Perceived burden and quality of life in Chinese caregivers
of people with serious mental illness: A path analysis
1Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Meidcal University, Guangzhou, China.
2School of Nursing, Guangzhou Medical University, Guangzhou, China
3Department of Nursing, Guangzhou Brian Hospital, Guangzhou, China)
Zeng Y, Zhou Y, & Lin J.(2016)
Perceived burden and quality of life in Chinese caregivers of people with serious mental illness: A path analysis.
International Journal of Psychosocial Rehabilitation. Vol 20 (1) 105-111
: Yingchun Zeng, Department of Obstetrics and Gynecology,
The Third Affiliated Hospital of Guangzhou Meidcal University
No 63 DuoBao Road, Liwan District, Guangzhou,
Guangdong Province, China, 510150.
In China, family members take on the major responsibility of caring for
people with serious mental illness (SMI). Caring for a family member
with SMI can result in numerous consequences for the caregiver. The
aims of this study were to investigate perceived caregiver burden and
quality of life (QOL) among Chinese family caregivers for people with,
to assess the role of social support as a mediator between caregiving
and QOL, and to test whether the proposed conceptual model can explain
the pathway of how caregiving influencing perceived burden and QOL.
In the current cross-sectional study, 231 family caregivers were
recruited and independently interviewed using the Chinese version of
the WHOQOL-BREF, Hospital Anxiety and Depression Scale, Social Support
Rating Scale, and Family Burden Interview Schedule as outcome measures.
Results: The path analysis
model provided a good fit for the data (χ2  = 13.96, p = 0.052, CFI
= 0.910, TLI = 0.875, IFI = 0.912, RMSEA = 0.068), with all individual
paths significant at p < 0.05. Caregiving time spent in SMI patients
was related directly with family burden. Caregivers’ depressive
symptoms were related directly levels of family burden and QOL. All
other significant variables were related indirectly with family burden
and QOL, social support plays the role of mediating effects.
Study findings show that social support can be regarded not only as a
protective factor in reducing the caregiving burden for family
caregivers, but also in promoting caregivers’ QOL.
Keywords: Family caregivers; Serious mental illness; Caregiver burden; Quality of life; Path analysis
for a family member with SMI can result in numerous consequences for
the caregiver [1,2]. Caregivers may experience considerable adverse
effects on their quality of life (QOL), as well as adverse health
effects such as distress . Caregivers could also experience a range
of negative emotions, impacting both their physical and mental health
. This impact of caregiving has been conceptualized as caregiver
burden . Caregiver burden has been associated with caregivers’
depressive symptoms and inadequate social support [3,4]. Previous
research found that insufficient social support was the most
significant predictor of caregiver depression, followed by caregiver
burden . Chan  indicated that social support appears to be an
important protective factor in caregiver burden in diverse cultures.
study investigated the mediating role of social support as a major
protecting factor, determining the influence of caregiving on
caregivers’ perceived burden and quality of life (QOL). The conceptual
model guided this study is illustrated in Fig. 1. The aims of this
study were to investigate perceived caregiver burden and QOL among
Chinese family caregivers for people with SMI, to assess the role of
social support as a mediator between caregiving and QOL, and to test
whether the proposed conceptual model can explain the pathway of how
caregiving influencing perceived burden and QOL.
SMI patients who met the following inclusion criteria were invited to
participate in the study upon their planned discharge: (1) Chinese
adults ages 18 to 65, (2) suffering from schizophrenia and/or other
psychotic disorders, using the consensus diagnosis according to DSM-5,
and (3) voluntary consent. Eligible family caregivers were recruited on
the day of SMI patients’ discharge from hospital. Caregivers who were
interested in participating signed up for the study. Inclusion criteria
included (1) caregivers who have spent two hours or more each day
looking after the discharged patients; (2) one caregiver per patient;
and (3) age 18 or above.
included in this study consist of five parts: 1) The Socio-demographic
sheet was used to collect participants’ age, gender, relationship with
the patient, marital status, employment status, education level,
monthly income, health status, length of time as a caregiver, and
average number of hours per week spent caring for the discharged
patient; 2) The World Health Organization Quality of Life – Brief Form
(WHOQOL-BREF) (Chinese version) was used to measure the quality of life
in subjects; 3) The Hospital Anxiety and Depression Scale (HADS) was
used to measure the psychological health of subjects; 4) The Social
Support Rating Scale (SSRS) was used to measure social support of
subjects; and 5) The Family Burden Interview Schedule (FBIS) was used
to assess caregiver burden of subjects.
Data collection and analysis
study was approved by studied hospitals’ Ethics Committee. Written
consent was obtained from participants before data collection. Data
were collected from May - July 2014. Trained research nurses collected
the data in face-to-face interviews, on the day of patients’ discharge
from hospital. Data were analyzed using SPSS and AMOS for Windows,
version 20. Statistical significance was set at 0.05. The findings
would be summarized by descriptive statistics, correlation and path
total of 231 family caregivers were recruited in this. Most patients
were suffering from schizophrenia or schizophrenia spectrum disorder,
while the remaining subjects were experiencing psychotic disorders or
major depressive disorders. Participants’ ages ranged from 18 to 73,
with a mean age of 45.46 (SD=13.18). The detailed characteristics of
family caregivers were listed in Table 1.
Means of measurement outcomes
of measurement outcomes was listed in Table 2. With regards to QOL by
WHOQOL-BREF, caregivers indicated a higher perceived QOL in the domains
of environmental and physical health, than in the areas of
psychological health and social relationships. Concerning symptom
severity by HADS, family caregivers had more severe psychological
symptoms of depression, than anxiety-related symptoms. In terms of
social support by SSRS, caregivers perceived better subjective support
than objective support and support use degree. In terms of a sense of
care burden, the most common burden perceived by caregivers was
Testing the research model by path analysis
correlation and regression analyses were conducted before performing
the path analysis. Only significant ones were kept in the path
analysis. As shown in Fig. 2, the model (Fig. 2) provided a good fit
for the data (χ2  = 13.96, p = 0.052, CFI = 0.910, TLI = 0.875, IFI
= 0.912, RMSEA = 0.068), with all individual paths significant at p
< 0.05. Caregiving time spent in SMI patients was related directly
with family burden. Caregivers’ depressive symptoms were related
directly levels of family burden and QOL. All other significant
variables were related indirectly with family burden and QOL, social
support plays the role of mediating effects. In other words,
caregivers’ age, health status, education levels and anxiety symptoms
had no direct relations to family burden and QOL, and social support
mediated the effect of caregiving on family burden and QOL.
the path analysis, the severity of depression was negatively associated
with caregivers’ QOL. Previous research reported that Chinese
caregivers of people with schizophrenia with higher psychological
distress were found to have a higher caregiving burden . Hence,
relevant interventions to promote Chinese family caregivers’
psychological health are urgently required. Additionally, education
levels had indirect relation to QOL. Among Chinese community, obtaining
a high level of education is valued. To some degree, individuals with
an increased education level may often have a greater financial income
and better working opportunity. Thus, higher education levels were
associated with better QOL among Chinese family caregivers. Another
significant indirect relation was weekly hours spent caring for the
family member with SMI associated with caregiver burden. Longer hours
spent caring for the SMI patient indicate a perception of higher levels
of burden , especially for employed caregivers dealing with both
work-related issues and providing care for a family member with SMI.
Previous research found that many family caregivers had to quit their
job or retire early in order to take care of family members with mental
illness . Thus, unemployment or early retirement could result in
financial difficulties for these family caregivers.
health status had indirect effects in family burden and QOL. One would
expect that having good health when providing care for a family member
with SMI would lead caregivers to experience a lighter burden.
Obviously, greater objective demand burden requires family caregivers
to put more effort into performing daily assistance activities,
supervising patients’ behaviour and providing financial assistance in
caring for SMI patients. In consequence, the QOL of caregivers was
significantly affected. Similar to previous research, social support is
one of the protective factors when providing care for a family member
with schizophrenia [3,6]. This study also found that social support can
be regarded not only as a protective factor in reducing the caregiving
burden for family caregivers, but also in promoting caregivers’ QOL.
study limitations should be taken into account. First, the convenience
sampling method limits the generalizability of study findings. Further
studies, at multiple sites and across regions, should be conducted.
Second, this study only recruited stabilized SMI patients, so
replications of the current findings among family caregivers for
acutely ill and ambulatory SMI patients is necessary. Finally, the
current study only reported and assessed study outcomes at a single
point in time. In consequence, the causality of relationships between
social-demographic variables, caregiver burden and QOL could not be
explored. However, this study is ongoing, with a year follow-up to be
conducted with these family caregivers for people with SMI.
this study has several limitations, its findings have important
practice implications. Lower levels of social support were a
significant protecting factor for higher caregiver burden and lower
levels of QOL among Chinese family caregivers of people with SMI.
Hence, providing caregiver support (e.g. support from friends or other
family members) might prove beneficial. In addition, providing
caregivers with knowledge about SMI is essential, since an increase in
knowledge about SMI might help reduce caregivers’ sense of burden .
Furthermore, caregivers experienced high levels of depressive symptoms,
which negatively influenced their QOL. More services, such as family
psycho-education, support groups and individual counselling should be
developed, with the goal of improving caregivers’ psychological health
and QOL .
Implications for future research include the
potential for developing and implementing effective intervention
strategies to reduce caregiver burden and improve caregivers’ QOL. For
example, intervention strategies to improve communication between
mental health service providers and families should be developed.
Health policy makers should provide relevant resources, such as
financial assistance with care for family caregivers, and it is
important that health policy fully recognizes the role of family
caregivers as a healthcare resource in caring for people with SMI .
Study findings show
that social support can be regarded not only as a protective factor in
reducing the caregiving burden for family caregivers, but also in
promoting caregivers’ QOL. Source of funding
This study was funded by Guangzhou Medical University Fund for Overseas Returners (No.2013C57).
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