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Impact of family care on sleep quality in perimenopausal women: mediating roles of anxiety and depression

BMC Women's Health volume 25, Article number: 19 (2025) Cite this article

Abstract

Background

This study aimed to investigate the relationship between family care, anxiety, depression, and sleep quality in perimenopausal women. Furthermore, it also aimed to examine the role of anxiety and depression in mediating family care and sleep quality. The study findings aim to provide theoretical support for alleviating anxiety and depression levels and improving sleep quality in perimenopausal women.

Methods

Perimenopausal women (n = 860) in Gansu Province were surveyed using the self-rating scale of sleep, self-rating anxiety scale, self-rating depression scale, and family adaptation partnership growth affection resolve.

Results

The sleep quality, anxiety, and depression scores of the perimenopausal women in Gansu Province were 25.33 ± 5.00, 40.74 ± 10.89, and 40.77 ± 10.03, respectively, and the family care score was 6.64 ± 2.36. Family care was negatively correlated with sleep quality, anxiety, and depression scores; anxiety was positively correlated with depression and sleep quality scores, and depression was positively correlated with sleep quality scores. Anxiety and depression in perimenopausal women partially mediated family care and sleep quality, with mediating effects accounting for 15.74% and 60.69% of the total effect, respectively.

Conclusion

Anxiety and depression are mediating variables between family care and sleep quality in perimenopausal women. It is recommended that hospital and community staff pay attention to the role of good family care in perimenopausal women, actively implement intervention strategies aimed at reducing anxiety and depression pathways, and improve their sleep quality.

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Background

In 1994, the World Health Organization proposed replacing the term ‘menopause’ with ‘perimenopause’ to describe the transitional stage women undergo from sexual maturity to old age [1]. In 2012, the International Reproductive Aging Staging Collaborative Group reaffirmed the staging standards for reproductive aging, known as the Stages of Reproductive Aging Workshop + 10 (STRAW + 10). This framework defines perimenopause as the period beginning with the menopausal transition and continuing until one year after the final menstrual period (FMP) [2, 3]. Recent statistics indicated that approximately 25 million middle-aged women worldwide enter perimenopause annually [4]. During this phase, a decline in ovarian function coupled with changes in metabolism, immunity, and hormone levels can lead to various symptoms [5]. Most perimenopausal women experience hot flashes, insomnia, and other symptoms primarily associated with autonomic nervous system dysfunction [6]. Research indicates that approximately one-third of perimenopausal women can achieve a neuroendocrine balanced state through self-regulation [7]. However, approximately two-thirds continue to experience neuroendocrine dysfunction for various reasons [8]. Among these symptoms, mental health issues, particularly anxiety and depression, are prevalent [9]. Studies have shown a strong correlation between perimenopausal symptoms and the incidence of depression, suggesting that more severe symptoms are associated with greater depressive symptoms [10, 11]. These mood disorders, specifically anxiety and depression, significantly impact both the physical and mental health, as well as the sleep quality, of perimenopausal women [10, 12].

Sleep quality is defined as an individual’s subjective assessment of various sleep parameters, including efficiency, latency, duration, and the frequency of awakenings after sleep [13]. Research indicates that sleep problems are most prevalent among pre- and perimenopausal women [14] with disorders characterised by difficulty falling asleep, insufficient sleep duration, and frequent awakenings, all of which significantly compromise sleep quality [15]. Notably, Chinese women’s perceptions of perimenopausal symptoms tend to be more conservative and traditional. Many view perimenopause as a natural phase of physiological change, considering it a necessary transition rather than a condition requiring intervention [16]. This mindset often results in limited awareness of perimenopause and insufficient recognition of the need for familial and medical support.

In the 1970s, the concept of family care was introduced, defined as an individual’s satisfaction with family dynamics through the support and care provided by family members; research has since highlighted the positive impact of family care on well-being [17]. Effective family care [18, 19] not only strengthens family cohesion but also facilitates emotional support, thereby reducing negative emotions and promoting positive feelings. Research has identified a correlation between family care and sleep quality, with higher levels of family support linked to improved sleep quality [20]. A harmonious family atmosphere and supportive relationships are beneficial to the sleep quality of individuals [21, 22]. Furthermore, family functioning has been shown to predict mental health, with effective family dynamics helping to alleviate anxiety, depression, and other negative emotions, thereby enhancing the overall quality of life [23].

Early studies on perimenopausal women explored anxiety and depression levels and their correlations [24, 25]. Subsequent research by Mao et al. [26] confirmed that family support significantly influences depression and the quality of life in perimenopausal women, although the results remain inconsistent. Additionally, limited research has investigated the potential mediating role of family care between anxiety, depression, and sleep quality [27]. Based on these considerations, we proposed the following hypothesis: (a) There is a correlation between perimenopausal women’s family care and their anxiety, depression and sleep quality. (b) Anxiety and depression in Perimenopausal Women may also regulate the relationship between family care and sleep disorders. It provides fresh insights into the interplay of these factors and scientific evidence for addressing sleep disorders, anxiety, and depression in perimenopausal women.

Methods

Inclusion criteria

A convenience sampling method was employed to randomly select perimenopausal women aged 45 to 60 years in Gansu Province.

The inclusion criteria were [27] (1) adherence to the WHO definition of perimenopause and (2) provision of informed consent and voluntary participation. The exclusion criteria were (1) taking anti-insomnia, anti-anxiety, or antidepressant medications; (2) having undergone hysterectomy or oophorectomy, and having gynaecological diseases, or experiencing menopause due to radiotherapy, chemotherapy, or long-term hormone use; (3) being diagnosed with severe heart, lung, liver, kidney, or other organ diseases, endocrine disorders, or malignant tumours; and (4) having a mental illness (as defined by the International Classification of Diseases 10th edition (ICD-10) for schizophrenia [28]).

Survey design and conduct

A cross-sectional survey was conducted. The self-rating scale of sleep (SRSS), self-rating anxiety scale (SAS), self-rating depression scale (SDS), and family APGAR index (APGAR) were used to measure sleep quality, anxiety, depression and family care.

The sleep status self-measurement form consists of 10 items, each scored on a five-point scale (too much sleep = 1, just enough sleep = 2, less sleep = 3, insufficient sleep = 4, and insufficient sleep = 5). A total score of ≤ 22 indicates normal sleep quality, scores of 23–29 are classified as mild sleep disorder, 30–39 as moderate sleep disorder, and 40–50 as severe sleep disorder [29]. Cronbach’s α was 0.889 in the current study.

The SAS developed by Zung [30], comprises 20 items and is used to evaluate the severity of individual anxiety symptoms. Each item was scored on a four-point Likert scale (never or rarely = 1, occasionally = 2, quite often = 3, and most or all of the time = 4). The initial score was calculated by summing the scores of all items, which were then multiplied by 1.25 to derive the standard score. A standard score of 72 indicates severe anxiety. Cronbach’s α was 0.913 in this study.

The SDS [31] comprises 20 items, each rated on a four-point Likert scale, yielding a maximum total score of 80 points. The standard score was calculated by multiplying the total score by 1.25. Scores under 53 indicated the absence of depressive symptoms, scores from 53 to 62 were classified as mild depression, 63–72 as moderate depression, and over 72 as severe depression. Cronbach’s α was 0.896 in this study.

We used the Chinese version of the Family Care Index Scale, developed by Professor Lv et al. [32] and Cronbach’s α was 0.807 in this study. This scale evaluates a family member’s perception of family functioning by assessing satisfaction with family relationships across five parameters: adaptation, partnership, growth, affection, and resolve. Each is assessed with the categories often, sometimes, and almost rarely. The total family function score is calculated by summing the scores across all dimensions. Scores from 0 to 3 indicate severe impairment, 4 to 6 reflect moderate impairment, and 7 to 10 good family function.

Sample size estimate

The sample size was estimated using G*Power 3.1 software. For multivariate analysis, a medium effect size of 0.3 was selected, with an alpha level (α) of 0.05 for two-sided testing and a desired power of 0.95. This calculation suggested an expected sample size of 107 cases. To account for potential attrition, an additional 20% was added, resulting in a target sample size of 128 cases. Ultimately, the study collected 860 valid cases, exceeding the required sample size.

Data collection

Before the study, the investigators—including instructors, undergraduates, and clinical internship students—received training. The training focused on developing communication skills, ensuring a shared understanding of the questionnaire items, and familiarising participants with common expressions. The investigation commenced after successful training completion. The investigator introduced the purpose and significance of the survey to participants and distributed the questionnaire after obtaining their consent. During the survey, one-on-one interviews were conducted, providing clear and detailed explanations to questions raised by the participants. Subsequently, the investigator collected the questionnaires and checked for missing or unclear responses. If more than two-thirds of the questions were unanswered, the questionnaire was deemed invalid and discarded. A total of 911 questionnaires were distributed, with 860 valid responses, yielding a recovery rate of 94.40%. This study was approved by the Medical Ethics Committee of Gansu Medical College ([2024]IEC(5)), and all participants provided informed consent.

Statistical analysis

The original data were imported into Excel software, and statistical analysis was conducted using SPSS version 26.0. Count data are described by the number of cases and composition ratios, while measurement data are presented as means and standard deviations (\(\bar x \pm s\)). Pearson correlation analysis was employed to examine the relationships between sleep quality, anxiety, depression, and family care in perimenopausal women. Model 4 in the SPSS PROCESS 3.4 macro software was employed to analyse the mediating effects of anxiety and depression on the relationship between family care and sleep quality in perimenopausal women. The Bootstrap method [33] was utilised to assess the significance of these mediating effects, with a focus on a 95% confidence interval. The resampling sample size was set to 5,000 iterations. If the 95% Bootstrap confidence interval did not include 0, this was interpreted as evidence of a significant mediating effect in the model.

Test method for common method bias-Harman’s single-factor

Because the same group of participants completed the scales, common method bias could have occurred. Following Shi Songqi’s suggestion [34], Harman’s single-factor test was used to assess common method deviation. This method typically employs exploratory factor analysis to examine bias, positing that a method factor accounts for the shared variation among all items representing different traits. A higher proportion of variation attributed to the method factor indicates greater bias. If the variation explained by the single factor (without rotation) does not exceed 50%, common method bias is not considered substantial. In Chinese applications, a variation threshold of 40% is commonly accepted.

Results

Demographic characteristics of surveyed perimenopausal women

Among the 860 women surveyed, the average age was 49.03 ± 3.05 years. Regarding education, 376 (43.7%) had completed primary school or less, 299 (34.8%) junior high school, and 185 (21.5%) high school or college education. In terms of occupation, 578 (67.2%) participants were farmers, 58 (6.7%) self-employed, and 224 (26.1%) employed in staff positions. Concerning marital status, 816 (94.9%) were married, 3 (0.3%) single, 25 (2.9%) divorced, and 16 (1.9%) widowed. For personal monthly income, 287 (33.4%) earned less than 1,000 yuan, 388 (45.1%) earned 1,000 to 3,000 yuan, 145 (16.8%) earned 3,000 to 5,000 yuan, and 40 (4.7%) earned 5,000 yuan or more. Regarding the number of children, 18 (2.1%) reported having none, 626 (72.8%) had one or two, and 216 (25.1%) had three or more. Finally, 432 (50.2%) participants were menopausal, and 428 (49.8%) were premenopausal.

Common method bias results

Without rotation, the first common factor accounted for 16.84% of the total loading, which is below the 40% critical threshold, indicating no significant common method bias.

Descriptive statistics and correlation analyses for family care, anxiety, depression, and sleep quality

The mean and standard deviation of the scores for these variables among perimenopausal women are presented in Table 1. Correlation analysis between sleep quality, anxiety, depression, and family care revealed that all variables were significantly correlated (P < 0.01).

Table 1 Descriptive and correlation analysis of sleep quality, anxiety and depression, family care (n = 860, r)
Full size table

The mediating effects of anxiety and depression on the relationship between family care and sleep quality were analysed using Model 4 of the process plug-in in SPSS software. In this analysis, sleep quality served as the dependent variable and family care was the independent variable. Menopausal status was included as a control variable due to its statistically significant impact on the data. The results indicate that family care negatively predicts sleep quality, with a direct effect of -0.150. Family care, anxiety, and depression together predict sleep quality, with a total indirect effect of -0.487 and an overall effect of -0.637. Notably, the 95% confidence interval for the direct effect of family care on sleep quality excluded zero. In the mediation paths of family care → anxiety → sleep quality and family care → depression → sleep quality, the 95% confidence intervals (CI) for both paths also excluded zero, indicating significant mediation effects. The total indirect effect accounts for 76.42% of the overall effect. Refer to Tables 2 and 3; Fig. 1 for further details.

Table 2 Results of the mediation model test between family care, anxiety, depression and sleep quality
Full size table
Table 3 Total effect of family care on sleep quality: direct and mediated effects via anxiety and depression
Full size table
Fig. 1
figure 1

Mediating effects of anxiety and depression on family functioning and sleep quality

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Discussion

Family care, anxiety, depression, and sleep quality levels of perimenopausal women

This study found that the family care score for perimenopausal women was 6.64 ± 2.36 points, indicating a generally moderate obstacle level. This aligns with the findings of Du et al. [35], suggesting that perimenopausal women face relatively limited material and emotional support from their families when confronted with the risks of perimenopausal-related symptoms, including hot flashes, night sweats, and insomnia. This may be partly attributed to a shift in family focus towards children’s education and employment. Additionally, role conflicts may be a significant factor, as perimenopausal women often play key roles in family and social activities. Conflicts can arise if these roles are not managed effectively. Furthermore, while perimenopausal women tend to contribute more to family dynamics, their desire for care and attention may decline compared to the earlier stages of life, leading to a perceived reduction in family care.

The anxiety and depression scores were 40.74 ± 10.89 and 40.77 ± 10.03, respectively. These scores were lower than those reported by Zhang et al. [36] (p < 0.01), but higher than domestic norms [37] (p < 0.01). This discrepancy may be due to differences in the participant selection and regional factors. The occurrence of anxiety and depression in perimenopausal women is closely linked to individual personality traits and the nature of their work. At this stage, women face various challenges, including changes in body shape and shifts in family structure. A lack of time to adapt to these changes may lead to symptoms, such as depression, irritability, and heightened anxiety.

Relevant studies [38, 39] have found that between 33% and 51% of perimenopausal women experience sleep disorders, whereas the rate of insomnia among domestic perimenopausal women is as high as 36.6%. Research conducted by Song et al. [40] identified fatigue, insomnia, hot flashes, and sweating as the three most common symptoms reported by perimenopausal women. In this study, the sleep status score for perimenopausal women was 25.33 ± 5.00, indicating mild sleep disorders. A possible explanation is that during perimenopause, women’s immunity and resistance continue to decline, increasing susceptibility to various diseases, including gynaecological and chronic conditions. Sleep disturbances are more likely to occur because of these health issues. Furthermore, women at this stage often face work and life pressures as well as multiple physical and psychological challenges. These factors can contribute to both physical and mental fatigue, leading to sleep disorders.

Correlation analyses for family care, anxiety, depression, and sleep quality of perimenopausal women

Our results also showed that family care was negatively correlated with sleep quality, anxiety, and depression in perimenopausal women, whereas anxiety was positively correlated with depression and sleep quality. Research suggests that symptoms in perimenopausal women are closely related to their sleep quality [14]. For instance, Vousoura et al. [41] demonstrated that depression was associated with difficulty in falling asleep and early awakening.

Family is one of the most important support systems. Qiu et al. [42] showed that family care is significantly negatively correlated with sleep quality, that is, the higher the degree of family care, the higher the sleep quality. The encouragement and companionship of family members can help reduce patients’ negative emotions and improve sleep quality [43]. Studies on stroke patients [44] and haemodialysis patients with diabetic nephropathy [45] have confirmed the significant role of family care in sleep quality. Moreover, previous studies have found that good family functions have a protective effect on adolescent mental health, such as reducing the occurrence of depressive symptoms [46]. Some studies have also found that family function, as a social support resource, can moderate the negative impact of stress on adolescent mental health [47].

As early as 2005, relevant agencies in the United States identified sleep disorders as a common health problem among perimenopausal women [15]. The sleep quality of perimenopausal women has since attracted increasing attention from researchers, as prioritising their physical and mental health has become a focal point. Studies indicate that sleep disorders and depression influence each other. For instance, sleep disorders can lead to nervous system disturbances, and heightened sensitivity to stress can induce anxiety, depression, and other negative emotions [48]. Furthermore, anxiety and depression can cause autonomic nervous system dysfunction, brain and body dysfunction, and sleep disorders, creating a cycle of adverse effects [49]. The study focused on women aged 45 to 60 because the health status of middle-aged women declines with age. As they grow older, sub-health status rises, and the incidence of chronic comorbidities increases. Concurrently, work pressures and family burdens may contribute to anxiety and depression [50]. These psychological symptoms adversely affect both the physical and emotional wellbeing of perimenopausal women.

Anxiety and depression in perimenopausal women serve as mediators between family care and sleep quality

The mediating effect model was used to analyse the relationship between anxiety and depression in family care and sleep quality. The findings indicated that anxiety and depression serve as mediators between family care and sleep quality. Therefore, family care not only affects sleep quality directly but also indirectly through anxiety and depression. Family care is a significant indicator of individual satisfaction with family dynamics [51]. Positive and harmonious family care fosters secure attachment between perimenopausal women and their families, enabling these women to better perceive the support provided by their family environment. This, in turn, allows them to accept themselves and manage their negative emotions more effectively, enhancing their emotional security. Conversely, inadequate family care may lead to self-doubt due to unmet psychological needs, leading to withdrawal, avoidance behaviours, and exacerbating anxiety and depression, which in turn increases the likelihood of sleep disorders. Anxiety and depression mediate the relationship between family care and sleep quality [27]. Clinical research has demonstrated that anxiety and depression, common affective disorders during perimenopause, adversely affect sleep quality [49]. Research by Zheng et al. [52] revealed that insomnia, a symptom of autonomic nervous system disorders, is primarily caused by anxiety and depression in perimenopausal women. Perimenopausal women aged 45 to 60 experience continuous ageing and a decline in bodily functions, which heightens the risk of anxiety and depression, thereby affecting sleep quality. Therefore, addressing the mental health issues in this population is crucial. Alleviating anxiety and depression symptoms is particularly important for improving sleep quality.

Family-centered interventions are recommended for implementation in community health or hospital settings. For example, combined with the current medical level of China and increasingly improved community chronic disease management experience, the medical staff have established a good doctor-patient relationship with perimenopausal women, allowing them to actively conduct the treatment. Community workers are responsible for publicizing the importance of early self-identification of perimenopausal symptoms, establishing files for perimenopausal women, conducting regular follow-up visits, and raising awareness of perimenopausal health care. Simultaneously, attention should be paid to the impact of family members on the mental health of perimenopausal women. In particular, spouses can provide care, understanding and psychological support to relieve perimenopausal women’s anxiety and depression symptoms and improve sleep quality.

Limitations and future directions

There are certain limitations of this study. First, its cross-sectional design precludes definitive conclusions regarding the direction of causality between family care, sleep quality, anxiety and depression. Further longitudinal studies are needed to evaluate the causal relationships and determine whether the impact of family care on sleep quality changes over time.

Second, the sample is not fully representative because the selection of participants was relatively limited. Future research should involve larger, more diverse samples from various provinces to enhance generalisability.

Third, the inherent limitations of self-reported measures must be acknowledged. Although previous studies have found that certain vasomotor symptoms are related to depression and anxiety, the impact of vasomotor symptoms on anxiety, depression, and sleep in perimenopausal women has not been fully explored in this study. Sweating caused by hot flashes may affect sleep quality indirectly through anxiety and depression [49]. Vousoura et al. [41] demonstrated that hot flashes and depression are associated with different sleep disorder patterns. This aspect warrants further investigation in future research.

Fourthly, while Harman’s single-factor method was employed, it is often criticised for its insensitivity to variations in common method variance and common method bias, and its evaluation criteria are regarded as insufficient [53].

Finally, this study may have overlooked the influence of other potential confounding factors, such as the socioeconomic status, occupation, or lifestyle. Considering the impact of additional variables in future studies can help broaden our understanding and provide a more comprehensive analysis of the results.

Conclusions

The sleep quality scores of perimenopausal women were found to be at a moderate level, with anxiety and depression mediating the relationship between family caregiving and sleep quality. It is recommended that medical and community health workers enhance psychological support for perimenopausal women. A family-centred medical model involving all family members should be gradually developed and improved to help perimenopausal women manage negative emotions, with the aim of improving sleep quality. This approach will enable perimenopausal women to reintegrate into their families and society in good physical and mental health.

Data availability

The datasets used and/or analysed in this study are available from the first author upon reasonable request.

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Acknowledgements

We appreciate the participation of all the perimenopausal women in Gansu Province who took part in the survey. Thanks to my husband for his strong support.

Funding

This study was supported by grants from the Gansu Provincial Department of Education College Teacher Innovation Fund Project (2024B-208).

Author information

Authors and Affiliations

  1. School of Nursing, Gansu Medical College, Pingliang, 744000, China

    Nana Liang, Juan Zhao & Haixia Zheng

  2. Affiliated Hospital Of Gansu Medical College, Pingliang, 744000, China

    Jishun Ren

  3. School of Nursing, Ningxia Medical University, Yinchuan, 750004, China

    Xiaohui Liu

Authors
  1. Nana Liang
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  2. Jishun Ren
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  3. Juan Zhao
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  4. Xiaohui Liu
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  5. Haixia Zheng
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Contributions

Conception and design of the research: NNL, JZ. Acquisition of data: JSR. Analysis and interpretation of data: HXZ. Statistical analysis: NNL, JZ. Drafting the manuscript: NNL. Revision of manuscript for important intellectual content: XHL.

Corresponding authors

Correspondence to Juan Zhao or Xiaohui Liu.

Ethics declarations

Ethics approval and consent to participate

This experiment was approved by the Ethics Committee for Medical Research of the Gansu Medical College ([2024] IEC(5)). All methods were carried out in accordance with relevant guidelines and regulations—Declaration of Helsinki. All participants signed an informed consent form.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Liang, N., Ren, J., Zhao, J. et al. Impact of family care on sleep quality in perimenopausal women: mediating roles of anxiety and depression. BMC Women's Health 25, 19 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-025-03551-3

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-025-03551-3

Keywords

BMC Women's Health

ISSN: 1472-6874

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