid family caregivers are individuals who support family members, friends, or neighbors, primarily those experiencing significant or chronic health issues.2 As the role of a caregiver often begins unexpectedly and may evolve based on disease progression, family caregivers have more burden or distress than non-caregivers.1,3 In particular, the caregivers of people living with dementia undertake a wide range of tasks, from helping their care recipients perform activities of daily living to handling their emotional and behavioral changes. Thus, family caregivers who provide care to people with dementia spend more time and energy on caring compared to those who care for people without dementia.3,4

Caring for people living with dementia engenders challenges, often leading to increased levels of burden or strain.5 Among several models that define caregiver strain, Poulshock and Deimling ‘s framework is one that identifies physical, psychological, financial, and social aspects of caregiver strain.5,6 This model suggests that caring for individuals living with dementia can cause a high level of caregiver burden, leading to various aspects of caregiver strain and subsequent health issues within the caregiving population.5 This framework aligns with other research focusing on caregiver strain, dividing it into three main components—physical, psychological, financial strain 7, 8, 9, 10, 11 with some studies acknowledging additional aspects, such as social or spiritual domains.12, 13, 14

According to the previous research, the characteristics such as gender, age, relationship and cohabitation status with care recipients, social support, household income, educational level, care recipients’ symptoms, and caregiving intensity, contribute to the strain.5,15, 16, 17, 18 Consequently, increased strain may cause reduced quality of life, absenteeism at work, anxiety, depression, sleep disorders, pain, hypertension, diabetes, or stroke.19, 20, 21, 22, 23, 24, 25, 26, 27, 28 Therefore, caregiver strain resulting from dementia care can be closely related to the negative impact of caregiving on health status.

Engaging in self-care behaviors can offset the negative impact of caregiver strain on caregivers’ health.29, 30, 31 Self-care is defined as the capacity to think and act in ways that promote and maintain one's optimal health and well-being.32,33 Previous articles addressed the effects of self-care awareness and practices (e.g., healthy habits or physical activities) on caregiver burden and physical and emotional health among caregiver of people living with dementia.32,34,35 Doing self-care activities could also lead to reducing healthcare costs, alleviating morbidity, and improving well-being.32 Several studies examined the mediating role of self-care between caregiver strain and caregiver health. Jang et al.36 and Hricová37 addressed that self-care difficulties partially mediated the positive association between care responsibilities and emotional exhaustion among people caring for both their parents and children and health professionals working for the social and health services, respectively. A similar result was also reported by Han et al.38 ; self-care behavior had a mediating role when a higher level of caregiver burden was associated with worsened mental health between Chinese American family caregivers of people living with mental health issues.

Despite the benefits of self-care practices for improving caregivers’ health, those caring for people living with dementia often face difficulties in taking care of themselves. The self-care difficulty among this caregiving population arises, as they prioritize care recipients’ needs over theirs and obtain fewer available resources regarding self-care for themselves.35,39, 40, 41 The self-care difficulty among caregivers of people living with dementia may include unhealthy eating patterns, reduced physical activity, and sleep deprivation.42 Such difficulties caring for self among this population may counteract the positive effects of conducting self-care behaviors, such as reducing missed healthcare appointments, balancing between caring for self and managing their care recipients’ needs, reducing anxiety and depressive mood, and improving self-reported health status.31,35,43

As such, previous research indicated that there were links among caregiver strain, self-care, and health outcomes, and self-care might have a mediating role in the relationship between caregiver strain and the impact of caregiving on health. However, to the best of our knowledge, the mediating role of difficulty caring for self in the relationship between the caregiver strain and the impact of caregiving on health has not been examined in dementia caregiving research. Therefore, we aim to identify the relationship between caregiver strain and the impact of caregiving on caregivers’ health status, focusing on the caregivers of people living with dementia. Furthermore, we intend to examine the mediating role of caregivers’ self-care difficulty in this association. To tackle the study objectives, we used a national caregiving study conducted in 2019 by the National Alliance for Caregiving (NAC) and the American Association of Retired Persons (AARP).1 The research questions are as follows:

Are there associations among caregiver strain, self-care difficulty, and the impact of caregiving on health status in unpaid caregivers of people living with dementia?

Does self-care difficulty mediate the relationship between caregiver strain and the impact of caregiving on health?