Caregiver burden among relatives of patients with schizophrenia in Katsina, Nigeria

Volume 15 No. 2 June 2009 SAJP Schizophrenia is one of the most devastating of psychiatric disorders, leading to long-term and progressive disability in numerous individuals. These disabilities are an onerous burden on both patients and their caregivers. Caregiver burden in mental illness can either be objective or subjective. Objective burdens are defined as readily verifiable behavioural phenomena, e.g. negative patient symptoms; caregivers’ lives disrupted in terms of domestic routine, social activities and leisure; social isolation; and financial and employment difficulties. Subjective burdens comprise emotional strain on caregivers, e.g. fear, sadness, anger, guilt, loss, stigma and rejection. The shift towards community care for patients with mental disease has resulted in transferring responsibility for day-to-day care of patients to their family members, which has lead to profound psychosocial, physical and financial burdens on patients’ families.

Ethical approval for the study was granted by the state's Health Services Management Board.

Measurements
Respondents were interviewed using the following instruments: • Data collection sheet.This was designed to collect socio-demographic details of respondents and patients.The information included gender, age, education, income and duration of illness.

• Zarith Burden Interview (ZBI).
This was developed to assess caregiver burden in relatives of patients with chronic mental illnesses. 10It is a 22-item instrument that includes the factors most frequently mentioned by caregivers as problem areas in providing care for mentally ill patients.The factors include the caregiver's health, psychological wellbeing, finances, social life, stigma details, and relationship between patient and caregiver.The instrument has a possible score of 0 -88, depending on the caregiver's responses.Responses are rated from 0 -4, based on the level of distress.The ZBI scores were converted into categorical responses in this study.Scores ranging from 0 to 1 were regarded as negative, while scores ranging from 2 to 4 were regarded as positive.The instrument has been used to assess caregiver burden not only in dementia but also in schizophrenia. 11The instrument has been validated in Nigeria among caregivers of patients with dementia. 12l the instruments were back-translated into the Hausa language and harmonised.In view of the low level of literacy among respondents, the instruments were administered by one of the authors.

Data analysis
Data were analysed using the Statistical Package for Social Sciences, Windows Version 13.The level of probability was set at 5% level of significance.

Socio-demographic characteristics
A total of 129 respondents were interviewed; their mean age was 45.1±8.9 years.The mean ages of the male and female respondents were 45.8±7.9 and 44.7±9.4 years, respectively.
The mean age of the male and female patients was 30.3±10.4 years and 26.2±5.9years, respectively.There was a significant difference in the mean ages of the male and female patients (t=2.79,p=0.006).The mean duration of illness was 4.1±4.5 years (median 2.0 years).All the patients lived with their caregivers in a multi-generational family setting.All the patients were receiving only typical antipsychotics for treatment of their illness.Other socio-demographic characteristics are shown in Table I.

ZBI and socio-demographic characteristics of subjects
The mean ZBI score was 26.4±7.9, while the median score was 27.There was no significant difference in the ZBI scores based on the subjects' socio-demographic characteristics, as shown in Table II.

Level of caregiver burden
A high level of caregiver burden was found in 61 (47.3%) respondents.A higher level of caregiver burden was significantly associated with place of residence and family size.The relationships between levels of caregiver burden and sociodemographic characteristics of respondents are as shown in Table III.

Respondents' answers to ZBI
Analysis of responses to items on the ZBI showed that factors related to stigma, negative behaviours of the patients and financial constraints were the caregivers' three most-reported causes of burden.Overall, 97 (75.2%) respondents indicated experiencing an enormous burden as a result of caring for their relatives (Table IV).

Discussion
The preponderance of female respondents in this study is consistent with the tradition of the area.In most sub-Saharan African communities, females are the traditional caregivers for patients with chronic illnesses.The pattern of living arrangements is multi-generational in nature, which is an advantage to the patient in terms of the large number of potential caregivers.This factor is more important in the absence of sheltered accommodation facilities for patients with chronic mental illness in Nigeria.
Similar observations were made by another study in southern Nigeria. 2 The respondents' and patients' mean ages showed that they were within the productive age group, which implies a loss of productivity that in turn has many economic implications, not only for caregivers and patients but also for the nation as a whole.The majority of patients were employed (mostly in farming) despite their illness.However, the employment status of patients is not significantly associated with the level of burden, which may be due to the enormous burden associated with the illness, and the absence of an effective health insurance scheme to pay for patients' medical expenses.As a result, the entire burden of medical bills is borne by patients and their relatives.
The mean ZBI scores showed no significant differences based on the respondents' or patients' socio-demographic characteristics, which could be due to the widespread burden being experienced by caregivers, irrespective of their sociodemographic characteristics.A similar observation was made by a study carried out in southern Nigeria. 2 A large proportion of respondents were experiencing a high level of burden; this was significantly associated with family size and place of residence.These respondents were found to be from larger families, in contrast to those reporting a low level of burden; this might have been due to the enormous burden of caring for the family and at the same time caring for the patient with schizophrenia.Respondents from rural areas were more likely to experience a high level of burden, compared with those from urban areas, which could be because of the additional burden articles

Limitation
The study is cross-sectional, with a relatively small sample size.

Conclusion
Relatives of patients with schizophrenia face enormous burdens, with financial, stigma and negative patient behaviour being more prominent.Efforts should therefore be made by the government to provide adequate financial and psychosocial support to caregivers of patients with schizophrenia.

Recommendations
Based on the findings of this study, we recommend that efforts should be made to reduce the burden associated with caring for patients with schizophrenia.The government should subsidise the cost of treatment and make mental health facilities more accessible to the community.Emphasis should be laid on prevention, early diagnosis and prompt treatment of mental illness.Communities should be educated about the nature of mental illness in an attempt to reduce stigma.Clinicians should also pay attention to the needs of caregivers of patients with mental illness, especially schizophrenia.

articles
Volume 15 No. 2 June 2009 -SAJP criteria for schizophrenia in the International Classification of Disease (ICD-10) on first contact with the hospital; this was ascertained from hospital records.A total of 129 caregivers who presented consecutively and fulfilled the inclusion criteria over a 3-month period from September 2008 to December 2008 were enrolled for the study.Informed consent was obtained from respondents before conducting interviews.

Table II . Mean scores of ZBI by socio-demographic characteristics of respondents
Volume 15 No. 2 June 2009 -SAJP