ORIGINAL ARTICLE The Journal of Nursing Research ▪ VOL. 27, NO.

3, JUNE 2019

Predictors of Caregiver Burden in Caregivers

of Bedridden Patients
Aysun BEKDEMİR1 • Nesrin İLHAN2*

in the care of the sick and those unable to take care of their
ABSTRACT own needs (Adelman, Tmanova, Delgado, Dion, & Lachs,
Background: Caregivers are at risk of experiencing caregiver 2014; Chiou, Chang, Chen, & Wang, 2009). Providing care
burden. It is therefore important to determine the caregiver bur- adversely affects the health and quality of life of the caregiver
den of caregivers who provide care to bedridden patients and (Bauer & Sousa-Poza, 2015; Jeong, Myong, & Koo, 2015;
related factors. Rha, Park, Song, Lee, & Lee, 2015). Caregivers are likely to
Purpose: The aim of this study was to determine the caregiver spend less time with their family and friends, experience in-
burden of caregivers who provide care to bedridden patients creased levels of emotional stress, and neglect self-care activ-
and the factors that impact this burden. ities such as getting a good night's sleep, exercising, and
healthy eating (Collins & Swartz, 2011).
Methods: This cross-sectional study was executed at a state
Caregivers are at risk of caregiver burden (Chang, Chiou,
hospital in Istanbul, Turkey, on bedridden patients registered in
the home healthcare unit and their caregivers. During study period,
& Chen, 2010; Chiou et al., 2009; Roopchand-Martin &
the researchers made 312 visits to patients and their caregivers. A Creary-Yan, 2014). Caregiver burden is defined as a multidi-
sociodemographic questionnaire, the Burden Interview, and the mensional response to perceived stress and negative assess-
Katz Index of Independence in Activities of Daily Living were used ments that derive from providing care to a sick person (Kim,
to collect data. Descriptive statistics, an independent sample t test, Chang, Rose, & Kim, 2012). The risk factors that have been
one-way analysis of variance, and stepwise multiple regression identified in the literature as affecting caregiving burden in-
analysis were used for data analysis. clude being female, having a lower level of education, living
Results: The participants reported a moderate level of caregiver in the same house with the care recipient, providing care for
burden. Existing caregiver health problems, caregiver employment long hours, having depression, being socially isolated, being
status, the ability of the caregiver to maintain his or her own good under financial stress, and having no choice but to be a care-
health, type of home, and the degree of patient dependence in giver (Adelman et al., 2014). Caregiver burden threatens the
terms of activities of daily living were each found to be significant physical, psychological, emotional, and functional health of
predictors of caregiver burden. caregivers (Bauer & Sousa-Poza, 2015; Etters, Goodall, &
Conclusions/Implications of Practice: The support provided Harrison, 2008; Ma, Lu, Xiong, Yao, & Yang, 2014). More-
to caregivers by home healthcare units is important in terms over, caregiver burden is known to be a significant predictor
of protecting the physical, mental, and social health conditions of quality of life (Jeong et al., 2015; Rha et al., 2015).
of caregivers and preventing the exacerbation of caregiver burden. Researchers have found that caregiver burden is affected
by many factors related to providing care. The health of both
KEY WORDS: caregivers and care recipients impact strongly on caregiver
caregiving, caregiver burden, caregiver health, home care, nurse. burden (Rha et al., 2015; Sanuade & Boatemaa, 2015). The
health of persons receiving care and their degree of depen-
dence affect caregiver burden (Abdollahpour, Noroozian, Nedjat,
Introduction & Majdzadeh, 2012; Conde-Sala, Garre-Olmo, Turró-Garriga,
Bedridden patients are patients who stay in bed for short or
long periods for various reasons, including chronic illnesses,
1
old age, and disability. Bedridden patients cannot perform MSc, Specialist Nurse, Home Health Services Coordination Center,
Üsküdar State Hospital, Istanbul, Turkey • 2PhD, Assistant Professor,
self-care and medical care partially or completely and need Faculty of Health Sciences, Department of Nursing, Bezmialem Vakif
the help of others. Bedridden patients are usually cared for University, Istanbul, Turkey.
by family members, paid caregivers, and/or health profes-
Copyright @ 2019 The Authors. Published by Wolters Kluwer Health,
sionals (Handicap International, n.d.; Vieira et al., 2015). Inc. All rights reserved.
Family caregivers are defined as relatives and friends
who provide care free of charge to individuals with chronic This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use,
or debilitating conditions (Collins & Swartz, 2011; Sanuade distribution, and reproduction in any medium, provided the original
& Boatemaa, 2015). Family members play important roles work is properly cited.

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The Journal of Nursing Research Aysun BEKDEMİR et al.

Vilalta-Franch, & López-Pousa, 2010; Zaybak, Güneş, Günay Methods

İsmagloğlu, & Ülker, 2012). Furthermore, caregiver burden af-
fects the level of well-being of the caregiver and, as a conse- Design and Data Collection
quence, reduces the caregiver's ability to provide good care This study used a cross-sectional design and was executed at
(Collins & Swartz, 2011; Sanuade & Boatemaa, 2015). a state hospital in Istanbul, Turkey, between January and
Chang et al. (2010) found that the mental health and care- April 2014. The participants were bedridden patients who
giver burden of care providers were related to the health were registered in the hospital's home healthcare unit and
problems experienced by caregivers. Women make up the their caregivers.
large majority of caregivers in family settings (Jeong et al.,
2015; Rha et al., 2015; Yıkılkan, Aypak, & Görpelioğlu,
2014). Whereas some research has identified gender as a sig- Participants
nificant predictor of caregiver burden (Brodaty et al., 2014;
Home healthcare services in Turkey are given by the Ministry
Etters et al., 2008; Sousa et al., 2016), some have found no
correlation between gender and caregiver burden (Orak of Health, municipalities and private organizations. Home
& Sezgin, 2015; Roopchand-Martin & Creary-Yan, 2014; healthcare units of Ministry of Health work in affiliation with
Sanuade & Boatemaa, 2015). Chiou et al. (2009) reported the hospitals. Individuals who require services from these
units at home are provided examination, testing, treatment,
that caregivers with poor social support and family func-
medical care, rehabilitation, and social and psychological
tions have a higher level of caregiver burden and that per-
support services during home visits. The costs of these ser-
ceived social support is a better indicator of caregiver burden
vices are covered by the social security administration. This
than the social support actually received. Furthermore, studies
study targeted the caregivers of bedridden patients regis-
have shown that living in the same house with a patient
(Adelman et al., 2014; Conde-Sala et al., 2010) and having tered in the home healthcare unit of a state hospital in An-
a direct role in that patient's physical care (Sanuade & atolian Istanbul (N = 4,500). The formula that was used to
Boatemaa, 2015) increase caregiver burden. determine the necessary sample size on the basis of a finite
population determined that a minimum sample size of 251
Professional healthcare providers have an important
bedridden patients and caregivers was required (Sümbüloğlu
impact on the health and well-being of caregivers (Yıkılkan
& Sümbüloğlu, 2002).
et al., 2014). Nurses may engage in training primary care-
givers and support caregivers by aiding in care-related activ- 2 2
Nt pq 4500ð2:58Þ 0:120:88 2992
ities. Thus, nurses have an important role to play in lessening n ¼ d2 ðN−1 Þþt 2 pq ¼ ð0:05Þ2 ð4500−1Þþð2:58Þ2 0:120:88 ¼ 2:5 ¼ 251
the caregiver burden of care providers (Schulz & Sherwood,
2008). Nurses are best positioned to make early diagnoses Abbreviations used in the formula:
of caregiver burden and to help caregivers avoid/minimize
the adverse effects of caregiving (Etters et al., 2008). Nurses N = Number of individuals in the target population
should observe caregivers during their home visits and eval- n = Number of individuals to be sampled
uate them in terms of caregiver burden risk (Etters et al., p = Frequency of occurrence of the event to be investigated (probability)
2008; Yıkılkan et al., 2014). When caregiver burden is iden- q = Frequency of nonoccurrence of the events to be investigated (1 p)
tified, the perceptions of caregivers regarding the burden that t = Theoretical value in the t table at a certain degree of freedom
they are taking on may be eased with appropriate interven- and at the determined error level
tions (Etters et al., 2008). Thus, for all of the above-stated d = The desired deviation according to the occurrence frequency
of an event
reasons, it is important to identify caregiver burden and its
N = 4,500 (number of patients registered at home health units
related factors, to ensure that caregivers receive support, and
in 2013)
to develop, organize, and implement caregiver-burden preven- p = .12 (the proportion of disabled in Turkey; Turkish Statistical
tion programs. Therefore, the purpose of this study was to de- Institute, 2002)
termine the caregiver burden of individuals who provide care q = 0.88
to bedridden patients and the factors that impact this burden. d = 0.05
This study is significant in that it was conducted in Turkey t = 2.58 (when t = 0.01 in the case of α = .01)
with a large sample and because many factors affecting care-
giver burden were examined as variables. The study sought The study was conducted on 312 bedridden patients and
answers to the following research questions: their caregivers who met the criteria for inclusion. The criteria
for inclusion included being responsible for the care of a bed-
• What is the relationship between the sociodemographic charac-
ridden patient, providing care for at least 1 month, willing to
teristics of caregivers and their caregiver burden?
• What is the relationship between the way caregivers provide care participate in this research, aged 18 years or older, able to read
and their caregiver burden? and write, and able to understand and answer questions. The
• What is the relationship between the degree of dependency of questionnaires were filled out during face-to-face interviews
bedridden patients and the caregiver burden of their caregivers? that were conducted with the participants during a home visit
• Are caregiving-related factors predictive of caregiver burden? by the researcher. Patient information was obtained from

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Caregiver Burden in Caregivers VOL. 27, NO. 3, JUNE 2019

patients and caregivers. Questionnaires with missing data “partially dependent,” and “independent,” which are assigned
were excluded from the study. scores of 1, 2, and 3, respectively. ADL index score totals are
assessed as follows: 0–6 = dependent, 7–12 = partial depen-
Ethical Considerations dence, and 13–18 = independent. The ADL Cronbach's alpha
Verbal and written permission was obtained from the institu- value for this scale found in this study was .92.
tion in advance. The university's ethics committee granted
its approval for this study (September 9, 2013, No. 47). Data Analysis
The purpose of this study was explained to the patients The study data were analyzed using SPSS 16.0 (SPSS, Inc.,
and their caregivers, and their written and verbal consent Chicago, IL, USA). Descriptive statistics (numbers, percent-
was obtained. ages, means, and standard deviations) were used in the analysis.
The one-sample Kolmogorov–Smirnov test was used to assess
Measures normal distribution, and the p value was found to be > .05. As
the data displayed normal distribution, parametric tests were
Demographic variables employed in the advanced analysis. The parametric tests used
included the independent sample t test for two independent
The descriptive characteristics of the caregivers (gender, age,
variables and the one-way analysis of variance for more than
educational status, civil status, type of residence, employment
two independent variables. Stepwise multiple regression analy-
status, and income status), their personal health situation,
sis was used to determine the factors affecting caregiver burden.
their ability to attend to their own health, their relationship
The Durbin–Watson statistic was used to measure autocorrela-
to the patient, the duration that they had been caring for
tion. The Durbin–Watson statistic was found to be 2.086.
their patient, the areas of caregiving, and the patient's gen-
Tolerance was found to be between .85 and .99, and the var-
der, age, and educational status were collected using a
iance inflation factor was 1.00–1.17. Tolerance and variance
standard questionnaire.
inflation factor values were both found to be within accept-
able limits. The results were found to be within the 95% con-
Caregiver burden
fidence interval, and significance was assessed as p < .05.
The caregiver burden of the caregivers was measured using
the Zarit Burden Interview (BI). In 1980, Zarit, Reever, and
Bach-Peterson developed BI as a scale to evaluate the level
of stress experienced in providing care to the sick and older
Results
adults. The scale questionnaire, which may be filled out either
by the caregiver or a researcher, consists of 22 statements on Sample Characteristics
the effect of caregiving on the respondent caregiver's life. Each Two thirds (65.1%) of the caregiver participants were women,
of the statements is answered using a Likert-type scale, with 57.4% were 36–55 years old, and 60.6% had received over
scores ranging from 0 to 4 (never, rarely, sometimes, fre- 8 years of training. In addition, 72.8% were married, 30.4%
quently, and always). Studies have indicated an internal con- were employed, 64.1% earned an income that was roughly
sistency coefficient of .87–.94 for the scale and a test–retest equal to their expenditures, and a large majority (80.1%)
reliability of .71. The total possible scores for the BI range lived in apartment residences. Slightly over two fifths (42.6%)
from 0 to 88, with 0–20 indicating “no burden,” 21–40 indi- self-reported as having some kind of health problem, and
cating “mild burden,” 41–60 indicating “moderate burden,” 57.1% stated that they did not tend to their health needs.
and 61–88 indicating “severe burden.” The scale items gener- It was found that 71.8% were taking care of their parent
ally address the social and emotional domains, with a higher or sibling, 56.7% had been a caregiver for 2 years or more,
total score associated with a greater burden experienced and 85.9% said they tended to every need of their patient.
(Zarit et al., 1980). İnci and Erdem (2008), who carried out In terms of care recipients, 56.7% were women, the large
the validity and reliability studies for the Turkish version of majority (82.4%) were older than 65 years, and 79.5%
this scale, found a Cronbach's alpha value of .95. The had an education of 8 years or less (Table 1). The ADL item
Cronbach's alpha value for the BI found in this study was .90. mean scores of the care recipients varied between 1.16  0.47
and 1.52  0.70, and their ADL total mean score was
Functional status 7.64  2.94 (Table 2).
The dependency status of participants was assessed using the
Katz ADL was used as Katz Index of Independence in Activities Factors Associated With the Burden
of Daily Living. In 1963, Katz, Ford, Moskowitz, Jackson, and of Caregiving
Jaffe developed Katz ADL as a tool to assess basic ADL, The BI total mean score in this study was 43.56  15.05. The
and Yardımcı (1995) completed the Turkish translation of BI mean score of the female caregivers was significantly
the index. The index contains six headings, including bath- higher than that of the male caregivers (p < .01). The BI mean
ing, dressing, toileting, transferring, continence, and feeding. score of the caregivers who were 56 years old or more was
Each heading has three possible responses: “dependent,” significantly higher than those of caregivers in the other age

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The Journal of Nursing Research Aysun BEKDEMİR et al.

TABLE 1.
Comparison of the Burden Interview Mean Scores of Caregivers According to
Various Personal Characteristics (N = 312)
Burden Interview
Variable n % M SD F/t p Post Hoc Test
Gender t = 2.709 .007**
Women 203 65.1 45.24 12.86
Men 109 34.9 40.44 18.11
Education (years) t = 1.620 .106
≤8 123 39.4 45.26 15.81
>8 189 60.6 42.44 14.47
Age (years) 12.861 < .001*** ③ > ①, ②
① 20–35 53 16.9 38.68 12.52
② 36–55 179 57.4 41.97 15.19
③ 56 and above 80 25.6 50.36 14.15
Marital status t = −0.444 .657
Married 227 72.8 43.79 14.66
Single 85 17.0 42.94 16.14
Employment status t = −5.629 < .001***
Employed 95 30.4 36.64 14.86
Unemployed 217 69.6 46.59 14.14
Family income status 1.992 .138
Income less than expenditures 56 17.9 47.02 15.50
Income equal to expenditures 200 64.1 42.51 14.87
Income more than expenditures 56 17.9 43.88 14.99
Type of home 8.207 < .001*** ①, ② > ③
① Squatter home 23 7.4 47.57 16.83
② Apartment 250 80.1 44.55 14.96
③ Private home 39 12.5 34.87 11.43
Health problems t = 6.694 < .001***
Yes 133 42.6 49.76 15.04
No 179 57.4 38.96 13.34
Ability to tend to own health t = 3.447 < .001***
Yes 134 42.9 40.23 14.69
No 178 57.1 46.06 14.88
Relation to care recipient 1.100 .334
Caring for spouse or child 62 18.9 45.95 13.77
Caring for parent or sibling 224 71.8 43.13 15.40
Distant relative 26 8.3 41.58 14.84
Caregiving duration 2.698 .046* ④>③
① 1–6 months 29 9.3 39.79 12.81
② 7–12 months 44 14.1 43.75 15.70
③ 1–2 years 62 19.9 39.97 14.41
④ 2 years and more 177 56.7 45.39 15.23
Areas of caregiving 4.295 .014* ③ > ①, ②
① Financial support 8 2.6 32.25 10.74
② Psychological support 36 11.5 39.28 15.27
③ All needs 268 85.9 44.47 14.94

(continues)

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Caregiver Burden in Caregivers VOL. 27, NO. 3, JUNE 2019

TABLE 1.
Comparison of the Burden Interview Mean Scores of Caregivers According to
Various Personal Characteristics (N = 312), Continued
Burden Interview
Variable n % M SD F/t p Post Hoc Test
Patients' gender t = 1.030 .304
Female 177 56.7 44.33 15.45
Male 135 43.3 42.56 14.51
Patients' age (years) t = −0.383 .702
< 65 55 17.6 42.85 15.27
≥ 65 257 82.4 43.71 15.27
Patients' educational status (years) t = −2.04 .042
<8 248 79.5 42.68 14.85
≥ 8 years and over 64 20.5 46.96 15.46

p < .05. **p < .01. ***p < .001.

*

groups (p < .001). The BI mean score of the unemployed mean score of the caregivers of patients with a level of educa-
caregivers was significantly higher than that of the employed tion over 8 years was significantly higher than that of care-
caregivers (p < .001). The BI mean score of caregivers living givers of patients with a level of education of 8 years or less
in squatters' homes and apartments was significantly higher
than that of caregivers living in private homes (p < .001). The TABLE 3.
BI mean score of caregivers who had health problems was
significantly higher than that of caregivers with no health
Comparison of Caregivers' BI Mean
problems (p < .001). Scores According to Patients' ADL
Those caregivers who did not tend to their health needs
BI
had a BI mean score significantly higher than that of care-
ADL n % M SD F p
givers who did take care of their health needs (p < .001).
Caregivers who had been tending to their patients for 2 years Bathing 2.841 .060
or more had a BI mean score significantly higher than that Dependent 277 88.8 42.87 14.94
of caregivers who had been tending to their patients for Partially dependent 21 6.7 50.43 15.97
1–2 years (p < .05). The BI mean score of caregivers who Independent 14 4.5 46.86 13.90
tended to all of the patients' needs was significantly higher Dressing 7.168 .001***
than that of caregivers who provided only financial or psycho- Dependent 247 79.2 42.01 14.90
logical support (p < .05). The BI mean scores did not display Partially dependent 48 15.4 50.69 14.32
Independent 17 5.4 45.94 13.92
any statistically significant differences based on the level of ed-
ucation, marital status, or family income level of the caregivers Toileting 2.712 .068
or on their relationship to the care recipient (p > .05). The BI Dependent 265 84.9 42.80 15.17
Partially dependent 27 8.7 49.59 14.13
Independent 20 6.4 45.55 13.20
TABLE 2. Transferring 0.856 .426
Patients' ADL and BI Mean Scores Dependent 269 86.2 43.13 15.43
Partially dependent 23 7.4 46.91 11.68
Scale Minimum Maximum M SD Independent 20 6.4 45.55 13.19
Continence 4.760 .009**
BI 0 82 43.56 15.05
Dependent 245 78.5 42.22 15.07
ADL Partially dependent 45 14.4 49.11 15.46
Bathing 1 3 1.16 0.47 Independent 22 7.1 47.14 10.75
Dressing 1 3 1.26 0.55
Feeding 7.272 .001***
Toileting 1 3 1.21 0.54
Dependent 190 60.9 41.05 14.64
Transferring 1 3 1.20 0.53
Partially dependent 83 26.6 48.10 15.23
Continence 1 3 1.29 0.58
Independent 39 12.5 46.15 14.34
Feeding 1 3 1.52 0.70
Total points 6 18 7.64 2.94 Note. BI = Burden Interview; ADL = activities of daily living.
*
p < .05. **p < .01. ***p < .001.
Note. ADL = Activities of Daily Living; BI = Burden Interview.

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The Journal of Nursing Research Aysun BEKDEMİR et al.

(p < .05). No statistically significant differences were found Discussion

between the BI mean scores of caregivers categorized, respec-
The aim of this study was to determine the caregiver burden
tively, by care recipient gender and age (p > .05; Table 1).
of individuals who were caring for bedridden patients and
In comparing the BI mean scores of patients according to
the factors that impact this burden. This study was con-
their ADL, the BI mean scores for caregivers of patients who
ducted on a sample of bedridden patients who were receiving
were partially dependent on the caregiver for dressing, conti-
services from a home healthcare unit and their caregivers. It
nence, and feeding issues were significantly higher than the
was determined that the caregivers experienced a moderate
mean scores for those caregivers who were caring for com-
level of caregiver burden. Using univariate analysis, a signif-
pletely dependent patients (p < .01). No statistically significant
icant relationship was found between caregiver burden and
differences were found between the BI mean scores of care-
the caregiver's gender, age, employment status, type of
givers based on the bathing, toileting, and transfer depen-
home, health problems, ability to tend to personal health,
dency needs of patients (p > .05; Table 3).
and duration of caregiving and the areas where caregiving
was needed as well as the patient's dependency in terms of
Determinants of the Burden of Caregiving ADL. Multiple regression analysis showed that caregiver
A stepwise multiple regression analysis was performed to de- health problems, their employment status, their ability to
termine the predictors of the burden of caregiving. In the uni- tend to their own health, their type of home, and the degree
variate analysis, the variables that had a significant effect on of dependence of patients in terms of ADL were each signif-
the burden of caregiving were considered as independent icant predictors of caregiving burden.
variables. Thus, gender, age, employment status, the health The caregiver burden scores for caregivers with health
problems of the caregiver, the ability of the caregiver to tend problems were higher than those of caregivers who had no
to personal health, type of home, duration of care, the areas health problems, indicating that caregiver burden increases
of care, and the patient ADL score were adopted as the inde- when caregivers have personal health problems. One study
pendent variables. It was determined that gender, age, dura- pointed to correlations between health problems and the
tion of care, and the areas of care of caregivers were not mental health of caregivers and caregiver burden (Chang
significant predictors of caregiver burden. However, signifi- et al., 2010). Half of the caregivers in one prior study had
cant relationships were found between burden of caregiving at least one chronic health problem (Collins & Swartz, 2011).
and the caregivers' health problems, employment status, Caregiving creates a physical and mental burden that adversely
ability to tend to personal health, type of home, and ADL affects the health of caregivers (Bauer & Sousa-Poza, 2015;
(R2 = .25, p < .001), with 25% of the total variance explained Etters et al., 2008; Kim et al., 2012), and poor personal health
by these variables. The order of significance for the variables disrupts personal quality of life (Jeong et al., 2015). Further-
ranged from the caregiver's health problems (β = .257, more, poor caregiver health lowers the quality of care given,
p < .001) to employment status (β = −.225, p < .001), type increases caregivers' formal demands for healthcare (Bauer &
of home (β = −.182, p < .001), ability to tend to personal Sousa-Poza, 2015; Collins & Swartz, 2011), and increases
health (β = −.170. p < .001), and the dependency of the pa- healthcare costs (Bauer & Sousa-Poza, 2015). It is important
tient in ADL (β = .147, p < .001; Table 4). that caregivers are supported by home healthcare units so
The burden of the caregivers in this study was found to that they do not feel alone and helpless, do not develop
be higher in those who had health problems, who were un- health issues, and do not experience a deterioration in their
able to manage their own health, who were not employed, existing health problems.
who lived in a squatter home or in an apartment, and who The caregiver burden of caregivers who do not tend
were less dependent on their patients. to their own health is higher than that of caregivers who

TABLE 4.
Caregiver Burden Predictors According to Results of Multiple Regression Analysis
Burden Interview
Variable B β t p
Constant 47.800 20.220 < .001
Caregiver's health problems 7.822 .257 4.816 < .001
Employment status −7.341 −.225 −4.274 < .001
Ability of caregiver to tend to own health −5.162 −.170 −3.427 < .001
Type of home −8.269 −.182 −3.581 < .001
Activities of daily living 0.751 .147 2.964 .003

Note. R2 = .254, adjusted R2 = .242, F = 20.84.

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Caregiver Burden in Caregivers VOL. 27, NO. 3, JUNE 2019

do. Paying appropriate attention to personal health reduces to accept the additional dependency-related burdens. As pa-
caregiver burden. The health of caregivers is known to im- tient dependency increases, caregivers tend to feel that the
pact caregiver burden strongly (Rha et al., 2015). Chiou et al. patients actually do need them and therefore accept the situ-
(2009) observed that caregivers with a low level of social and ation, leading to lower levels of perceived caregiver burden.
functional family support experienced higher levels of caregiver In a study by Taşdelen and Ateş (2012), as patient depen-
burden. The fact that caregivers allocate time to deal with dency grew in terms of ADL, the caregiver's emotional bur-
their own health problems indicates that they receive social den lessened, which is consistent with the results of this study.
support from friends and family when needed. The literature However, contrary to the results of this study, other studies
supports that social support reduces the caregiver burden have shown that caregiving burden increases as patient de-
and increases the quality of life of caregivers who provide pendency rises (Abdollahpour et al., 2012; Kim et al.,
care for patients with chronic diseases (Atagün, Balaban, 2012; Zaybak et al., 2012). It is important that further qual-
Atagün, Elagöz, & Özpolat, 2011). itative studies be conducted to discover the reasons for these
This study found that the caregiving burden of unem- outcomes, so that appropriate interventions may be designed
ployed caregivers was higher than that of their employed to lessen the burden of caregiving.
counterparts, indicating that outside employment reduces Women comprised a large majority of caregivers in this
caregiver burden. A prior study reported that the caregiver study. Other studies have also found that most caregivers
burden of employed caregivers is of a lower level compared are women (Rha et al., 2015; Unver, Basak, Tosun, Aslan,
with that of unemployed caregivers (Sanuade & Boatemaa, & Akbayrak, 2016; Yeşil et al., 2016). Whereas the univari-
2015). Another study found that self-employed caregivers ate analysis revealed a higher level of caregiver burden in
had lower caregiver burden scores (Roopchand-Martin & female caregivers compared with male caregivers, the multi-
Creary-Yan, 2014). As caregivers who hold jobs outside ple regression analysis did not reveal a significant relationship
the home cannot serve as primary, full-time caregivers, their between gender and caregiver burden. Similar to the results
caregiving time is shorter than that of caregivers who are not of this study, other studies have not detected any significant
employed, which may explain why employed caregivers relationship between gender and caregiver burden (Orak &
have a lower caregiver burden. Chiou et al. (2009) found Sezgin, 2015; Roopchand-Martin & Creary-Yan, 2014;
that caregiver burden increases as the duration of caregiving. Sanuade & Boatemaa, 2015). However, other studies still
In Yeşil, Uslusoy, and Korkmaz (2016), no difference was have pointed to female caregivers having greater levels of
found in caregiver burden based on employment status. caregiver burden than their male counterparts (Sanuade &
The caregiver burden of caregivers who live in squatter Boatemaa, 2015; Sousa et al., 2016; Unver et al., 2016). These
houses or apartments was shown to be higher than those results reveal that the burden of caregiving in women may be
who live in private houses, indicating that living in a private affected not only by gender but also by normal responsibili-
house reduces caregiver burden. This result indicates that ties such as housework and childcare, by personal character-
physical circumstances may affect caregiver burden. Istanbul istics, by employment status, and by other relevant factors.
is one of Turkey's most densely populated and most expen- Although the burden of caregiving was found to be
sive cities. Accordingly, it is likely that people who live in pri- higher in caregivers aged 56 years and above, age was found
vate homes in Istanbul are of a relatively high socioeconomic not to be a significant determinant of this burden. Similarly,
status. As caregivers at higher economic levels care for their other studies have shown age not to significantly impact the
patients in more comfortable physical conditions and are burden of caregiving (Abdollahpour et al., 2012; Roopchand-
more likely to employ outside help, their caregiver burden Martin & Creary-Yan, 2014). Despite this, it is still believed
may subsequently be less. that the older a caregiver is, the higher the caregiving bur-
Caregivers of patients with higher levels of education den may be because of age-related health problems and
were found to have higher burdens of care than those of pa- physical limitations.
tients with low levels of education. As patients with higher It was found that caregivers with 2 or more years of care-
levels of education have higher life expectancies, they likely giving experience had a higher level of caregiver burden than
have greater expectations from their caregivers. This may in- those with durations of care of 1–6 months and 1–2 years.
crease the burden of care of their caregivers. Similar to the results of this study, Çetinkaya and Karadakovan
This study found that patients were most commonly de- (2012) found that longer caregiving durations were positively
pendent on their caregivers for bathing and least dependent associated with higher caregiver burden. In a study by
for feeding, with results showing that the degree of patient Yıkılkan et al. (2014), caregivers who cared for their pa-
dependency was a significant predictor of caregiving burden. tients for more than 3 years had higher levels of depression
As patient dependency lessened, caregiver burden increased. and anxiety than caregivers with shorter caregiving durations.
Concurrently, the caregiver burden of individuals caring for Regression analysis showed that duration of caregiving was
patients who were partially dependent because of continence not a significant predictor of the burden of caregiving. This
or feeding issues was higher than the burden of those caring finding is an important outcome, as it shows that caregiver
for dependent patients. This outcome suggests that the care- burden is associated with more than only the duration of
givers of partially dependent patients may not have been able the caregiving. It may be that long-term caregiving results in

7
The Journal of Nursing Research Aysun BEKDEMİR et al.

higher caregiver burden because of the increases in frequency Adelman, R. D., Tmanova, L. L., Delgado, D., Dion, S., & Lachs, M. S.
and severity of physical, mental, and social problems. (2014). Caregiver burden: A clinical review. JAMA, 311(10),
1052–1060. https://doi.org/10.1001/jama.2014.304
In this study, the caregiver burden of caregivers who were
required to meet all of the needs of their patients was higher Atagün, M. İ., Balaban, Ö. D., Atagün, Z., Elagöz, M., & Özpolat, A. Y.
(2011). Caregiver burden in chronic diseases. Current Ap-
than that of caregivers who met only the financial needs or
proaches in Psychiatry, 3(3), 513–552. https://doi.org/10.5455/
provided psychological support to their care recipients. Mul- cap.20110323 (Original work published in Turkish)
tiple regression analysis found no significant relationship be-
Bauer, J. M., & Sousa-Poza, A. (2015). Impacts of informal care-
tween areas of care and caregiver burden. Mollaoğlu, Özkan giving on caregiver employment, health, and family. Journal
Tuncay, and Kars Fertelli (2011) found that those caregivers of Population Ageing, 8(3), 113–145. https://doi.org/10.1007/
who met all of the needs of their patients had a higher level of s12062-015-9116-0
caregiver burden. Moreover, Sanuade and Boatemaa (2015) Brodaty, H., Woodward, M., Boundy, K., Ames, D., Balshaw, R., &
found that caregivers who provided only financial support PRIME Study Group. (2014). Prevalence and predictors of bur-
and caregivers who received outside financial and physical den in caregivers of people with dementia. The American
support had lower levels of caregiver burden. Caregivers Journal of Geriatric Psychiatry, 22(8), 756–765. https://doi.
org/10.1016/j.jagp.2013.05.004
who provide patients with only financial or psychological
support are not primary caregivers. In these types of cases, Çetinkaya, F., & Karadakovan, A. (2012). Investigation of care bur-
the main caregiver is usually another member of the family, den in dementia patient caregivers. Turkish Journal of Geriat-
rics, 15(2), 171–178. (Original work published in Turkish)
and the caregiver's burden is less compared with those who
must meet all of their patients' needs. Chang, H. Y., Chiou, C. J., & Chen, N. S. (2010). Impact of mental
health and caregiver burden on family caregivers' physical
The cross-sectional approach used in this study limits
health. Archives of Gerontology and Geriatrics, 50(3), 267–271.
its generalizability to similar populations only. In addition, https://doi.org/10.1016/j.archger.2009.04.006
the self-report nature of data collection potentially limits the
Chiou, C. J., Chang, H. Y., Chen, I. P., & Wang, H. H. (2009). Social
accuracy and generalization of results. The relatively large support and caregiving circumstances as predictors of care-
sample size is a strength of this study. Future studies should giver burden in Taiwan. Archives of Gerontology and Geriatrics,
consider more complex variables dealing with caregiving as 48(3), 419–424. https://doi.org/10.1016/j.archger.2008.04.001
predictive variables (e.g., caregiver-perceived social support, Collins, L. G., & Swartz, K. (2011). Caregiver care. American Family
coping strategies, daily care hours, having help available at Physician, 83(11), 1309–1317.
home, number of caregivers). Furthermore, in line with the re-
Conde-Sala, J. L., Garre-Olmo, J., Turró-Garriga, O., Vilalta-
sults of this study, it is recommended that experimental studies Franch, J., & López-Pousa, S. (2010). Differential features of
be carried out to evaluate the effectiveness of nursing interven- burden between spouse and adult–child caregivers of patients
tions that are carried out to reduce the caregiver burden of with Alzheimer's disease: An exploratory comparative design.
individuals who provide care to bedridden patients. International Journal of Nursing Studies, 47(10), 1262–1273.
https://doi.org/10.1016/j.ijnurstu.2010.03.001
Conclusions Etters, L., Goodall, D., & Harrison, B. E. (2008). Caregiver burden
The caregivers in this group reported a moderate overall level among dementia patient caregivers: A review of the literature.
Journal of the American Academy of Nurse Practitioners, 20(8),
of caregiver burden. Furthermore, the health status, employ- 423–428. https://doi.org/10.1111/j.1745-7599.2008.00342.x
ment status, ability to tend to personal health matters, and
type of home of the caregiver and the degree of dependence Handicap International. (n.d.). Training material—PT protocol for
bedridden patients. Retrieved from https://static.aminer.org/
of the patient in terms of ADL were all found to be significant pdf/PDF/000/355/038/therapy_of_bedridden_patients.pdf
predictors of caregiver burden.
İnci, F. H., & Erdem, M. E. (2008). Validity and reliability of the bur-
den interview and its adaptation to Turkish. Atatürk University
Accepted for publication: May 28, 2018 School of Nursing Journal, 11(4), 85–94. (Original work pub-
*Address correspondence to: Nesrin İLHAN, No.189, Silahtarağa St., lished in Turkish)
Merkez Neighborhood, Eyüp District, Istanbul 34050, Turkey.
Tel: +90 533 2237958; E-mail: nilhan@bezmialem.edu.tr Jeong, Y. G., Myong, J. P., & Koo, J. W. (2015). The modifying role
The authors declare no conflicts of interest. of caregiver burden on predictors of quality of life of care-
givers of hospitalized chronic stroke patients. Disability and
Cite this article as: Health Journal, 8(4), 619–625. https://doi.org/10.1016/j.dhjo.
Bekdemİr, A., & İlhan, N. (2019). Predictors of caregiver burden in 2015.05.005
caregivers of bedridden patients. The Journal of Nursing Research,
27(3), e24. https://doi.org/10.1097/jnr.0000000000000297 Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffe, M. W.
(1963). Studies of illness in the aged. The index of ADL: A stan-
dardized measure of biological and psychosocial function.
JAMA, 185(12), 914–919. https://doi.org/10.1001/jama.1963.
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