Introduction
At the global level, the number of older people is increasing rapidly; it is predicted that their number will reach from 795 million people to 2 billion people from 2010 to 2050 [1, 2]. The increase in the elderly population is associated with an increase in chronic diseases and dependency in performing daily tasks [3]. Stroke is one of the most common disabling neurological diseases in the middle age and old age [5], and is the third leading cause of death in adults [6]. Caring for a patient with a stroke, like caring for patients with other chronic diseases, creates a lot of stress for the caregiver and the patient’s family [9]. Caregivers of stroke patients experience a high level of caregiving burden, which affects their physical and mental health [8]. Education and follow-up over the phone is one of the main services for chronic patients at home. Considering the chronic nature of stroke, supporting in-home caregivers can improve their efficiency in caring for patients [13]. The present study aims to determine the effect of an education & telephone follow-up program on the care burden of the family caregivers of older patients with stroke.
 Methods
This clinical trial study was conducted on 79 family caregivers of older patients with stroke in Qazvin, Iran. The sampling method was purposive and convenience; firstly, the list of older patients (aged ≥60 years) with stroke hospitalized in the neurological department of Bo Ali Hospital during the last 1-6 months was extracted, and if they met the entry criteria, they were contacted and invited to participate in the study. The inclusion criteria for the caregivers were: a consent to participate in the study, having direct responsibility in caring the patient for at least 8 hours a day, having a family relationship with the patient (being their spouse, child, brother, sister, etc.), having a mobile phone with the ability to install the WhatsApp application, a being the resident of Qazvin city, and not getting paid for care. The inclusion criteria for the patients were age 60 years and above, confirmation of stroke diagnosis by the attending physician and having a caregiver at home. The participants were randomly divided into intervention and control groups using the 4×4 random blocks. The intervention group received education for 12 weeks on WhatsApp and by telephone follow-up.
A Demographic form, Barthel Index for Activities of Daily Living (ADL), and Zarit burden interview (ZBI) were used to collect data. The ZBI contains 22 items assessing personal, social, emotional and economic burdens. The total score ranges from 0 to 88; a lower score indicates lower care burden. Data were analyzed using dependent t-test, independent t-test and ANOVA.
Results
In the present study, most of the caregivers in the two groups were female (n=52, 65.8%), with a bachelor’s degree (n=45, 57%), unemployed (n=47, 54.9%), married (n=65, 82.2 %), with moderate income level (n=48, 60.7%) and were living with their spouses and children (n=76, 96.2%). Most of them did not report a history of previous illness (n=63, 79.7%) and were living in their own house (n=56, 70.8%). The mean age of the intervention and control groups was 46.20±12.20 and 46.12±10.54, respectively.
Before the intervention, there was no significant difference between the two groups in the amount of care burden (26.20±11.08 for intervention group and 28.70±11.63 for the control group) (P=0.333); however, after the intervention, the care burden of the intervention group (18.28±10.07) and the control group (29.80±11.76) showed a significant difference (P<0.001). The results showed that 12 weeks of education & telephone follow-up caused a significant reduction in the care burden of the family caregivers (P<0.001).
Discussion
The caregiving burden and its domains after 4 weeks of education & telephone follow-up were significantly decreased in the family caregivers, which is consistent with the results of other national and international studies on caregivers of patients with diseases such as heart failure [21], Alzheimer’s [22] and dementia [23, 24]. This result can be due to the increased self-efficacy of caregivers. Taghinejad et al. in a study showed that telephone follow-up by the nurse after the patient’s discharge significantly increased the self-efficacy of caregivers of stroke patients [40].
It can be concluded that education & telephone follow-up can significantly reduce the care burden of the family caregivers of stroke patients in different areas, including personal, social, economic, and emotional. This method can be used as an effective and low-cost method for reducing the care burden of the caregivers of elderly patients diagnosed with stroke.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Qazvin University of Medical Sciences, Qazvin, Iran (IR.QUMS.REC.1399.037). The written consent form was obtained from all caregivers before participation in the study. 

Funding
This article is taken from the thesis of Hoda Bani Ardalan, a master's student in geriatric nursing, Faculty of Nursing and Midwifery, Qazvin University of Medical Sciences.

Authors' contributions
Conceptualization, methodology, research and review, draft writing, editing and finalization and sources: Hoda Bani Ardalan, Seyedah Amina Matlabi, Akram Shahrokhi and Fatemeh Mohammadi; Analysis: Seyedah Amina Tebali; Financing: Hoda Baniardlan; Project management: Fatemeh Mohammadi.

Conflicts of interest
The authors declared no conflict of interest

Acknowledgements
The cooperation of the patients and their families, the educational supervisor and the staff of the department of neurology and medical records of Bo Ali Sina Hospital in Qazvin city, and the research assistant of Qazvin University of Medical Sciences are appreciated.


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