An-Najah National University Faculty of Graduate Studies Family Burden among Caregivers of Mentally Ill Patients in Nablus District By Haneen To’meh Supervisor Dr. Mariam Al-Tell This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Masters of Community Mental Health Nursing, Faculty of Graduate Studies, An-Najah National University, Nablus, Palestine. 2013 iii Acknowledgement I would like to express my love and gratitude to my fiancé and my family; for their support & endless love. I would like also to thank “Al-Najah National University” represented by Dr. Rami Hammdallah who always supports us and our faculty. Furthermore I would also like to thank Faculty of Nursing represented by Dr. Aida Al-Qaisi, and my great thank to my supervisor Dr. Mariam Al-Tell for her assistance and guidance with this paper. Finally, I would like to thank the team of Mental Health Clinic at Al- Makhfeia for facilitating data collection. iv االقرار :أنا الموقع أدناه مقدم الرسالة التي تحمل العنوان Family Burden among Caregivers of Mentally Ill Patients in Nablus District أقر بأن ما اشتملت عليه هذه الرسالة إنما هي نتاج جهدي الخاص، باستثناء ما تمت اإلشارة إليه أو أي جزء منها لم يقدم لنيل أية درجة أو لقب علمي أو بحثي حيثما ورد، وأن هذه الرسالة ككل، .لدى أية مؤسسة تعليمية أو بحثية أخرى Declaration The work provided in this thesis, unless otherwise referenced, is the researcher's own work, and has not been submitted elsewhere for any other degree or qualification. Student's Name : : اسم الطالب Signature: : التوقيع :Date : التاريخ v List of Contents Page Subject No. Iii Acknowledgement iv Declaration vii List of Tables ix Abstract 1 Chapter 1: Introduction 3 Problem statement 1.1 4 Significant of the study 1.2 5 Aim 1.3 6 Hypothesis 1.4 6 Conceptual definition 1.5 8 Operational definition 1.6 10 Chapter 2:Literature review 11 Family burden 2.1 14 Factors related to burden of family caregiver 2.2 14 Patient’s characteristics 2.2.1 81 Burden and its relation with caregiver’s characteristics 2.2.2 22 Social support 2.2.3 23 Coping strategies 2.2.4 31 Theoretical framework 2.3 34 Chapter 3: Methodology 3 34 Design 3.1 34 Setting 3.2 35 Sample and sampling method 3.3 35 Population size 3.3.1 vi 35 Sampling & sample size 3.3.2 35 Inclusion criteria 3.3.3 36 Exclusion criteria 3.3.4 36 Assessment tool 3.4 40 Validity 3.5 40 Reliability 3.6 41 Ethical Considerations 3.7 41 Field work 3.8 42 Statistical and analyzing methods 3.9 43 Chapter 4: Results 33 Chapter 5: Discussion 91 Conclusions 92 Limitations 92 Recommendation 93 Summary 96 References الملخص ب vii List of Tables No. Subject Page 1 Distribution of percentage of participants regarding their socio-demographic 44 2 Distribution of demographical characteristics of patients 46 3 Distribution of percentage and means of burden 47 4 Distribution of burden types in regard to gender 49 5 Distribution of burden types in regard to socioeconomic status 50 6 Distribution of burden types in regard to health status 52 7 Distribution of burden types in regard to employment 54 8 Distribution of burden types in regard to time spent with patient 55 9 Distribution of burden types in regard to the performed activities in helping the patient 57 10 Distribution of burden types in regard to age 58 11 Distribution of burden types in regard to education level 60 12 Distribution of burden types in regard to marital status 62 13 Distribution of burden types in regard to family size (number of family members) 64 14 Distribution of burden types in regard to relationship 65 viii 15 Distribution of burden types in regard to diagnosis of mental illness 67 16 LSD results of education levels 69 17 LSD results of relationship levels 70 18 LSD results of marital status 71 19 LSD results of type of mental illness 72 ix Family Burden among Caregivers of Mentally Ill Patients in the Nablus District By Haneen To’meh Supervisor Dr. Mariam Al-Tell Abstract Aim: The aim of this study was to assess family burden of caregivers of mentally ill patients and find out whether there is any relation between the perceived burden of caregivers of patients with mental illness and independent variables such as age, sex, education, economic status, and type of mental illness in Nablus District. Methodology: Descriptive, cross sectional design was used to achieve the aim of the study. Convenient sampling method was used to select the subject during the period from November 2012 – January 2013; it was distributed using quota method; 50 patients for each one of the following diagnosis: schizophrenia, mood disorder, and mental retardation, who were attending psychiatric outpatient clinics in Nablus district. The Zarit burden interview and the objective burden section from the Montgomery Borgatta caregiver burden scale were used to assess the burden. Result: The mean of subjective burden was mild to moderate (28.84), while objective was low (17.93). Also, the mean of psychological, social, and economic burden was low, and physical burden was low to moderate. The results showed that burden scores were significantly x correlated with gender, educational level, and economic status. No significant differences were found between participants according to their age and type of mental illness. Conclusion: Higher subjective burden scores were correlated to being female, low educational level, and low economic status. While higher objective burden scores were correlated to being male, high educational level, and high economic status. Taking care of mentally ill patients affects the family negatively, so psychiatric nursing intervention should be focused on the need of the caregivers and an emphasis placed on community care for mentally ill patients as well as family intervention. 1 Chapter 1 Introduction Mental illness is distressing for the people affected and their family members (Heller et al., 1997). It is a leading cause of global burden of disease (WHO, 2008). These family members are often inadequately prepared to be the main caregiver for their ill relative (Knudsen et al., 1996). There are different mental disorder categories; some examples of mental illness are schizophrenia, depression, anxiety, and mental retardation (WHO, 2013). Schizophrenia is a severe mental disorder, characterized by profound disruptions in thinking, affecting language, perception, and the sense of self. It often includes psychotic experiences, such as hearing voices or delusions. It can impair functioning through the loss of an acquired capability to earn a livelihood, or the disruption of studies (WHO, 2013). It is estimated that 1% of the population develops schizophrenia during their lifetime (Mental Health Research Association, 2006). Mood disorder Refer to disturbance in mood, inappropriate, exaggerated, or limited range of feelings. It include bipolar disorder, cyclothymic disorder, dysthymic disorder, major depressive disorder (APA, 2000) Bipolar affective disorder “characterized by repeated (i.e. at least two) episodes in which the patient's mood and activity levels are significantly http://allpsych.com/disorders/mood/bipolar.html http://allpsych.com/disorders/mood/cyclothymia.html http://allpsych.com/disorders/mood/dysthymia.html http://allpsych.com/disorders/mood/majordepression.html 2 disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (mania or hypomania), and on others of a lowering of mood and decreased energy and activity (depression)”.(WHO, 1992) . Mental retardation is concurrent deficits or impairments in adaptive functioning in at least 2 of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self- direction, functional academic skills, work, leisure, health, and safety. It is also characterized by significantly sub average intellectual functioning, an intelligence quotient (IQ) of approximately 70 or below, and onset before the age of 18 years (APA, 2000). Until the mid-1950s hospitalization of mentally patients was the routine approach to manage mental illness. One of the major changes in the care of people with serious mental illness in the twentieth century was that the process of deinstitutionalization which shifted the treatment of these people from state institutions to community care centers. This process had a substantial impact on the mental health system and on the families of the people with mental illness as well (Thompson & Doll, 1982). Numerous studies have demonstrated that family caregivers of persons with severe mental illness suffer from significant stress, experience moderately high levels of burden and often receive inadequate assistance from mental health professionals (Saunders, 2003). 3 1.1 Problem Statement According to a health report by Palestinian Health Information Center the number of new reported cases of all mental disorders in mental health clinics in primary health care facilities was 958(MOH, 2012). The number of mentally ill patients in Palestine is increasing which mean putting more burden on their care givers and their families because these patients need help in their daily activity either completely or partially. Those families are being expected to assume care giving responsibilities toward those members with mental illness although they have no formal training or support, in addition and they often find burdensome and they face emotional, physical, social, and financial problems and other difficulties. Moreover these families have to meet patient need and to face stigma that might indicate to the need to training to be able to fulfill these needs and to take care of them. While there are many studies assessing the burden of caregivers of patients with mental illness (Prafulla et al.(2010); Rudnick,(2004); (Ukpong, 2012) , there are no studies in Palestine assessing this issue. This study aimed to assess family burden of caregivers of mentally ill patients and find out whether there is any relation between the perceived burden of caregivers of patients with mental illness and age, sex, 4 education, socioeconomic status, and type of mental illness in Nablus district. 1.2 Significance of the Study After discharged from the hospital, mentally ill patients are followed-up outside of the hospital setting, and family members assume responsibility for those patients in addition to their responsibilities. Therefore , and in addition to the lack of studies in Palestine discussing this issue, it is crucial to evaluate the impact of caring for mentally ill patients on caregiver burden in order to better understand which factors produce the most stress for caregivers. The results of this study will provide some insights and information on the problems and difficulties that result from caring for or living with a mentally ill patient. Also it will help health policy makers to involve families in patients care. Moreover, this study will provide recommendations to focus on the needs of these caregivers and emphasize community care for mentally ill patients, and family intervention. 5 1.3 Aim The aim of this study was to assess family burden of caregivers of mentally ill patients. Specific objective:  To find out whether there is any relation between the perceived burden of caregivers of patients with mental illness and caregiver’s age caregiver.  To find out whether there is any relation between the perceived burden of caregivers of patients with mental illness and caregiver’s gender.  To find out whether there is any relation between the perceived burden of caregivers of patients with mental illness and educational level of caregiver.  To find out whether there is any relation between the perceived burden of caregivers of patients with mental illness and economic status of caregiver.  To find out whether there is any relation between the perceived burden of caregivers of patients with mental illness and type of mental illness. 6 1.4 Hypothesis  There is a relationship between the caregivers’ gender and family burden?  There a relationship between the caregivers’ age and family burden?  There is a relationship between educational level of caregivers and family burden?  There is a relationship between economic status of caregivers and family burden?  There is a relationship between type of mental illness and family burden? 1.5 Conceptual Definition “Mental disorders comprise a broad range of problems with different symptoms. However, they are generally characterized by some combination of abnormal thoughts, emotions, behavior and relationships with others. Examples are schizophrenia, depression, mental retardation and disorders due to drug abuse” (WHO, 2013). Family caregivers provide a complex array of support tasks that extend across physical, psychological, spiritual, and emotional domains (Honea et al., 2008). Family caregiver burden may be defined as the problems, difficulties, and negative life events influencing the life of family members caring for a loved one with a mental illness (Platt, 1985). Also (Natalie et 7 al.,2003) defined caregiver burden as the negative feelings and subsequent strain experienced as a result of caring for a chronically sick person. Objective burden is the existence of problems and changes in family life (household routine, relationships, and leisure time) (Ivarsson et al., 2004). Also Montgomry, (2002) defined it as perceived infringement or disruption of tangible aspects of a caregiver's life. Subjective burden is the emotional feelings and mental health status (guilt, feelings of loss, and anxiety) of family caregivers (Ivarsson et al., 2004). Self care: according to Orem theory, self care is “practice of activities that individual initiates and perform on their own behalf in maintaining life , health and well being”. In other hand, self-care deficit delineates when nursing is needed. Nursing is required when an adult is incapable of or limited in the provision of continuous effective self-care. Orem identifies three components to the Self-care nursing model, the compensatory system, the partial compensatory system and the educative- developmental system(Orem, 1991). The Compensatory system is when the nurse provides total care for the patient. This patient cannot do anything for themselves including but not limited to activities of daily living and ambulation. This patient is totally dependent of the nurse for survival, such as an acute Stroke patient. The second of Orem’s systems is the Partial Compensatory. The nurse 8 must assist in the care of the patient but the patient can assist as well (Orem, 1991). Depending on Orem theory the researcher used: - Complete help in self care: patient can’t do self care . - Partial help in self care: patient can do self care but need help. 1.6 Operational Definition The study measured the family burden by: - Zarit Burden Interview (subjective burden). The ZBI was developed to assess caregiver burden in relatives of patients with dementia, but it has also been used to assess burden in relatives of patients with schizophrenia in previous studies (Hanzawa et al., 2008). The ZBI is one of the most widely used scales for burden assessment in caregivers of elderly patients with dementia. Therefore, the ZBI has been used to assess the burden of caregivers of elderly patients with dementia and of elderly people and adults with other mental and physical diseases. - Montgomery Borgatta Caregiver Burden Scale (objective burden) It is measured by six items: amount of time one has for one's self; amount of personal privacy one retains; time available for 9 recreational activities; restrictions on vacations and trips; amount of time available to do one's own work and daily chores; and amount of time for friends and relatives (Montgomery, 2002). 11 Chapter 2 Literature Review In May 1994, the Palestine Council of Health, formed in July 1992, began its implementation of an Israeli/Palestinian agreement on health care in the West Bank and Gaza. In regard to mental health services some of its objectives included reduction in disability associated with mental illness, decrease in mortality and disability associated with interpersonal and self- directed violent behavior and the revitalization of the psychiatric hospitals in the West Bank and Gaza, as well as of the community psychiatric health clinics in various Palestinian cities(Palestine Council of Health, 1994). In the West Bank there is one psychiatric hospital in Bethlehem, which has 320 beds, of which 178 are for males and 142 for females. Wards are gender segregated but male and female patients can meet in the social club. Mental health services are provided in community psychiatric clinics in Jenin, Tulkarm, Nablus, Qalqilia, Ramallah, Hebron and Jericho. Mental health disorders constitute one of the largest health problems in Palestine, nearly a third of Palestinians are in need of mental health interventions. The Palestinians have been exposed to a series of traumatic events, like torture, human rights abuses, house demolitions, and movement restrictions. Adults who are exposed to house demolitions show a higher level of anxiety, depression and paranoia (Afana et al., 2004). http://pb.rcpsych.org/content/26/1/28#ref-14 11 Taking care of people with mental health problems at home is often a particular hardship with enduring strain for the family (Loukissa, 1995).Since the 1950s the adverse consequences of taking care of relatives with severe mental illnesses have been studied (Chan et al., 2000; Reine et al., 2003). Montgomery et al. (1985) defined burden as objective burden and subjective burden. They stated that subjective burden is caused by an emotional reaction impacted by care giving experience, while objective burden is the disruption or change in many aspects of caregiver’s household or life. From the 1970s to 1980s, the term caregiver’s burden has been used to describe the adverse consequences of mental disorders for family caregivers, but now it is more widely used to refer to the physical, psychological, or emotional, social and financial problems that are experienced by family members caring for a chronically ill, or impaired family members (Chow, 2000). 2.1 Family burden Family refers to two or more individuals who depend on one another for emotional, physical, and /or financial support (Hanson, 2001). The family may range from traditional notions of the nuclear and extended family to such post-modern family structures as single-parent, step-, and same-gender families, family structure were categorized to three types: 12 married family (e.g. traditional nuclear family, Dual career family, and stepfamily); single-parent family (e.g. widow with children, and divorced with children); and multiadult household (e.g. affiliated family and extended family)(Stanhope & Lancaster, 2004). Nuclear family is a new family that is created by husband and wife, while extended family is the family network beyond the family into which a person is born, it includes grandparent, aunts, uncles, cousins, nephews, and grandchildren.(Bowen, 1978; Heno and grose, 1985; Nichols and Everett,1986). Family function are: to achieve financial survival, to produce the species, to provide protection from hostile forces, passing along the culture, family educate their young, and confer status in society (Hanson, 2001). Duvall (1977) has described six functions as family; generating affection, providing personal security and acceptance, giving satisfaction and sense of purpose, assuring continuity of a companionship, guaranteeing social placement and socialization, and calculating controls and what is right. When chronic illness occurs and home care is required, the family caregiver system can be at risk for crisis. Family can respond in many ways to chronic illness. Ideally, primary intervention occurs as a response to accurate assessment of underlying factors that could precipitate a crisis. 13 Hanson, (2001) define family health as “a dynamic changing relative state of well-being which includes the biological, psychological, spiritual, sociological, and cultural factors of the family system”. An individual’s health (the wellness and illness continuum) affects the functioning of entire family, and in turn the family’s functioning affects the health of individuals. The adverse consequences of mental disorders for relatives have been studied by several scholars. Platt (1985) defined family caregiver burden as the problems, difficulties and negative life events that influence the life of family members caring for a loved one with a mental illness. According to Natalie et al.(2003), caregiver burden refers to the negative feelings and subsequent strain experienced as a result of caring for a chronically sick person. Also, different types of burden have been discussed in several studies. Schene (1990) recognized two types of family caregiver burden: objective and subjective burden. Lefley (1996) identified three types of burdens faced by family caregivers; first: objective burdens in coping with the mental illness (financial burden, time and effort in care giving, disruption of daily routine and social life); second: subjective burdens in facing the mental illness (feelings of loss, shame, worry, anger and hopelessness towards the client with mental illness);and third: burdens in management of problem behaviors of clients with mental illness (assault, mood swing, unpredictability, and negative symptoms). 14 To distinguish between the objective and subjective burden, Reine et al. (2003) identified objective burden as those related to the patient's symptoms, behavior, and socio-demographic characteristics, and factors such as changes in household routine, family or social relations, work, leisure time, and physical health. Subjective burden is the mental health and subjective distress among family members. According to Ivarsson et al. (2004), objective burden is the existence of problems and changes in family life (household routine, relationships, and leisure time) that occur because a family member requires care due to an illness, while subjective burden is the emotional feelings and mental health status (guilt, feelings of loss, and anxiety) of family caregivers. 2.2 Factors related to burden of family caregiver Caregiver burden is influenced by several factors; patient characteristics, caregiver characteristics, social support, and coping skills. 2.2.1 Patient’s characteristics In relation to patient’s characteristics, Ochoa (2008) assessed the relationship between the patients’ needs especially those needs related to daily activities (food, looking after home, self-care, company, child care, money…) and other clinical and disability variables and the level of family burden. Results showed that the number of patients’ needs was correlated with higher levels of family burden in daily life activities, disrupted 15 behavior and impact on caregiver’s daily routine. A higher number of needs, higher levels of psychopathology and disability, being male and older all accounted for higher levels of family burden. The presence of patients’ needs (daytime activities, alcohol and drugs) and the severity of psychotic symptoms and disability are related to higher levels of family burden. According to the age of patients, studies found that caregivers who had patients with schizophrenia displayed a very high degree of burden, especially while taking care of younger patients (Caquezo-Urizar & Gutierrez-Maldonado ,2006). Younger patients with schizophrenia had not been able to take care of themselves, and they might be in early stage of disease. Therefore, caregivers feel burden when they take care of the younger patients (Juvang et al. 2007).Higher burden subscale scores were variously associated with patient's younger age as well (Zahid & Ohaeri,2010). Regarding gender, patient gender can affect the burden of care (Awad &Voruganti, 2008).Higher burden subscale scores were variously associated with patient's female gender (Zahid&Ohaeri, 2010). Other factors affecting family burden are the clinical symptoms, according to Perlick et al. (2006); clinical symptoms were predictors of caregivers’ burden. Also, the severity of patient symptoms affects the burden of the caregiver (Shu-Ying H. et al., 2008). Grandon et al. (2008) 16 found that positive symptoms can predict caregiver’s burden more than the negative symptoms. In relation to type and duration of mental illness, Sreeja et al. (2009) found that the longer duration of illness might have contributed to the increased burden of the caregivers and Solomon & Draine (1995) found that a greater degree of subjective family burden is related to a greater severity of mental illness in relatives with less availability of social support and fewer coping resources of family members. Both objective and subjective burden was significantly more in relatives of schizophrenics when compared with an affective disorder either bipolar disorder or recurrent major depression (Chakrabartiet al., 1995). Also, relatives of schizophrenics presented a tendency for a higher degree of both objective and subjective burden in some area when compared with relatives of people with mental retardation (Pariante&Carpiniello, 1996). Other studies that compared burden of depression and burden of schizophrenia reported similar amounts of burden (van Wijngaarden et al., 2009).While van Wijngaardenet al. (2004) found that the burden of depression is less and care giving consequences occur less often than in schizophrenia. On the other hand, another study among partners of people suffering from anxiety disorders, depression or schizophrenia did not find any http://www.ncbi.nlm.nih.gov/pubmed?term=Chakrabarti%20S%5BAuthor%5D&cauthor=true&cauthor_uid=21743729 javascript:shindig.container.getGadget(2).closeGadget(); javascript:shindig.container.getGadget(2).closeGadget(); javascript:shindig.container.getGadget(2).closeGadget(); javascript:shindig.container.getGadget(2).closeGadget(); javascript:shindig.container.getGadget(2).closeGadget(); 17 relationship between strength of burden and type of diagnosis or duration of the illness (Wittmund et al., 2002). Similarly, Sreeja et al. (2009) conducted a study to assess the burden between sixty family caregivers of patients having schizophrenia and epilepsy (30 caregivers of patients having schizophrenia and another 30 caregivers of epilepsy). They found that the caregivers of both long term physical illness like intractable epilepsy and a mental illness like schizophrenia experience a high level of burden in the areas of: patient care, finance, physical and emotional burden, family relations and occupation. There was no significant difference in both groups of caregivers. The reason for this result might be related to the mean duration of illness of schizophrenia which was 6 years whereas that of epilepsy was 12 years. The longer duration of illness of Epilepsy might have contributed to the increased burden of the caregivers. Another possible reason for the equal burden could be the fact that most of the patients having Schizophrenia were not having active positive symptoms. 2.2.2 Burden and its relation with caregiver’s characteristics: A comparative study of Euro-Americans and Latinos suggested that the types and levels of family burden could be correlated to contextual factors including gender, ethnicity, diagnosis, and living situation of caregivers (Jenkins & Schumacher, 1999). 18 2.2.2.1 Burden and its relation to caregiver’s age Baronet (1999), in his study, highlighted different findings regarding the association between caregiver's age and burden. It was suggested that these differences might be due to differences in the intensity of the relative's illness so that crisis conditions may produce a greater burden regardless of age, whereas stable conditions may not produce a great burden in elderly caregivers due to more experience in dealing with the illness. Also a study by Juvang (2007) was conducted to investigate the relationship between demographic characteristics of caregiver’s burden when providing care for a member with schizophrenia in China. A purposive sampling technique was used to recruit 96 subjects from 3 hospitals. Findings showed that the age of caregiver had a positive correlated to the burden of the caregiver; increase caregivers age (older age)led to increase burden. Similarly, Chan et al. (2009) and Chien et al. (2007) found that caregivers' burden score was positively correlated with their age. In contrast, a study of Mexican Americans found that a younger caregiver age was predictive of higher levels of caregivers' depressive symptoms (Magaña et al., 2007). 19 2.2.2.2 Burden and its relation to caregiver’s gender Women are more likely to be regarded as natural caregivers and to assume major responsibility for the care of family members, especially for individuals with mental illness (Huang, 2004). About (58%) of caregivers in the United Kingdom were women (Nolan, 2001). The World Federation of Mental Health (WFMH) (2010) estimated that globally, about (80%) of caregivers are women, which could be the mother, wife, or daughter of the clients. Studies showed that middle aged and older women who provided care for an ill spouse or a spouse with disability were almost six times as likely to have depressive or anxious symptoms as were those who had no care-giving responsibilities (WFMH, 2010). To determine gender difference Hsiao (2010) conducted a study to assessed gender effects on family demands, social support and caregiver burden, and examined the contributing factors of caregiver burden in caring for family members with mental illnesses. The results found that female family caregivers perceived less social support and experienced higher degrees of caregiver burden compared to male family caregivers. Also Schneider et al. (2010) found in their study that women had a higher score in burden of care giving when compared to men. The same results were found in study in Turkey by Akpınar et al. (2011), which was conducted to determine the effects of gender on caregiver burden among caregivers of persons with Alzheimer’s disease. Results of this study 21 suggest that female caregivers are subjected to a higher level of caregiver burden than male caregivers. In subscales, female caregivers experienced more burden than male caregivers in the time dependence, developmental, physical, and social burdens. Emotional burden was similar in both genders. Similarly, Kumari et al. (2009) conducted a study to assess and compare patterns of subjective burden on spouses of schizophrenic patients using a socio-demographic data sheet and the Family Burden Interview Schedule. The sample was comprised of 50 spouses (25 male and 25 female spouses of schizophrenic patients). The results were that both male and female spouses of schizophrenic patients showed a moderate level of subjective burden, and no significant difference was found between male and female spouses of schizophrenic patients with regard to the level of subjective burden. 2.2.2.3 Burden and its relation to caregiver’s educational level Juvang et al.(2007) conducted a study to investigate the relationship between demographic characteristics of caregivers and family caregiver’s burden when providing care for a member with schizophrenia in China. Findings showed that the education level has a negative correlation with caregiver’s burden. It was assumed that the increased level of education led to an increase in the salary, and a high salary would decrease financial problems related to providing care for the ill family member. A high level of education of the caregiver also tends to indicate more knowledge to deal with stressful events. 21 2.2.2.4 Burden and its relation to economic status Folkman & Lazarus (1979) suggested that utilitarian resources, such as money, greatly increase the coping options available to any person. Financial difficulties were associated with poorer well-being in the caregivers (Schofield et al., 1998). Similarly, Quine & Pahl (1991) reported that being middle class with few financial worries appeared to buffer the effect of stressful behavior for mothers of children with severe learning difficulties. Another study conducted by Andren & Elmstahl (2007) in Sweden examined the relationship between income, subjective health and caregiver’s burden in people with dementia. Findings showed that low income was associated with a higher degree of burden on the caregivers. In addition, caregivers' burden score was negatively correlated with their income; families with lower socioeconomic status experienced a higher level of burden (Chien et al., 2007; Martens & Addington,2001; Ohaeri,2001). A review of research on the quality of life of caregivers in schizophrenia by Caqueo-Urizar et al.( 2009) showed that the burden of care increases and caregiver quality of life decreases with inadequate social support, family dysfunction, and a negative prognosis. Moreover, economic burden can negatively affect the quality of life of caregivers in developing 22 countries, in which there is a limited number of healthcare professionals and healthcare centers, and the cost of schizophrenia’s treatment is high. 2.2.2.5 Burden and its relation to ethnicity: Stueve et al. (1997) conducted a study to examine the effect of ethnicity on perceived caregiving burden. The results showed that African caregivers reported less burden than did western caregivers. There was no significant difference in perceived burden between Hispanic and western caregivers. Another study was conducted by Horwitz & Reinhard (1995) to examine the effect of ethnicity on caregiver duties and caregiver burden. There was no ethnic difference in caregiving duties between western and African parents, but ethnicity had the strongest impact on sibling caregiving duties. Western parents and siblings reported significantly more burden than did Africans. 2.2.2.6 Burden and its relation to patient-caregiver relationship: In a study by Zahid & Ohaeri (2010), caregivers who were either children or spouses of patients had a tendency to have higher burden scores than other relationship groups. 2.2.3 Social support: Chii et al. (2009) conducted a study on 301 caregivers in Taiwan to examine the correlation between caregivers’ burdens and perceived and received social support. They found that the perceived social support had a 23 negative correlation with the burden of caregiver. Caregiver’s burden increased when informal support could not meet the caregiver’s need. Magliano et al. (2000) also found that a reduction of family burden over a time was found among relatives who received more practical support from their social network. A review of research on the quality of life of caregivers of schizophrenics (Caqueo-Urizar et al., 2009) showed that the burden of care increases and caregiver quality of life decreases with inadequate social support. 2.2.4 Coping strategies: Hassan et al.(2011) studied the burden and coping strategies in caregivers of schizophrenic patients and identified the relationship between burden and coping strategies among them.100 caregivers of schizophrenic patients from psychiatric inpatient and outpatient clinics of Neuropsychiatry Department at Assiut University Hospital were assessed by utilizing the caregiver burden self-report and ways of coping questionnaires. They found that the level of burden reported by caregivers of schizophrenic patients was high. The most coping strategies used by caregivers of schizophrenic patients were self controlling, positive reappraisal and escape avoidance. Burden was positively and not significantly correlated with self controlling, accepting responsibility, escape-avoidance and problem solving. There were no significant associations between socio-demographic variables and burden and coping strategies; burden was not significantly correlated with coping strategies. 24 Another study was conducted by Creado et al. (2006) to evaluate the burden and coping of caregivers in relation to the level of functioning in patients with chronic schizophrenia.100 patients with their primary caregivers were assessed; the Global Assessment of Functioning (GAF) scale was used for patients, and caregivers were assessed by the Burden Assessment Schedule (BAS) and Mechanisms of Coping (MOC) scale. The findings were that fatalism and problem-solving were the two most preferred ways of coping. Problem-focused coping, i.e. problem-solving and expressive-action, decreased the burden of caregivers, while emotion- focused coping, i.e. fatalism and passivity, increased it. As the level of functioning of the patient decreased, the burden increased. The use of problem-solving coping by caregivers showed a significant correlation with a higher level of functioning in patients. Coping mechanisms such as problem-solving can decrease the burden of illness on caregivers and may even improve the level of functioning of patients. Several studies were conducted to assess family burden in different countries; Prafulla et al.(2010) conducted a study to assess the burden faced by the families and the needs for rehabilitation among the beneficiaries of a rural mental health camp in South India in which50 caregivers were interviewed. The results indicated mild to moderate objective burden experienced by the families. All participants had some kind of need pertaining to the rehabilitation of the ill family member. Similar results 25 were found in Israel, where the mean burden of Israeli family members of mentally ill individuals was moderate in 53 family members. Also, it was found that caregiver age was not associated with burden, and females were significantly more burdened than males (Rudnick, 2004). On the other hand, Papastavrou et al. (2010) examined the burden and emotional well- being experienced by Cypriot families caring for a member suffering from schizophrenia. A total of 113 caregivers were assessed using the family burden scale (FBS) and a socio-demographic data sheet. The findings showed a high level of burden among family caregivers; (43%) of the participants scored above 24/42 in the Family Burden Scale. Also, Ukpong (2012), in his study of burden and psychological distress among 101 Nigerian family caregivers of schizophrenic patients, found that about one third of caregivers (33.7%) were experiencing moderate to severe levels of burden even though there was a mean burden score of 32.6± 14.1 in the Zarit Burden Interview (ZBI); more than half of the caregivers were females (58.4%). High caregiver burden scores were also associated with the patient being unemployed and the caregiver having a lower education. Also, the 30-Item General Health Questionnaire (GHQ- 30) was used to measure psychological distress; the results showed that high levels of emotional distress in the caregiver was related to the patient being female and the patient having a lower education level. A Brazilian study, Torres et al. (2008) evaluated the emotional burden, psychological morbidity, and level of family accommodation in 50 26 caregivers of Brazilian obsessive-compulsive disorder (OCD) patients. Caregivers and patients were evaluated using the Family Accommodation Scale, the Zarit Burden Interview (ZBI), the Self-Report Questionnaire (caregivers), the Yale- Brown Obsessive-Compulsive Scale, and the Beck Depression Inventory. The burden was mild to moderate: their mean ZBI score was 28.9, while most caregivers (80%) were between 30 and 59 years of age and lived with the patient (88%).42% presented a common mental disorder. Family accommodation was moderate in 26% and severe or very severe in 24%. Caregivers’ levels of psychological morbidity, accommodation and emotional burden were associated with each other and with the severity of the patient’s obsessive-compulsive and depressive symptoms. In 2009, Nasr and Kausar studied the impact of psycho-education on the burden of schizophrenia on the family in a randomized controlled trial. The sample size was 108 patients and their family members from the outpatient department of a teaching hospital in Lahore, Pakistan. All patients received psychotropic drugs but one group received psycho- education in addition. Family burden was assessed at the time of recruitment and at 6 months post intervention by the Family Burden Interview Schedule (FBIS).99 patients and their relatives completed the treatment. There was significant reduction in burden at post intervention assessment in the psycho-education group based on an intention to treat analysis. 27 Another study was conducted to investigate the effect of a designed psycho-educational program on improving patient symptoms and reducing caregiving burdens among family caregivers with chronic schizophrenic patients. The study was conducted in an outpatient department at Abassia hospital in Egypt. Four developed tools were used to collect data: socio- demographic and medical data sheet, assessment of negative symptoms for schizophrenic patient, socio-demographic data sheet for caregivers, and family burdens assessment sheet to measure burdens among caregivers. 40 chronic schizophrenic patients with their family caregivers were divided into the control and the experimental group. 10 sessions (one session every other week) were done in this program for a study group for 45-60 minutes for each one. The results revealed that there were no statistically significant differences among groups; the designed program had an effective impact on reducing caregivers burdens in relation to recreational family activity, family interaction within and outside the family, physical health and psychological health of the family members. In addition, family burden decreased in relation to the improvement of patient's symptoms. This study concluded that, when relatives of patients with schizophrenia have enough knowledge and efficient skills to deal with patient problems, it is possible for burden to be reduced and patient symptoms improved (Abd-el-Aziz, 2011). El-Tantawy et al. (2010) evaluated depressive disorders among caregivers of schizophrenic patients and their relationship with burden of 28 care and perceived stigma. Sixty primary caregivers of patients with schizophrenia, and 30 healthy non-caregivers who served as a control group were screened for depressive symptoms using the Center of Epidemiological Studies for Depression Scale. Diagnosis of depressive disorders was made according to DSM-IV-TR criteria. The Caregiver Strain Index and the Discrimination-Devaluation Scale were administered to the caregivers. They found that depressive disorders were higher among caregivers (18.33%) than the control group (3.33%) with (p ‹0.05). The most common depressive disorders among the caregivers group was adjustment disorder with mixed anxiety and depressed mood (6.67%). Depressive disorders were correlated with burden of care and perceived stigma. Depressive symptoms were associated with increased number of hours per week spent providing care, older age of the caregiver and duration of care giving. Another study was conducted to determine the prevalence of depressive disorders among caregivers of patients with schizophrenia, its association with patient’s and caregiver’s socio-demographic characteristics and family functioning. A total of 232 caregivers of patients with schizophrenia at the outpatient clinic completed the self-administered socio-demographic questionnaire, the General Health Questionnaire (GHQ- 30) and the McMaster Family Assessment Device. A total of 33 caregivers with the GHQ-30 cut-off point of 7/8 were assessed further by the Mini International Neuropsychiatric Interview to diagnose depressive disorders. 29 The prevalence of psychological distress was 14% (n = 33) and that of depressive disorders was 6% (n = 14). There was no association between patients’ and caregivers’ socio-demographic characteristics and depressive disorders, but there were significant associations between depressive disorders and family functioning dimensions in terms of communication and roles. Depression had a significant association with family functioning among caregivers of patients with schizophrenia (Osman et al., 2010). Similarly, another study of depressive symptoms and family functioning in the caregivers of recently hospitalized patients with chronic/ recurrent mood disorders was conducted by Heru & Ryan (2002) to determine the relationship between family dysfunction and depression in caregivers.16 caregivers of patients with chronic recurrent mood disorders were assessed during the period that their relatives were in-patient and completed self-reports instruments including the Center for Epidemiologic Studies Depression Scale (CESD), Family Assessment Device(FAD) and measures of burden. Results showed that caregivers were mostly males (56%) and spouses (69%) while (72%) of the caregivers scored positively for depressive symptoms. Caregivers who reported poor family functioning had dysfunction in all areas of family functioning and were significantly more likely to report depressive symptoms. Family functioning and depression are closely associated in the caregivers of patients with chronic recurrent mood disorders. 31 Also, Perlick et al. (2007) conducted a longitudinal study to present the design and preliminary data on the costs and consequences of caring for the primary caregivers of 500 patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder.89%, 52%, and 61% of caregivers, respectively, experienced moderate or high burden in relation to patient problem behaviors, role dysfunction, or disruption of household routine. High burden caregivers reported more physical health problems, depressive symptoms, health risk behavior and health service use, and less social support than less burden caregivers. They also provided more financial support to their bipolar relative. Burdens experienced by family caregivers of people with the bipolar disorder are associated with problems in health, mental health, and cost. Another study was conducted by Fan & Chen (2011) explored the factors associated with care burden and quality of life among caregivers of the mentally ill in Chinese society. Ninety caregivers of patients with mental illness who were attending outpatient clinic services in Taipei City Psychiatric Centre were assessed using a burden questionnaire and the brief questionnaire of the World Health Organization Quality of Life instrument (WHOQOL-BREF). The results showed that burden scores were significantly correlated with the number of care hours the caregivers spent daily with the patient, irrespective of their age, gender, kinship and educational level. Caregivers of patients with different psychiatric illnesses had similar levels of burden. Higher burden scores were correlated with a 31 lower quality of life and retained unique predictive variance in multiple regressions in all four domains of the WHOQOL-BREF. The findings indicate that care burden has a significant impact on caregivers’ quality of life. Schmid et al. (2006) studied the sibling role as caregivers of patients with schizophrenia. 37 narrative interviews with siblings of schizophrenic patients were analyzed using a summarizing content analysis. The global statements and categories were quantitatively analyzed to assess their relative importance. Analysis of the 492 individual statements of the siblings revealed 26 global types of statements, which were assigned to five categories. 1: burden arising in the daily contact with the sibling (36.2 %); 2: burden with respect to the healthy sibling's privacy (26.8 %); 3: burden with respect to the contact with the family (15.7 %); 4: burden with respect to the contact with institutions and professionals (14.2 %); 5: burden with respect to the siblings' own social contacts (friends and public) (7.1 %). The three types of burden most reported by the healthy siblings are: handling the symptoms of illness (100 %), emotional burden due to the illness of the sibling (100 %) and uncertainty in judging what amount of stress the schizophrenic patient can cope with (81.1 %). 2.3 Theoretical framework: Family burden was classified into objective burden and subjective burden, as illustrated in Figure (1) which explained the frame work of 32 family caregiving burden. Many predictors of caregiver burden have been identified; these include the ill relative’s characteristics, such as age, gender, duration of illness, and symptoms; and caregiver characteristics, such as gender, age, socioeconomic status, ethnicity, and relationship, while reported mediating factors include social support and coping skills. This framework was adopted in this study, but educational level was added to caregiver’s characteristics. Mental illness is distressing for the patients and their family. Patient’s characteristics  Age  Gender  Duration of illness  symptoms Caregiver’s characteristics  Age  Gender  Relationship  Ethnicity  Socioeconomic status Objective Burden Subjective burden Coping skills Social support Figure1: Family Care giving Burden Framework (Rungreangkulkij & Gilliss, 2000). 33 Families of people with serious mental illnesses have major responsibility for providing care and support to their ill relatives. Many of these families experience substantial levels of stress and burden that adversely affect the health of individual members, as well as the health of the family. Burden can to be physical, psychological, or emotional, social and financial problem. Caregiver burden are influenced by several factor; patient characteristics, caregiver characteristics, social support, coping skills. Families may take on the role of day-to-day care. This often happens with little training or support, or acknowledgment of their own needs and mental health. When families are accepted as partners in care and do receive training and support, there is strong evidence that this leads to better outcomes for patient and family. 34 Chapter 3 Methodology This chapter presents in details the methodology that was used to in the study. It includes design, setting, sample and sampling method, assessment tool, administrative parts, ethical considerations, reliability and validity, field work, and statistical and analyzing methods. 3.1 Design A descriptive, cross-sectional design was used to achieve the aim of the study, because it is simple, easy, inexpensive, and quick data collection. 3.2 Setting The data was collected from the Community Mental Health Center – Nablus (Al-Makhfeia), which is the first mental health clinic in Nablus. It was created tracking Bethlehem Hospital in 1967 and worked for one day because of the war and occupation, which caused a postponement in functioning until 1974. It was the only center for mental health for the Northern West Bank until other clinics were opened. In 2009 the clinic was developed into the Center for Mental Health to provide integrated services. The project was implemented with funding from the French Agency for Development and the UN Development Program (UNDP). The 35 Department of Occupational Therapy was developed to provide rehabilitation services to patients (MOH, 2013). 3.3 Sample and Sampling Method 3.3.1. Population size: The population of this study was the caregivers of mentally ill patients who followed up at the mental health clinic in Nablus district during the period from November 2012 – January 2013. 3.3.2. Sampling & Sample size: Convenient sampling method was used to select the subject during the period from November 2012 – January 2013; it was distributed using quota method; 50 patients for each one of the following diagnosis: schizophrenia, mood disorder, and mental retardation, who were attending psychiatric outpatient clinics in Nablus district. Caregivers of patients with these illnesses were selected because these were the most common illnesses of patients who follow up at the clinic during the period of data collection. 3.3.3. Inclusion criteria:  Families living with and caring for one relative with mental illness.  The caregiver does not suffer from mental illness. 36 3.3.4. Exclusion criteria:  Participants who are taking care of more than one patient, because taking care of more than one patient may increase burden.  Participants who are younger than 18 years old, because usually who are younger than 18 not able to take care of other and themselves are in need for caring. 3.4 Assessment Tools A structured questionnaire was used to collect the data through face to face interviews with the caregiver by the researcher herself. The questionnaire consisted of two parts: 1- Patient part Demographic data for the patient which includes: gender, age, educational level, diagnosis of mental illness, employment, marital status, and psychiatric history. (Appendix 1). 2- Caregiver part (consisted of 3 sections): A) Demographic data for the family caregiver, which included gender, age, educational level, economic status, health status, employment, marital status, number of family members, and relationship between patient and caregivers. (Appendix 2). 37 - Economic status refers to food consumption divided by total consumption. It is distributed into three categories: First: better-off (food consumption to total consumption less than 30%) Second: middle range (food consumption to total consumption between 30- 44%). Third: worse-off (food consumption to total consumption between 45- 100%) (United Nation UN + Palestinian Central Bureau of Statistics PCBS, 2012). - Full time: 24 hours with patient. - Partial time: less than 24 hours (2, 3, 4,…). - Having medical disease: complain of medical disease like HTN, DM, etc. B) Zarit Burden Interview (ZBI) (Appendix 3) The ZBI is a list of (22) statements, (ratings are on a 5-point Likert scale), and scores range from 0-88, with higher scores indicating increased burden. The scale levels of burden are categorized as little or no burden (0-20), mild/moderate (21-40), moderate/severe (41- 60), and severe burden (61-88). 38 Based on literature the scale was classified according to type of items to subscale by the researcher, which included psychological, social, physical, and economic burden. Psychological burden is measured by six items: feelings of stress (item 3), feelings of anger (item 5), fear of the future (item 7), feelings of strain (item 9), feelings of loss of control of one’s life (item 17), and feelings of uncertainty about what to do (item 19). The levels of burden are categorized as low or no burden (0-8), moderate (9-16), and high burden (17- 24). Social burden is measured by three items: effects on relationships with other family members or friends (item 6), effects on social life (item 12), feeling uncomfortable about having friends (item 13). The levels of burden are categorized as low or no burden (0-4), moderate (5-8), and high burden (9- 12). Physical burden is measured by two items: effects on health (item 10), feeling of burden or tiered (item 22). The levels of burden are categorized as low or no burden (0-2), moderate (3-5), and high burden (6- 8). Economic burden is measured by: feeling of not having enough money (item 15). The levels of burden are categorized as low or no burden (0-1), moderate (2-3), and high burden (4). 39 C) The Montgomery Borgatta Caregiver Burden Scale (Montgomery, Borgatta, & Borgatta, 2000). (Appendix 4). This scale consists of 14 items, and these items contain 3 subscales: objective burden, subjective demand burden, and subjective stress burden. Only objective burden was used in this study, because the previous scale (ZBI) was used to measure both kinds of subjective burden. In addition, this scale (objective) measures others items that are not included in the subjective burden. Objective burden: Is defined as perceived infringement or disruption of tangible aspects of a caregiver's life. It is measured by six items: amount of time one has for one's self; amount of personal privacy one retains; time available for recreational activities; restrictions on vacations and trips; amount of time available to do one's own work and daily chores; and amount of time for friends and relatives. Scores on this measure have range from 6 to 30. Previous research indicates that mean scores for large samples of caregivers range between 19.3 (standard deviation = 3.8) and 19.5 (standard deviation = 3.15). (Montgomery, 2002). Based on this information scores above 23 could be considered quite high burden. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3063059/#R31 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3063059/#R31 41 3.5 Validity After the study tools were developed, they were translated to Arabic by a translator from the Academy of Languages and Translation, and then content validity was used, the tool was reviewed by 2 nursing academic staff, 2 psychologists, one social worker, and one psychiatric nurse. 3.6 Reliability ZBI: Studies of the original scale version, which include the assessment of its internal consistency with different subjects, obtained good results, with Cronbach's alpha index varying from 0.79 to 0.91 (Zarit SH.et al., 1987). The test-retest of the scale's original version was conducted and obtained a good result (alpha=0.71) (Gallagher et al., 1985). The Montgomery Borgatta Caregiver Burden Scale: The internal consistency (Cronbach Alpha) for this measure has ranged from .87 to .90. The internal consistency (Cronbach Alpha) in this study for ZBI was 64.2, and for objective burden from The Montgomery Borgatta Caregiver Burden Scale was 62.1 Pilot study: The pilot study was accomplished after developing the questionnaire on 10% of the sample (which was the caregivers of mentally ill patients 41 who followed up at the mental health clinic in Nablus district), aiming to ensure subjects understanding of the questionnaire, time needed for completing it. As a result of the piloting, no modification was made. 3.7 Ethical Considerations Institutional Review Board (IRB) was obtained from the Faculty of Graduate Studies (Appendix 5), then approval letters were attained from the Ministry of Health (Appendix 6), and request letters were sent to the primary health care center in Nablus (the Mental Health Clinic at Al- Makhfeia Clinic). Permission and consent forms (Appendix 7) were taken from participants before starting the study. 3.8 Field work After having the acceptance from the Mental Health Center in Nablus and the data collection tool and consent form were developed, the study was conducted at the Mental Health Center during the period from November 2012 to January 2013. The psychologist who was the director of the center was met with to explain aim of the study. Then subjects of the study were met with in the waiting room, where the study aim, related questionnaire, ethical issues and consent form were explained to them. When the subjects agreed to 42 participate in the study, a consent form was taken from them, and then they were interviewed by the researcher to complete the questionnaire. 3.9 Statistical and Analyzing Methods Data was entered and analyzed using Statistical Package for Social Science (SPSS). Chi-square test was used for categorical variables; T-test and ANOVA were used to test the relationship between burden types and demographical characteristics. Fisher's Least Significant Difference (LSD) was used to measure the differences. 43 Chapter 4 Results This chapter presents in details the results of the study. It includes a description of the sample, demographic characteristics of caregivers and patients, means of burden types, association between burden types (psychological, social, physical, economical subjective and objective) and the demographic characteristics of caregivers, association of burden types and type of patient mental illness, measures of the differences between mean score of burden and demographic characteristics of caregivers and diagnosis of patient, and measures of the relationship between the burden types. The number of caregivers who met the inclusion criteria was 150 caregivers; 50 caregivers of patients with schizophrenia, 50 caregivers of patients with mood disorder, and 50 caregivers of patient with mental retardation. The data of patients themselves were taken from their caregivers. 44 Socio-Demographic Data Table (1): Distribution of percentage of participants regarding their socio-demographic (%) No. Variable 30.7 69.3 46 104 Male Female Gender 4 9.3 33.3 40 4 9.3 6 14 50 60 6 14 18-24 25-34 35-44 45-54 55-65 More than 65 Age Category 0.7 62.6 36.7 1 94 55 High Medium low Economic status 5.3 8 33.3 53.4 8 12 50 80 Bachelor's degrees(BA) Diploma Secondary Other (Below secondary) Educational Level 80 20 120 30 Not having medical disease Having medical disease Health Status 28 72 42 108 Employed Unemployed Employment 13.3 77.3 9.4 20 116 14 Single Married Other(divorced, widowed/widower) Marital Status 10 72.7 17.3 15 109 26 1-3 4-7 8 and more Family Size (no. of family members) 9.3 21.4 19.3 15.3 25.4 1.3 0.7 4 3.3 14 32 29 23 38 2 1 6 5 Father Mother Brother Sister Wife Husband Son Daughter Other relatives Relationship with the patient 47.3 52.7 71 79 Full time Partial Time spent with patient 33.3 66.7 50 100 Complete help in self-care Partial help in self care The performed activities in helping patient 45 Table (1) shows the distribution of demographic characteristics of caregivers. It illustrates that most participants were female (69.3%), and (30.7%) were male. (40%) of participants were in the age group of (45- 54), and (62, 6%) of them had medium economic status, and (36.7%) were at a low. Regarding educational level, (53.4%) had an educational level below secondary, while (5.3%) had BA. It also shows that (80%) of participants do not have medical diseases, and (72%) of them were unemployed. Also, (77.3%) of participants were married, and (72.7%) had a family size of (4-7) family members. Most of participants were wives and mothers of patients (25.4%, 21.4%); regarding the time that participants spent with patients (42.7%) spent partial time, and (66.7%) of them helped their relative partially in self care. 46 Table (2): Distribution of demographical characteristics of patients (%) No. Variable 54 46 81 69 Male Female Gender 14.7 16.7 32 27 6.7 2.7 22 25 48 41 10 4 18-24 25-34 35-44 45-54 55-65 More than 65 Age Category 6.7 2 23.3 68 10 3 35 102 B.A Diploma Secondary Other(Below secondary) Educational Level 9.3 90.7 14 136 Employed Unemployed Employment 59.4 33.3 7.3 89 50 11 Single Married Other Marital Status 33.3 33.3 33.3 51 51 51 schizophrenia affective disorder mental retardation Type of mental illness 8.7 14 20 57.3 13 21 30 86 Less than 5 years 5-10 11-15 More than 15 Illness History (time of diagnosis) 14.7 50 28 7.3 22 75 42 11 One Two Three More than three Drugs Used 78.7 14 7.3 118 21 11 Less than 50 50-100 More than 100 Treatment cost Table (2) shows the distribution of demographical characteristics of patients. It depicts that (54%) of patients were male, (32%) of them were in the age group (35-44), and (68%) of them had an educational level below secondary. Also, it shows that (90.7%) of patients were unemployed, and (59.4%) were single. In terms of illness history, (57.3%) had been diagnosed as having a mental illness 15 years or more ago, and (50%) 47 were using two types of medication, while (78.7%) of patients have to pay less than 50 shekels monthly for medication. Types of burden: Table (3): Distribution of percentage and means of burden. Table (3) shows the mean values; standard deviation and the response degree of the study sample responses were calculated. The results show the distribution of burden types; it illustrates that the mean score of subjective burden was (28.84), while (39.3%) had little or no burden, (32.6%) had mild to moderate, and (5%) had severe burden. Category Criteria Degree No. % Mean± Std. Deviation S u b jectiv e B u rd en Psychological Burden 0-8 9-16 17-27 Low/no Moderate High 99 40 11 66.0 26.6 7.4 7.5067 ± 5.11577 Social Burden 0-4 5-8 9-12 Low/no Moderate High 112 30 8 74.6 20.0 5.4 2.7467 ± 3.12209 Physical Burden 0-2 3-5 6-8 Low/no Moderate High 80 33 37 53.4 22.0 24.6 2.7733 ± 2.44715 Economical Burden 0-1 2-3 4 Low/no Moderate High 67 73 10 44.7 48.7 6.6 1.6933 ± 1.41396 Subjective Burden 0-20 21-40 41-60 61-88 Little/ no burden Mild –Moderate Moderate– severe Severe 59 49 35 7 39.3 32.6 23.1 5.0 28.8400 ± 16.12080 Objective Burden ≥23 <23 High burden Low/no burden 18 132 12.0 88.0 17.9267 ± 4.03191 48 According to subtypes of subjective burden, the mean score of psychological burden was (7.5067) and (34%) of caregivers had moderate to high burden. The mean score of social burden was (2.7467) and (25.4%) of caregivers had moderate to high burden. While (46.6%) of caregivers were experiencing moderate to high physical burden with a mean score of (2.7733), (55.3%) of them had moderate to high economic burden with a mean score of (1.6933). Regarding objective burden, the mean score was (17.9267), and (88%) had low or no burden, while (12%) had high burden. 49 Relationship between burden types and the demographic characteristics of caregivers Table (4): Distribution of burden types in regard to gender. Burden type Male Female t P value no mean±std. deviation no mean±std. deviation -2.696 0.008* S u b jectiv e B u rd en Psychological Burden 46 5.8478± 4.31518 104 8.2404± 5.28690 Social Burden 46 1.9783± 2.65405 104 3.0865± 3.26235 -2.025- 0.045* Physical Burden 46 1.5217± 1.82256 104 3.3269± 2.49053 -4.417 0.000* Economical Burden 46 1.6522± 1.40186 104 1.7115± 1.42565 -.236 0.813 Subjective Burden 46 22.8261± 13.30214 104 31.5000± 16.59337 -3.127 0.002* Objective Burden 46 19.1304± 3.53779 104 17.3942± 4.13702 2.473 0.015* Table (4) shows t – test results of the relation between the burden and the caregiver’s gender; the mean score of subjective burden for males was (22.83 ± 13.30), and for females was (31.50± 16.59) with significant differences between males and females; for females (P value 0.002). The mean scores of psychological and physical burden for females were (8.24± 5.29) and (3.33± 2.49) respectively, with significant differences for females (P value (0,008), (0)) respectively. Also, there were significant differences between males and females in regard to social burden and these differences were for females (P value 51 0.045). On the other hand, significant differences were not found between males and females in their economical burden (P value 0.813). According to objective burden the mean score for males was (19.13± 3.54), while for females it was (17.39± 4.14) with significant differences for males (P value 0.015). Table (5): Distribution of burden types in regard to economic status. Burden type Medium Low t P value no mean±std. deviation no mean±std.de viation -3.722 0.000* S u b jectiv e B u rd en Psychological burden 94 6.3617± 4.51247 55 9.4727± 5.56062 Social Burden 94 2.1809± 2.98369 55 3.7091± 3.17206 -2.947 0.004* Physical Burden 94 2.0213± 2.22391 55 4.0909± 2.27932 -5.432 0.000* Economical Burden 94 1.1489± 1.31948 55 2.6364± 1.04285 -7.152 0.000* Subjective Burden 94 24.6064± 14.12100 55 36.1091± 16.98766 -4.447 0.000* Objective Burden 94 18.7660± 3.56031 55 16.3818± 4.32260 3.640 0.000* Table (5) shows t – test results of the relation between the burden and the caregiver’s economic status: it shows that the mean score of subjective burden for those who had a medium level of economic status was (24.60 ± 14.12), and for those with low level economic status the score was (36.1091± 16.98766), with significant differences for the low level (P value 0). 51 It also shows that the mean score of physical burden for those who had a medium level was (2.02± 2.22), and for those with low level was (4.0909± 2.27932), with significant differences for the low level (P value 0). There were significant differences in the mean score of psychological, social, and economic burden and the level of the economic status (medium and low), and these differences were for the low level. Regarding the objective burden, the mean score for those had a medium level of economic status was (18.77± 3.56), and for those with a low level was (16.38± 4.32), with significant differences for the medium level (P value 0). 52 Table (6): Distribution of burden types in regard to health status. Burden type Does not have medical disease Has medical disease t P value no mean±std .deviation No mean±std.dev iation -0.072 0.943 S u b jectiv e B u rd en Psychological Burden 120 7.4917± 4.98906 30 7.5667± 5.68533 Social Burden 120 2.8083± 3.09593 30 2.5000± 3.26687 0.483 0.630 Physical Burden 120 2.6167± 2.38406 30 3.4000± 2.63400 -1.576 0.117 Economical Burden 120 1.7583± 1.35966 30 1.4333± 1.61210 1.127 0.262 Subjective Burden 120 28.9583± 15.43182 30 28.3667± 18.91448 0.179 0.858 Objective Burden 120 18.1750± 3.73190 30 16.9333± 5.00988 1.515 0.132 Table (6) shows t – test results of the relation between the burden and the caregiver’s health status of participants: the mean score of subjective burden for those who did not have a medical disease was (28.95± 15.43) and for those who had a medical disease was (28.37± 18.91), with no significant differences (P value 0.858). According to subtypes of subjective burden, the mean score of psychological burden among those who had a medical disease was (7.57± 5.69), and the mean score of physical burden was (3.40± 2.63). No significant differences were found between those who had a medical disease and those who did not have a medical disease in relation to psychological, social, physical, and economical burden; p>0.05. 53 Regarding objective burden, the mean score for those who had a medical disease was (18.18± 3.73) and for those who did not have a medical disease was (16.93± 5.01), with no significant differences (P value 0.132). 54 Table (7): Distribution of burden types in regard to employment. Burden type Employed Unemployed t P value no mean±std .deviatio n no mean±std. deviation -2.132- 0.035* S u b jectiv e B u rd en Psychological Burden 42 6.0952± 5.16465 108 8.0556± 5.01369 Social Burden 42 2.1190± 3.02995 108 2.9907± 3.13704 -1.542- 0.125 Physical Burden 42 1.5238± 1.97840 108 3.2593± 2.44709 -4.102- 0.000* Economical Burden 42 1.5000± 1.31130 108 1.7685± 1.45079 -1.045- 0.298 Subjective Burden 42 23.6429± 15.87116 108 30.8611± 15.83174 -2.506- 0.013* Objective Burden 42 19.0476± 3.68883 108 17.4907± 4.09124 2.149 0.033* Table (7) shows t – test results of the relation between the burden and the caregiver’s employment status. The mean score of subjective burden for the employed participants was (23.6429± 15.87116), and for unemployed participants was (30.86± 15.83), with significant differences for unemployed caregivers (P value 0.013). The mean score of psychological and physical burden for the unemployed participants were (8.06± 5.01) and (3.26± 2.45) respectively, with significant differences between employed and unemployed participants for the unemployed. While in relation to social and economical burden, no significant differences were found between employed and unemployed caregivers. 55 According to objective burden the mean score for employed participants was (19.05± 3.69), and for those who were unemployed was (17.49± 4.09), with significant differences for the employed (P value 0.033). Table (8): Distribution of burden types in regard to time spent with patient. Burden type Partial Full t P value no mean±std .deviation no mean±std. deviation -5.361 0.000* S u b jectiv e B u rd en Psychological Burden 71 5.3380± 4.29599 79 9.4557± 5.03016 Social Burden 71 1.7042± 2.52074 79 3.6835± 3.32259 -4.075 0.000* Physical Burden 71 1.4648± 1.72238 79 3.9494± 2.41204 -7.187 0.000* Economical Burden 71 1.4225± 1.34867 79 1.9367± 1.43529 -2.254 0.026* Subjective Burden 71 21.5634± 13.82103 79 35.3797± 15.28054 -5.783- 0.000* Objective Burden 71 19.2254± 3.64573 79 16.7595± 4.02624 3.916 0.000* Table (8) shows t – test results of the relation between the burden and the time that the participants were spending with their patients. The mean score of subjective burden for those who were spending partial time with the patient was (21.5634± 13.82103) and for those who were spending full time was (35.38± 15.28), with significant differences for full time (P value 0). According to subtypes of subjective burden, the mean score of psychological burden for those who were spending partial time with the 56 patient was (5.34± 4.29) and for those who were spending full time was (9.46± 5.03), with significant differences for full time (P value 0). Regarding social burden, the mean score for those who were spending partial time with the patient were (1.70± 2.52) and for those who were spending full time was (3.68± 3.32), with significant differences for full time (P value 0). Also, in regard to physical and economical burden there were significant differences for those who spending full time with patient, with mean score of burden for those who were spending full time (3.95± 2.41), and (1.94± 1.44) respectively. Regarding objective burden, the mean score for those who were spending partial time with the patient was (19.23± 3.65), and for those who were spending full time was (16.76± 4.03), with significant differences for partial time (p value 0). 57 Table (9): Distribution of burden types in regard to the performed activities in helping the patient. Burden type Complete help Partial help T P value no mean±std. deviation no mean±std. deviation 2.575 0.011* S u b jectiv e B u rd en Psychological Burden 50 9.0000± 5.23333 100 6.7600± 4.91364 Social Burden 50 3.2000± 3.48173 100 2.5200± 2.91800 1.260 0.210 Physical Burden 50 3.0600± 2.54278 100 2.6300± 2.39804 1.015 0.312 Economical Burden 50 1.6600± 1.31878 100 1.7100± 1.46539 -0.204 0.839 Subjective Burden 50 33.6600± 16.15184 100 26.4300±15.63359 2.641 0.009* Objective Burden 50 16.8200± 4.70644 100 18.4800±3.54617 -2.415 0.017* Table (9) shows t – test results of the relation between the burden and the performed activities in helping the patient. The mean score of subjective burden for those who helped the patient completely was (33.66± 16.15), and for those who helped the patient partially was (26.43±15.63), with significant differences for complete help in self-care (P value 0.009). The result also shows that there were significant differences in psychological burden and these differences were for those who helped their relative completely in self-care (P value .0011), with a mean score of (9.00± 5.23). According to objective burden, the mean score for those who helped the patient completely was (16.82± 4.71), while for those who helped the patient partially was (18.48±3.55), with significant differences for partial help in self-care (P value 0.017). 58 Table (10): Distribution of burden types in regard to age. Burden Type Age Categories ( F) Sig.* 18-24 25-34 35-44 45-54 55-64 65 and more S u b jectiv e B u rd en Psychological Burden 5.6667 6.0000 8.2400 7.4667 5.8333 8.0714 0.761 0.580 Social Burden 3.6667 1.9286 2.5600 2.9833 3.1667 2.6429 0.418 0.836 Physical Burden 2.0000 1.8571 2.8600 3.0500 2.8333 2.5000 0.707 0.619 Economical Burden 1.3333 1.5000 2.1400 1.5000 1.1667 1.5000 1.603 0.163 Subjective Burden 22.6667 20.9286 31.0200 29.6333 26.3333 29.2857 1.097 0.365 Objective Burden 18.1667 20.0714 18.2000 17.3667 17.5000 17.2857 1.165 0.330 59 Table (10) shows ANOVA tests of the relation between burden and caregiver’s age group. It illustrates that the mean score for subjective burden was (31.02) for age group (35-44), and (29.63) for age group (45- 54), and it was (20.93) for age group (25-34) with no significant differences (P value 0.365). Regarding subtypes of subjective burden, the mean score of psychological and economical burden were (8.24) and (2.14) respectively for age group (35-44). In regard to social burden, the mean score for age group (18-24) was (3.67), while for physical burden the mean score was (3.05) for age group ( 45-54), with no significant differences. According to objective burden, the mean score for age group (25-34) was (20.07), and (17.29) for age group (65 and more), with no significant differences (P value 0.330). 61 Table (11): Distribution of burden types in regard to education level. Burden Type Education level ( F) Sig.* University (B.A) Diploma Secondary Other (Below secondary) S u b jectiv e B u rd en Psychological Burden 3.7500 8.0000 6.2200 8.6125 4.004 0.009* Social Burden 1.0000 3.5833 2.0800 3.2125 2.553 0.058 Physical Burden .5000 2.8333 2.3200 3.2750 4.259 0.006* Economical Burden .0000 1.6667 1.6200 1.9125 4.862 0.003* Subjective Burden 13.7500 31.5000 24.2400 32.8250 5.976 0.001* Objective Burden 20.0000 18.0000 19.0800 16.9875 3.709 0.013* 61 Table (11) shows ANOVA tests of the relation between burden and caregiver’s educational level. It illustrates that the mean score of subjective burden for participants who had an education level below secondary was (32.83), and for those who had a B.A was (13.75), with significant differences for educational level below secondary (P value 0.001). The mean score of psychological, physical, and economic burden for those who had an educational level below secondary were (8.61), (3.28), and (1.91) respectively, with significant differences between levels of education for the below-secondary level (P value (0.009), (0.006),(0.003)) respectively. Regarding objective burden, the mean score for those who had a B.A was (20), and for those who had an educational level below secondary was (16.99), with significant differences for B.A (P value 0.013). 62 Table (12): Distribution of burden types in regard to marital status. Burden type Marital status ( F) Sig.* Single Married Other (divorced, widow, widower) S u b jectiv e B u rd en Psychological Burden 7.8500 7.2759 8.9286 0.701 0.498 Social Burden 2.9500 2.6034 3.6429 0.739 0.480 Physical Burden 2.5000 2.7241 3.5714 0.891 0.412 Economical Burden 1.7000 1.6983 1.6429 0.010 0.990 Subjective Burden 27.8500 28.5776 32.4286 0.397 0.673 Objective Burden 20.0000 17.7328 16.5714 3.699 0.027* 63 Table (12) shows ANOVA tests of the relation between burden and caregiver’s marital status of participants. It shows that the mean score of subjective burden for divorced, widow, and widower caregivers was (32.43), and for single caregivers was (27.85), with no significant difference (P value 0.673). According to subtypes of subjective burden, the mean score of psychological, social, and physical burden for divorced, widow, and widower caregivers was (8.93), (3.64) and (3.57) respectively, with no significant differences between marital status of caregivers. It also shows that the mean score of objective burden for single participants was (20), and for divorced, widow and widower participants was (16.57), with significant differences for single caregivers (P value 0.027). 64 Table (13): Distribution of burden types in regard to family size (number of family members). Burden type Family size ( F) Sig.* 1-3 4-7 8 and more S u b jectiv e B u rd en Psychological Burden 9.0667 6.9266 9.0385 2.619 0.076 Social Burden 3.1333 2.5229 3.4615 1.078 0.343 Physical Burden 3.1333 2.5780 3.3846 1.327 0.269 Economical Burden 1.4667 1.6972 1.8077 0.275 0.760 Subjective Burden 30.2000 27.6239 33.1538 1.300 0.276 Objective Burden 17.9333 18.3028 16.3462 2.522 0.084 Table (13) shows ANOVA tests of the relation between burden and the number of family members. It illustrates that the mean score of subjective burden was (33.15) for participants who had family size of 8 or more, and (27.62) for those had family size (4-7), with no significant differences (P value 0.276). Regarding social, physical, and economic burden, the mean score for those who had a family size of 8 or more were (3.46), (3.38), and (1.81), respectively, with no significant differences. According to objective burden, the mean score was (18.3028) for those who had family size (4-7), and (16.35) for those had family size of 8 or more, with no significant differences (P value 0.084). 65 Table (14): Distribution of burden types in regard to caregiver-patient relationship. relationship Burden type Subjective Burden Subjective Burden Objective Burden Psychological Burden Social Burden Physical Burden Economical Burden Father 4.9286 1.5000 1.0714 1.2857 19.8571 19.8571 Mother 9.0645 3.3548 3.8710 1.3226 34.1935 17.0645 Brother 6.7586 2.3103 1.8276 1.6897 24.6207 19.0345 Sister 8.1304 2.6522 2.8696 1.7391 29.9130 20.0000 Wife 8.4737 3.1316 3.6842 2.1842 33.1053 15.8684 Husband 0.0000 0.0000 0.0000 3.0000 17.0000 18.0000 Son 7.6667 3.3333 2.6667 1.0000 21.6667 16.0000 Daughter 5.5000 4.3333 1.6667 2.0000 25.0000 18.5000 Other relatives 3.7500 1.0000 1.0000 0.5000 19.7500 18.0000 (F) 2.141 1.137 4.176 1.750 2.091 3.319 Sig* 0.036* 0.342 0.000* 0.092 0.040* 0.002* 66 Table (14) shows ANOVA tests of the relation between burden and patient-caregiver relationship. It shows that the mean score of subjective burden was (34.19) for mothers and (33.11) for wives, with significant differences for mothers (P value 0.04). According to subtypes of subjective burden, the mean score of psychological burden for mothers was (9.06), for wives (8.47), and for sisters (8.13) with significant differences for mothers (P value 0.036). In regard to social burden the mean score was (4.33) for daughters without significant differences. The mean score of physical burden for mothers was (3.87), and (3.68) for wives, with significant differences for mothers (P value 0), while the mean score of economic burden for husbands was (3), with no significant differences (P value 0.092). Regarding objective burden, the mean score for sisters was (20) and for fathers was (19.86), with significant differences for sisters (P value 0.002). 67 Relationship between burden types and type of mental illness of patient Table (15): Distribution of burden types in regard to diagnosis of mental illness. Burden type Diagnosis ( F) Sig.* Schizophrenia Mood Disorder Mental Retardation S u b jectiv e B u rd en Psychological Burden 7.4200 8.1600 6.9400 0.719 0.489 Social Burden 3.3000 2.6800 2.3400 2.005 0.138 Physical Burden 2.7200 3.3600 2.1600 1.871 0.158 Economical Burden 1.9800 1.8800 1.2200 4.463 0.013* Subjective Burden 30.1600 30.1000 26.2600 0.960 0.385 Objective Burden 16.9000 18.2400 18.6400 2.610 0.077 68 Table (15) shows ANOVA tests of the relation between burden and type of mental illness. It illustrates that the mean score for subjective burden for caregivers of schizophrenic patients was (30.16) and for caregivers of mentally retarded patients was (26.26), without significant differences (P value 0.385). The mean score of psychological and physical burden for care givers of patients with mood disorder were (8.16) and (3.36) respectively, with no significant differences between types of mental illness in psychological and physical burden. On the other hand, there were significant differences in economic burden between types of mental illness for schizophrenia (P value .013) with a mean sore of (1.9800). According to objective burden, the mean score for caregivers of mentally retarded patients was (18.64), and for caregivers of schizophrenic patients was (16.9), without significant differences (P value 0.077). 69 Measures of the differences between mean score of burden and demographic characteristics of caregivers and diagnosis of patient: In order to measure these differences, LSD test (Fisher's Least Significant Difference) was used and the results are in the following tables: Table (16): LSD results of education levels Burden type Educational Level Other (Below secondary) University (B.A) Secondary Psychological Burden 2.39250* 4.86250* Physical Burden 2.77500* 0.95500* Economical Burden 0.191250* ________ Subjective Burden 19.07500* 8.58500* Objective Burden University (B.A) Other(Below secondary) 3.012500* secondary 2.092500* Table (16) shows the differences between caregivers who had a B.A and those who had an educational level below secondary in subjective burden and its subtypes (psychological, physical, and economic burden), and there were differences for the level of below secondary. (Those who had below secondary level were experiences 2.4 times more than who had B.A). It also shows that there were differences between caregivers who had a secondary level of education and those who had a below-secondary level 71 in subjective, psychological, and physical burden, and these differences are for the level of below secondary. (Those who had below secondary level were experiences 4.8 times more than who had secondary level). According to objective burden, the differences were for those who had a B.A; they were experiencing higher burden 3 times more than those who had an educational level of below secondary. Table (17): LSD results of relationship levels. Burden type Relationship Father Husband Other relatives Psychological Burden Mother 4.13594* 9.06454* 5.3145* Sister _____ 8.13043* _______ Wife 3.54511* 8.47368* _______ Physical Burden Father Husband Daughter Other Mother 2.79954* 3.87097* 2.20430* 2.87097* Sister 1.79841* _______ _______ ______ Wife 2.61278* 3.68421* 2.01754* 2.68421* Subjective Burden Father Brother Son Other Mother 14.33641* _______ _______ _______ Wife 13.24812* _______ _______ _______ Objective Burden Father Brother Sister Other Mother 2.79263* _______ _______ _______ Wife 3.98872 _______ _______ _______ Table (17) shows the differences between burdens in regard to the patient-caregiver relationship. It illustrates that mothers and wives had higher subjective burden than fathers (mothers were experiencing burden 4 times more than fathers, and wives were experiencing burden 3 times more than fathers) . 71 According to subtypes of subjective burden, mothers, sisters, and wives had higher psychological and physical burden than fathers, husbands, and other relatives. Regarding objective burden, fathers had a higher burden(2.7 times) than mothers and (3.9 times) than wives. Table (18): LSD results of marital status. Objective Burden Marital status Single Married Other(divorced/ widowed) 2.26724* 3.42857* Table (18) shows that there were differences in objective burden between single participants and married, divorced, or widowed participants and these differences were for the single caregivers.( single caregivers were experiencing burden 2.2 times than married caregivers, and 3.4 times than others. 72 Table 19: LSD results of type of mental illness. Economic Burden Diagnosis Mental retardation schizophrenia Mood disorder 0.7600* 0.6600* Table (19) shows the differences in the economic burden among caregivers of mentally ill patients and these differences were for schizophrenia and affective illnesses (caregivers of patients with schizophrenia were experiencing economic burden .76 more than those with mental retardation and those with mood disorder .66 more than those with mental retardation. 73 Chapter 5 Discussion This chapter discusses the main finding of testing hypothesis Socio-Demographic characteristics According to demographic characteristics of caregivers (Table 1) more than two-thirds of caregivers were female and they were wives and mothers of patients, more than one third of them were in the age group of (45-54) which is reflects the age that are taking the caring responsibility in our society, and most of them had an educational level below secondary, so most of them were unemployed and more than third were having low economic status level. Regarding to patients, (Table 2) more than half of patients were male, and most of them (90.7%) were unemployed, and depending on their caregivers. According to an MOH report in 2012, the distribution of new reported cases of mental disorders was 170 patients were with schizophrenia, nearly two-thirds (62.3%) of them were male, and half of them (50.5%) were in the age group (30-59). According to the report, there were 150 patients with affective disorder (62%) of them were male, and (47.3%) of them in the age group (30-59). Regarding mentally retarded patients, there were 151 patients, (60.2%) of them were male, (23.8%) were in the age group (30-59), and more than two-thirds (73,5%) of them were in the age group (0-29). 74 Types of burden According to burden types (Table 3), nearly one third of caregivers (32.6%) were experiencing mild to moderate levels of subjective burden and (23.1%) of them were experiencing moderate to severe level of burden. While in regard to objective burden more than (10%) of caregivers were experiencing a quite high level. This finding reflect that the caregivers of mentally ill clients are in high level of burden, which should realized the need of psycho-education, advice, information, counselling. Also the mental health professionals should pay attention to the needs of caregivers of patients with mental illness. Palestine is regarded as a regional pioneer in the development of a national mental health strategy that encourages community-based mental health services. Nevertheless the development of community mental health services in Palestine is still in progress and needs further support and long- term commitment to ensure the provision of comprehensive services and support to sufferers and their families(Abu Sway, 2011). Similar findings were found in Israel by (Rudnick, 2004); the mean burden of Israeli family members of mentally ill individuals was moderate. Also Ukpong (2012) in his study about burden and psychological distress among Nigerian family caregivers of schizophrenic patients found that about one third of caregivers (33.7%) were experiencing a moderate to severe level of burden. In another study by Papastavrou et al. (2010) about 75 burden and emotional well-being among Cypriot families’ caregivers of schizophrenic patients illustrated a high level of burden among family caregivers where (43%) of the participants scored above 24/42 in the Family Burden Scale. Also Prafulla et al. (2010) conducted a study to assess the burden faced by families and the needs for rehabilitation among the beneficiaries of a rural mental health camp in South India; they found that families had mild to moderate level of objective burden. Regarding subtypes of subjective burden( Table 3) nearly one third (34%)of caregiver were experiencing moderate to high level of psychological burden, and nearly one quarter(25.4%) of them were experiencing moderate to high level of social burden, (46.6%) of them were experiencing moderate to high level of physical burden. According to the level of economic burden, more than half (55.3%)of caregivers were experiencing moderate to high burden, which might be related to economic status of caregivers; more than one third (36.7%) of caregivers had low socioeconomic status and (72%) of them were unemployed. In addition, they are responsible for their patients and they have to meet their needs of food, medication, and transportation. Different studies discussed these subtypes; Magliano et al. (2005) illustrated in their study the consequences of care giving in families of patients with schizophrenia or a long-term physical disease, which were constraints in social activities, negative effects on family life, and a feeling of loss. Also, Ostman & Kjellin (2002) found that the majority of relatives http://www.sciencedirect.com/science/article/pii/S0277953604006495 76 of people with mental illnesses experienced psychological distress in relation to stigma, and these consequences were reflected in the social and psychological burden. Lafely (1987) found that caring for chronic patients affect the psychological and sometimes the physical health of caregivers. Relationship between burden types and the demographic characteristics of caregivers Relationship between the caregivers’ gender and the family burden The mean score of subjective burden (Table 4) was higher among female caregivers (31.50± 16.59) than male caregivers which was (22.82 ± 13.30), with significant differences between males and females for females (P value 0.002).These results were in agreement with Schneider, et al.(2010), who found that there was a significant difference in gender in term of their burden, which was explained by social gender role and hormonal factors. Women were predominant in caregiving and spent more time in caregiving than men. In terms of hormonal, oxytocin hormone contributed in distress and women’s need to nurture. When caring for patient women experienced distress, her oxytocin level and nurture need will increase, but at the same time she had to pay more attention to the patient. Therefore women felt more burden than men. Also Hsiao (2010) and Akpınar et al. (2011) found that caregiver burden is highly prevalent among females. Some of the reasons that led to the males’ lower reporting 77 of burden may be that males are more likely to hide their real emotions and may not admit to the difficulties they face. In relation to subtypes of subjective burden (Table 4), the mean scores of psychological, social, and physical burden for females were (8.24± 5.29),(3.0865± 3.26235) and (3.33± 2.49) respectively, with significant differences for females. Similarly, Ostman & Kjellin (2002) found that women experience more psychological distress. According to objective burden (Table 4), the mean score for male caregivers was higher (19.13± 3.54) than female caregivers, with significant differences for males (P value 0.015). Adeyemi et al. (2012) found that males appeared to experience more than average burden than females which is possibly be due to negative caregivi