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 Table of Contents  
Year : 2017  |  Volume : 33  |  Issue : 3  |  Page : 189-195

Burden and coping styles among caregivers of patients with major mental disorders and hypertension attending a Nigerian tertiary hospital

1 Federal Neuro-psychiatric Hospital, Benin-City, Edo State, Nigeria
2 Department of Mental Health, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria

Date of Web Publication14-Sep-2017

Correspondence Address:
A F Osundina
Federal Neuropsychiatric Hospital, Benin-City, Edo State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9962.214603

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Background: Previous research on caregiver burden in Nigeria has focused mainly on caregivers of patients with mental disorders. None of these studies compared the level of burden among the caregivers of patients with chronic mental disorders with caregivers of those with chronic medical illnesses. Furthermore, previous studies on caregiver burden in Nigeria did not examine the relationship between caregiver burden and coping style. Objectives: The objective of the study was to compare the level of burden and the coping styles used by the caregivers of patients with major mental disorders with that of caregivers of patients with hypertension, and also to determine any relationship between the caregiver burden and coping style. Methods: Four hundred caregivers were recruited from the psychiatry and cardiology clinics of a tertiary hospital. Psychiatric diagnosis was confirmed with the MINI-International Neuropsychiatric Interview (MINI). Caregivers completed a semistructured sociodemographic questionnaire, the Zarit Burden Interview, and the Coping Orientation to Problems Experienced Inventory. Results: There was a statistically significant difference in the level of burden experienced by the caregivers of patients with major mental disorders and hypertension. Overall, both groups of caregivers adopted similar coping styles except in the use of denial coping style, which was used significantly by caregivers of patients with major mental disorders. There was no significant relationship between the caregiver burden and coping style. Conclusions: This study found that caregivers of patients with major mental illnesses experienced a considerable burden than caregivers of patients with hypertension and also found that both groups of caregivers made use of similar coping styles.

Keywords: Caregiver burden, coping style, chronic illnesses, Nigeria

How to cite this article:
Osundina A F, Fatoye F O, Akanni O O, Omoreagba J O, Akinsulore A, Oloniniyi I O. Burden and coping styles among caregivers of patients with major mental disorders and hypertension attending a Nigerian tertiary hospital. Indian J Soc Psychiatry 2017;33:189-95

How to cite this URL:
Osundina A F, Fatoye F O, Akanni O O, Omoreagba J O, Akinsulore A, Oloniniyi I O. Burden and coping styles among caregivers of patients with major mental disorders and hypertension attending a Nigerian tertiary hospital. Indian J Soc Psychiatry [serial online] 2017 [cited 2022 Jan 22];33:189-95. Available from: https://www.indjsp.org/text.asp?2017/33/3/189/214603

  Introduction Top

In Nigeria and other African countries, family members usually serve as informal caregivers to their ill relatives who are receiving treatment for chronic medical or mental illnesses. Most of these caregivers usually have substantial demands placed on their personal, financial, and social resources because of their role in caregiving. All these challenges on the part of the caregivers may result in burden.

The burden of caregiving can be broadly categorized into either objective or subjective burden. Objective burden describes the burden experienced on account of patient's symptoms, behavior, changes in household routines, family or social relations, work, leisure time, and physical health. Subjective burden on the contrary is the impairment in the mental health and feelings of distress among family members and also refers to the emotional reactions of the caregiver such as worry, anxiety, frustration, or fatigue.[1]

Relatives of patients with chronic illnesses have different methods of coping with the challenges of their role as caregivers. Coping refers to the cognitive behavioral strategies used by individuals to adapt to excessive demands that trigger a stress response.[2] These coping methods can either be emotion-focused or problem-focused, and they may lead to re-appraisal of the patient's illness by the caregiver from time to time.[3] Previous studies in other countries have shown that the coping method adopted by the caregiver may influence the level of burden they experience.[4],[5]

Generally, findings have also shown that the use of avoidance, denial, and resignation are linked to greater burden, while using social support and a sense of mastery over the situation is associated with lesser degree of burden.[6],[7] However, it is not so clear whether there is any relationship between coping style and burden among caregivers of patients with chronic illnesses in Nigeria. Furthermore, it has been reported that caregivers of patients with schizophrenia,[8],[9],[10],[11] epilepsy,[12] and dementia[13] are strained while caring for their relatives, but little is known about the experience of carers of the patients with other major mental disorders such as affective disorders and those with chronic medical condition such as hypertension.

This study was undertaken against the backdrop that there are no available published studies that have compared the caregiver burden and coping styles among caregivers of patients suffering from major mental disorders (such as schizophrenia and affective disorder) with caregivers of those having hypertension. The overall aim of this study was to bridge this gap in literature by evaluating and comparing the level of burden and the coping styles between the caregivers of patients with chronic mental illness (such as schizophrenia and affective disorder) and hypertension, and also to examine any relationship between the caregiver burden and coping style.

  Methods Top

Study design and location

This cross-sectional study was conducted at a tertiary hospital in the southwest geopolitical zone of Nigeria. The location of this hospital makes it accessible for referrals from hospitals within the southwest region of the country.

Sampling and inclusion/exclusion criteria

A sample size of 400 patients was evaluated, and caregivers of consecutive outpatients attending the psychiatry and cardiology clinics were recruited for the study. The sharing of the sample between patients with major mental illnesses and hypertension was done using the ratio 2:1, respectively, based on the frequency of clinic attendance obtained from the hospital record.

The criteria for recruiting the caregiver into the study were as follows: caregivers who were 18 years and above whom had given informed consent, those who had been living with and following the patient regularly to the clinic for at least 1 year and were directly involved in caring for the patient, and caregivers who were supportive either emotionally and/or financially to the patient. Caregivers who were not able to communicate in English language and those with a history of a medical or psychiatric illness or both and those who clinically had symptoms of medical and/or psychiatric illness were excluded from the study.

The patients who these participants care for also satisfied some criteria. For patients with schizophrenia and affective disorder, they were diagnosed based on the International Classification of Disease, 10th edition (ICD-10) diagnostic criteria, and it was ensured that they did not have any comorbid chronic medical condition such as hypertension or diabetes.

Patients with hypertension who were recruited for this study were those diagnosed by a consultant cardiologist based on the 7th report of the Joint National Committee (JNC-7) criteria on prevention, detection, evaluation, and treatment of high blood pressure, that is, blood pressure greater than 140/90 mmHg that was taken at two different times and those who were free from any other comorbid chronic medical or psychiatric illnesses. In addition, both groups of patients were 18 years and above.

Ethical approval

Ethical approval was obtained from the ethics and research committee of the tertiary hospital.

Assessment tools

For the purpose of this study, the caregiver (relative) interviewed was a nonprofessional person who was mostly involved with the everyday care of the patient and is most likely to respond to any request for special assistance at any time if such request was made by the patient; the patients with major mental disorder were those with ICD-10 diagnoses of schizophrenia and affective disorder and whose diagnoses were further confirmed by the MINI-International Neuropsychiatry Interview (MINI). The following tools were administered by two of the researchers after they had been adequately trained in the administration of the research instruments by a trained senior colleague.

Sociodemographic and illness-related variables questionnaire

This was specifically designed for this study to inquire about some sociodemographic and illness-related variables. It was administered to the caregivers and supplemented by information from the clinical records of the patients they cared for.

  Mini-International Neuropsychiatric Interview Top

The diagnosis of schizophrenia and affective disorder was ascertained with the MINI, version 5.0.[14] Although not routinely administered to patients in clinical practice, the MINI was specifically used in this study because validation and reliability studies done comparing MINI to Composite International Diagnostic Interview (CIDI), a well-established instrument, showed that it had similar properties and can be administered in a much shorter period (mean 18.7 ± 11.6 min, median 15 min).[15] Interrater and test–retest reliability tests for all the 16 diagnostic modules produced satisfactory κ values ranging from 0.79 to 1.0 and 0.35 to 1.0, respectively.[15] It has been used in Nigeria for various studies.[16],[17]

  The Zarit Burden Interview Top

The 22-item version of the Zarit Burden Interview (ZBI) was used for this study. Caregivers were asked to indicate how often they had various thoughts or feelings on a five-point scale ranging from 0 (never) to 4 (nearly always). The test–retest reliability and face validity of ZBI has been established in Nigeria and the instrument has been widely used in Nigeria.[18]

  The Coping Orientation to Problems Experienced Inventory Top

The Coping Orientation to Problems Experienced (COPE) Inventory consists of 60 items, which assess a broad range of coping responses that people make use of when they are confronted with difficult or stressful events and items are rated on a four-point Likert scale. The COPE Inventory has a strong theoretical base and sound evidence of validity.[19] It also has evidence for factor replicability.[20] The scale showed high internal consistency, Cronbach α of 0.79, and a high test–retest reliability of 0.76.[21] The COPE Inventory has been validated for use in Nigeria.[22]

Statistical analysis

Analysis was done using the Statistical Package for Social Sciences (SPSS) software version 17. Most of the variables were grouped and results were calculated as frequencies. Level of burden was dichotomized into little or no burden, and mild to severe burden using a cutoff of 20 on ZBI. Comparison between the major mental illness caregivers group and those with hypertension was determined using t test when the outcome was coping style, whereas χ2 was used when the dependent variable was the level of burden. Level of statistical significance was set at P < 0.05.

  Results Top

There were significant differences in the patients' age of onset of illness, and the relationship of the caregiver to the patient between the two groups [Table 1]. Majority of patients with major mental illnesses developed the illness between 20 and 39 years of age and their caregivers were their parents, whereas most of the hypertensive patients developed the illness after 40 years and the spouses were significantly their caregivers. A statistically significant difference (χ2 = 68.1, df = 1, P = 0.000) was also observed in the level of burden when caregivers of patients with major mental disorders were compared with those with hypertension [Table 1].
Table 1: Sociodemographic characteristics of the caregivers

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With regard to coping styles used by caregivers, a significant difference was observed only in the use of denial coping style (P = 0.01) among the caregivers of patients with mental disorders and hypertension [Table 2].
Table 2: Mean scores of coping styles used by caregivers

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There was no significant relationship between the level of burden experienced by the caregiver and the coping style they used [Table 3].
Table 3: Comparison of coping styles between caregivers with little–no burden and mild–severe burden

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  Discussion Top

In this study, the caregivers of patients with major mental disorders experienced a greater burden of care than caregivers of patients with hypertension. This finding is in-keeping with previous studies[23],[24] on the caregiver burden among relatives of patients with chronic medical disorders compared with caregivers of patients with chronic mental illnesses.

One of the studies, conducted by Prasanth et al.,[23] compared more diverse groups of caregivers of patients with psychiatric diagnoses (schizophrenia, mood disorders, and substance use disorders) with those with chronic medical illnesses (refractory tuberculosis, chronic bronchial asthma, diabetes mellitus, and rheumatoid arthritis), although a smaller sample of 50 participants was used.

Despite these differences in methodology, the findings were similar, which further suggests that caregivers of patients with major mental disorders may experience more burden than caregivers of patients with chronic medical conditions.

Several reasons can be posited to explain the greater burden experienced by caregivers of patients with mental illnesses. It may be as a result of stigma associated with mental illnesses unlike chronic medical conditions such as hypertension.

Previous studies have identified family stigma among relatives of patients with psychiatric illnesses,[25] which has been proven to be an important contributor to caregiver burden.[26] It is possible that many of the caregivers of the mentally ill patients experienced a greater degree of stigma, which ultimately contributed to the level of burden they experienced. It is also possible that marked functional impairment in patients with mental illnesses, because of the debilitating nature, may explain the greater burden of care seen among caregivers.

Marked functional impairment is one of the reasons that have been adduced to unemployment or underemployment among patients with chronic mental illnesses.[27],[28] However, this study did not examine the relationship between the caregiver burden and stigma or functional impairment, and future studies in our environment in this direction would be helpful.

Another plausible explanation for the greater burden experienced by caregivers of mentally ill patients may be because many of the caregivers of patients with mental illnesses recruited in this study were significantly their parents. Roick et al.[29] identified that parent caregivers experienced greater burden of care than either spouse or child caregivers.

Individuals with severe mental illnesses are usually looked after by their relatives because of the limitations imposed on them by the severity of the illness.[30] In this study, many of the caregivers who accompanied the patients being managed for major mental disorders to the clinic were their parents. This may be because these illnesses usually develop during adolescence and in most cases affect the individual's social and occupational functioning, resulting into difficulty in their securing life partners and having children who would have served as caregivers to these patients.

Among the hypertensive patients, majority of the caregivers were either the spouse of the patient or the child. This observation is understandable because hypertension usually starts later than the major mental disorders, at a time when the patients would have been married and have children to take care of their needs when they become old and retire from work.

With regard to the use of coping styles, this study found that caregivers of patients with mental disorders only significantly used denial coping style more than hypertensive caregivers. The fact that parents significantly provided care for most of the patients with major mental disorders may explain the significant difference in the use of denial between caregivers of patients with major mental disorders and caregivers of patients with hypertension. This finding is similar to that reported by Rammohan et al.[6] that parent caregivers used denial coping strategy more than spouses.

Caregivers of patients with major mental illnesses may have also used denial coping style more than the caregivers of patients with hypertension because of the stigma associated with mental illnesses. It is easier in this environment to accept that one's relative has been diagnosed with a medical illness than accepting that one's relative is suffering from a psychiatric illness.

The disabling nature of mental disorders, particularly the severe type, could make caregivers embrace denial coping style to be able to focus more on some other aspects of their lives, which gave them fulfillment and a better frame of mind to concentrate on their jobs.

It is interesting to note that the most utilized coping style among the two groups of caregivers was religious coping style. Nigeria has been described as probably one of the most religious nations in the world and this may be responsible for the high level of use of religious coping in this environment. A study on coping methods conducted among military men in the course of their duties in Northern Nigeria also reported a greater use of religion than the other coping strategies.[31]

Planning was more utilized as a means of coping in the group of caregivers with little or no burden (X = 13.31) than those with mild to severe burden (X = 12.91), whereas denial coping style was more employed in caregivers who had mild to severe burden (X = 7.65) than those with little or no burden (X = 7.32), although they were at nonsignificant levels.

Even though Rammohan et al.[6] reported significant relationship between denial coping style and burden in caregivers of persons with schizophrenia, the lack of relationship between any of the coping styles and burden in this study may be ascribed to the mixture of subpopulations of illnesses (schizophrenia, affective disorder, and hypertension). In general, problem-focused coping style, which includes planning, seeking assistance, taking action to get rid of the problem, and the like, have been believed to be associated with a better outcome among caregivers compared with the use of emotion-focused coping styles, such as religious coping, denial, procrastinating, distracting oneself by engaging in activities such as the use of alcohol, and other psychoactive substances.[32]

  Conclusion Top

Generally, taking care of relatives with chronic illnesses may be challenging for family caregivers; this is worse for caregivers of patients with major mental disorders because they experience greater burden than the caregivers of patients with hypertension. The coping style used by the caregiver may have little influence on the extent of burden experienced. A significant difference was observed in this study in the use of denial coping style between the two caregiver groups. Efforts should be made by clinicians to teach caregivers of patients with chronic mental illnesses, adaptive methods of coping. Mental health support programs should be put in place for caregivers of these patients to take care of their emotional needs as well.

Strengths of Study

This study unlike most other similar studies in Nigeria was not confined to chronic mental disorders alone but compared chronic mental and chronic medical disorders.

The study made use of a larger sample size compared with most of the previous studies.

Limitations of Study

The study was conducted in only one hospital and this restricts the extent to which its findings can be generalized.

Self-report questionnaires were used and, as a result, respondents may have introduced some bias.

Financial support and sponsorship


Conflict of interest

There are no conflicts of interest.

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