Introduction

The term family caregiver is used to refer to relatives, friends, or neighbors who render support to an individual with an underlying physical or mental disability, providing assistance in vital daily activities and are usually unpaid without formal training required for the services provided (1, 2). For individual’s requiring surgical procedure, the caregiver may play a considerable role in their care, rehabilitation, and support. Though this responsibility is usually voluntary, it often impacts a burden on the caregivers. Caregiver burden is the cumulative physical, financial, emotional, or/and social discomforts perceived by an individual providing care for an ailing individual (3, 4).
Physical/health burden could include back pain or injury from handling and moving the patient, physical stress associated with care giving tasks such as feeding, bathing, and dressing (5). Emotional burden could include anxiety, fear, helplessness, grief, depression, and impulsivity (6), while financial burden could be cost of care, time spent idling away/economic loss due to staying away from work/business (7).
The degree of caregiver burden is closely tied to the level of dependency needed by patients, which increases with patient’s inability to carry out daily chores (8). Other factors that may impact caregiver burden includes lack of financial gains, personal economical loss, feeling of unpreparedness, inability to deliver proper care due to a lack of knowledge and guidance from formal healthcare providers (5), feelings of restriction and despair as they try to meet the demands of care giving, potentially affecting their satisfaction and ability to attend to their own needs, as well as the quality of care provided to the patient (9), patient-related factors such as age, severity of illness, type of surgery, educational level, level of income, duration of stay in the health facility, etc. (10, 11).
In the context of surgical patients, which refers to patients who undergo a surgical procedure to treat a medical condition (12), caregiver burden can arise due to various responsibilities, including apprehension of the surgical procedure, post-operative care and rehabilitation, medication management, wound care, and other duties that may arise depending on the patient’s age, health condition, and needs (13). A significant aspect of the burden experienced by family caregivers of surgical patients is the economic loss (14). However, there is a scarcity of studies performed within Southern Nigeria to measure the burden on family caregivers of surgical patients and identify factors that could contribute to the burden experienced by family caregivers. Therefore, measuring the burden and identifying the factors that contribute to the burden experienced by family caregivers of surgical patients is crucial for developing effective strategies to mitigate their burden and improve their caregiving experience. Caregiver burden is best studied within unique disease conditions. Thus, this study was conducted to measure caregivers’ burden and identify factors that contribute to the burden on family caregivers of surgical patients in Southern Nigeria.

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Materials and Methods

Study design/area
This was a cross-sectional study carried out in two major centers—a university teaching hospital and a central hospital in Delta State, Nigeria. 

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Study duration
Data collection was from May 31 to July 31, 2023.

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Study population
The study population comprised patients who had surgery and one family caregiver per patient (a person responsible for providing care for the surgical patient before, during, and after the surgical treatment). Surgical patients include individuals who needed emergency or elective surgeries in general surgery, orthopedics, plastics and burns, pediatrics’ surgery, urology, neurosurgery, otorhinolaryngology, oral and maxillofacial, ophthalmology, obstetrics, and gynecology departments in the two hospitals. 

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Inclusion criteria
All patients who had surgery in the centers were included in the study, family members or friends providing care and support to surgical patients, who were above 18 years of age and able to communicate effectively in the language of study.

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Exclusion criteria
Exclusion criteria include caregivers with conflict of interest, such as being an employee of the study centers.

Sample size determination and sampling technique
The minimum sample size was calculated using the Cochran formula:
 

where n is the sample size, z is the standard normal deviate at 95% confidence level=1.96, and p is the estimated proportion of the level of caregiver burden that is present in the population, which was assumed at 50%=0.5.
q=1–p 
d=Desired level of precision; taken to be 5% (0.05).
Calculations 
A 10% attrition rate was added; thus, the minimum sample size for this study was 422. All patients admitted for surgery and their caregivers were studied.

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Method of data collection/research instruments
Data were collected using an interviewer-administered questionnaire. Patients and their caregivers were approached in the surgical wards of the healthcare facilities utilized for this study. The questionnaire consists of the following sections: Section A entails sociodemographic characteristics of the caregivers, and section B entails patients sociodemographic and clinical-related factors (severity of illness, type of surgery, presence of comorbidities), which were obtained from the attending surgeon’s documentation in the patient’s case note. Severity of illness was categorized as mild, moderate, and severe. The type of surgery was categorized as minor, intermediate, and major in the surgeon’s documentation based on the type of anesthesia administered and the duration of the hospital stay. Comorbidities was measured in this study as either present or absent. Comorbidities considered in this study were hypertension, diabetes mellitus, sickle cell disease, cancers, and other chronic ailments. Section C of the questionnaire assessed the patients’ functional state using the Palliative Performance Scale (PSS) (15). Section D assessed the caregiver’s burden using the Zarit Burden Index (ZBI) tool (16).

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Data analysis
The Statistical Package for Social Sciences (SPSS) version 26.0 (IBM Corp., Armonk, NY, USA) was used to analyze data obtained in this study. The age, income, length of hospital stays, Palliative Performance Score (PPS), and ZBI were measured as continuous variables. Gender, educational status, marital status, religion, relationship to caregiver, presence of comorbidities, severity of illness, and type of surgery were measured as categorical variables. All variables were summarized using descriptive statistics. Analysis of covariates (ANCOVA) was used to test the relationship between ZBI and the categorical variables, after adjusting for the effects of the covariates variables (age, income, PPS). The statistics, tolerance, and variance inflation factor (VIF) were used to detect multicollinearity (correlation between the covariate variables). VIF >10 or tolerance <0.1 indicates significant multicollinearity. Pearson’s correlation coefficient test and analysis of variance (ANOVA) were used for age and ZBI. The p value was set as <0.05. 

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Ethical considerations
Ethical approval to carry out this study was sought from the Health Research Ethics Committee of DELSUTH, Oghara, with approval number HREC/PAN/2023/018/0551. Written informed consent was obtained from the caregivers and the patients recruited for the study. Confidentiality and equity were ensured.
 

Results

A total of 469 caregivers were recruited for the study, with the age ranging from 18 to 72 years, median age 30 years. Almost two-fifths of the caregivers were females (279 [59.5%]), more of the caregivers (312 [66.5%]) had tertiary level of education. Christianity is the dominant religion among the caregivers (453 [96.6%]). About 142 (30.3%) were students, while 129 (27.5%) were self-employed. Monthly income of caregivers ranged from N3000 to N500,000 ($1.93–$322.41) with a median of N50,000 ($32.24) and an interquartile range (IQR) of N40,000– N100,000 ($25.79–$64.48) (see Table 1).

 

Table 1.

Sociodemographic characteristics of caregivers

The ages of patients ranged from 1 to 85 years, with median 38 years (IQR, 34–50 years). Majority of the patients were females (264 [56.3%]). Half of the patients had attained tertiary education (242 [51.6%]), a substantial percentage of patients were either married 220 (46.9%) or single 183 (39.1%). Christianity predominates as the religion of choice (455 [97%]). The monthly income distribution among patients ranged from N0 to N1.6M ($0–$1031.73) with a median of N50,000 ($32.24) and an IQR of N40,000–N100,000 ($25.79–$64.48). Comorbidity is present in a significant portion of patients (187 [39.9%]). Severity of patients’ conditions varies, with half falling into the moderate category (236 [50.4%]), while others have severe conditions (214 [45.6%]). The main types of surgical interventions measured are intermediate (260 [55.4%]) and major (172 [36.7%]). The patients have diverse relationships with the caregivers, with the most common being children (106 [22.6%]), siblings (113 [24.1%]), and parents (100 [21.5%]) (see Table 2).
The PPS of patients ranges from 10% to 100%. Most of the patients (306 [65.2%]) had PPS 70% and above. The mean PPS is 70±17% SD (see Table 3).

 

Table 2.

Sociodemographic characteristics of patients

aOthers (aunt 18, niece 9, Church member 2, cousin 31, friend 11, grandmother 4, daughter-in-law 2, neighbor 2, sister-in-law 7, son-in-law 2, and nephew 2).

 

Table 3.

Distribution of the Palliative Performance Score of patients

A substantial portion of caregivers (187 [39.9%]) reported experiencing little or no burden; 181 (38.6%) caregivers indicated a mild-to-moderate level of burden, while 83 (17.7%) reported a moderate to severe burden. Only a small percentage (18 [3.8%]) expressed experiencing a severe level of burden (see Figure 1).

 

Figure 1.

Distribution of responses on ZBI. ZBI, Zarit Burden Index.

The collinearity statistics tolerance and VIF were performed to check for multicollinearity for all variables entered in the model. The collinearity statistics tolerance was more than 0.1, and VIF was <10 for all our variables. The highest correlation between the independent covariate variables was 0.215 (age and income). Thus, none of our covariate variables suffered from multicollinearity. The income of patients and ZBI showed a correlation of r=–0.17; it did not meet the criteria and was removed from the model. The duration of the hospital stay had 200 missing values, so it was removed from the model. The ANCOVA test shows statistically significant differences between the following patients’ variables (marital status p = 0.04, presence of comorbidity p = 0.03, types of surgery p = 0.001, and severity of illness p ≤ 0.0001) and ZBI of caregivers, after adjusting for age and PPS (see Table 4).

 

Table 4.

Relationship between patients’ variables and ZBI of caregivers

Results are based on modified population marginal mean. ANCOVA, analysis of covariates; ZBI, Zarit Burden Index.

The mean ZBI score was higher among caregivers caring for patients with the presence of comorbidity (29.9±1.5 SE) than those with no comorbidity (25.4±1.3 SE, p = 0.03). The mean ZBI scores were higher among caregivers caring for patients with severe illnesses (30.6±1.3 SE) than those with moderate illness (23.8±1.4 SE) and mild illness (14.5±3.4 SE, p ≤ 0.0001). Caregivers of patients who had minor surgery had a lower mean ZBI burden score of 20.4±2.4 SE when compared to those who cared for patients with intermediate surgery (27.2±1.3 SE) and major surgery (31.5±1.5 SE, p = 0.001). Caregivers who cared for patients who are cohabiting had higher ZBI (42.3±6.0 SE), compared to widow (31.7±3.0 SE), separated (28.4±4.5 SE), married (26.4±1.5 SE), and single (25.1±1.9, p = 0.04). There was no statistically significant difference between patients’ relationship to caregiver and ZBI scores. 
There was a weak positive correlation between patients’ age and ZBI scores of caregivers, r=0.218, p = 0.01. The ANOVA test conducted between the age group and ZBI was statistically significant, p = 0.001. The ZBI of children <18 years was 19.5±10.9 on caregivers; the ZBI of ages 18–45 years was 26.5±14.6 on caregivers; the ZBI of ages 46–59 years was 25.1±16.1, while that of ages 60 years and above was 27.6±17.1.

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Discussion

Our findings show little-to-moderate caregivers’ burden—about four-fifths of the caregivers had low-to-moderate levels. Families living together in Nigeria, sharing one another’s burden and relying on mutual support, may play a role in our findings. In countries such as Nigeria, where cultural values are handed down through generations, prioritizing others’ well-being is seamless and natural. A study carried out in a neurosurgery department in a hospital in Turkey also reported mild-to-moderate ZBI (8). Similar results of low-to-medium caregiver burden were reported in another research study looking at the burden among caregivers from several Asian countries (17). The results were linked to the cultural context in Asian countries, where individuals raised within closely knit families often consider caregiving as a natural and prepared part of their lives. As a result, family caregivers could adopt favorable perspectives on the caregiving process. This is in contrast to a study performed by Rajeshwari et al. (18), in India, with a substantial portion of caregivers reporting moderate–severe stress (slightly above half of the participants). The increased burden was attributed to the caregivers in India experiencing health-related challenges within their families, emotional difficulties, and physical strain (18). Future research on caregiver burden may focus on patients with severe PSS scores and low quality of life. 
In our study, the variable age was adjusted for in the model, although we found a weak correlation between age and caregivers’ burden. Children <18 years exerted lesser burden on caregivers when compared to the younger age group (18–45 years) and the middle-aged group (46–59 years). More burden was exerted on the caregivers by the elderly. According to Khosravi et al. (19), older patients tend to require more care and attention from caregivers than younger patients due to the natural aging process and the increased likelihood of having multiple medical conditions. As a result, caregivers of older surgical patients may experience greater physical and emotional demands than caregivers of younger patients. Hence, caregivers of older patients should solicit support when necessary, in order to alleviate the burden they might experience. Another study reported that older surgical patients need assistance with mobility, physical therapy, and personal hygiene, as well as manage the patient’s medical appointments and medication schedules (20). These tasks can be physically burdensome, especially if the caregiver is also responsible for other household tasks or engaged in formal works. Another study reviewed suggested older surgical patients require more emotional support from their caregivers; they experience anxiety, depression, or cognitive decline as a result of surgery or the hospitalization process (6). Thus, caregivers may need to provide emotional support, monitor the patient’s mental health, and advocate for their needs within the healthcare system resulting in greater caregiver burden. Another study attributed the limited financial resources of older surgical patient has a contributor to increase caregiver burden caregivers; thus, their caregivers may be required to provide financial support for medical expenses (21).
We found that patients with severe forms of illnesses exert more burden on caregivers. It has been previously stated that patients with more severe illnesses may require more extensive care, such as feeding tubes, catheters, and wound care, which is physically burdensome and has a significant impact on caregivers’ burden (11). A study conducted in the United States found that caregivers of individuals with chronic illnesses experienced higher levels of caregiver burden compared to caregivers of individuals without chronic illnesses (10).
In our study, the patient’s functional status was computed using the PSS and was controlled for in the model. The caregiver burden decreases with increased PSS. As reported in two studies, similar studies report that patients who are unable to perform activities of daily living, such as bathing, dressing, grooming, mobility, and communication, caregivers may need to provide more extensive support, leading to physical and emotional distress, thereby increasing the burden (22, 23). This can be due to temporary or permanent changes resulting from the surgical procedure or the underlying condition. 
Our study also found that the type of surgery performed impacted the caregiver’s burden in families of surgical patients. Studies have found that the severity of the surgical procedure, with major surgeries such as cardiac surgery or cancer surgery, surgeries that require extensive post-operative care, such as orthopedic surgeries, can be physically and emotionally demanding for caregivers, usually requiring a more extensive post-operative period, which can lead to greater demands on caregivers (6, 24). Minimally invasive surgeries such as laparoscopic procedures usually require less post-operative care and result in shorter hospital stays, leading to a lower level of burden on caregivers (25). 
The presence of comorbidities plays a role in caregivers of surgical patients’ burden. A study conducted by Schmaderer et al. (26) found that caregivers of surgical patients with comorbidities reported higher levels of burden than those without comorbidities. Caregivers of patients with comorbidities have been found to report higher levels of stress, anxiety, and depression than those caring for patients without comorbidities (27). Additionally, comorbidities can affect the functional status of the patient, leading to increased dependency on caregivers. 
In our study, there was no significant relationship between patients’ sex, patients’ education, patients’ monthly income, and caregivers’ burden. This was contrary to another study where patient’s income level was found to be a significant factor influencing caregivers’ burden (28).

 
Study limitations
One of the independent variables, duration of hospital stay, had 200 missing values, so it was removed from the analysis; this can affect the study’s validity. The results of this study may not be generalized to other hospitals.

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Conclusion

Findings from the study revealed that the family caregiver burden is notably low, and this could be attributed to the prevailing family-centric culture in many communities in Nigeria where family members share each other’s burden. In such communities, prioritizing others’ well-being is seamless and natural; thus, caring for an ailing family member is not seen as a burden. Future research on caregiver burden may focus on patients with severe PSS scores and low quality of life.

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Author contributions

OO led in methodology, supervision and in reviewing & editing of the original draft. OEC led in formal analysis. All authors equally contributed to conceptualization, data curation, project administration and in writing of the original draft.

 

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