The result of this study showed that caregiver burden, patient’s functional status, caregiver’s age, and social support could predict health status of stroke
caregivers. However, caregiver’s income and family conflict were not significant predictors of health status of stroke caregivers.
5.4.1 Caregiver burden
In this study, the findings revealed that the mean score of caregiver burden was at a high burden level (mean = 44.25; SD = 9.25). This indicated that the caregiver had a high level of burden during period performing caregiving for stroke patients. This finding was consistent with those of previous studies (Akosile et al., 2013; Asiret & Kapucu, 2013; Costa et al., 2015; Dankner et al., 2016). A study of Rigby and colleagues (2009) showed that the prevalence of caregiver burden ranged from 25 to 54 percent. Similarly, Visser-Meily et al. (2005) also found that 54 percent of spouses of stroke patients had the significant burden at one year after stroke. These caregivers are often placed in overwhelming situations, experiencing feeling of burden and depression, decreasing physical and mental health (Asiret & Kapucu, 2013; Van Exel et al., 2005). The Zarit Burden Interview (ZBI) was used to measure caregiver burden. The finding revealed that increase burden was a significant predictor of decrease the caregiver’s HRQoL (Physical function, general health and mental health).
Morimoto and colleagues (2003) investigated a study about burden and health-related quality of life of stroke caregivers in Japan. Findings revealed that increased burden significantly relates to decreased HRQoL among stroke caregivers both physical and mental health. Caregiver burden, caregiver’s age, and presence of a chronic illness were significant predictors of declining HRQoL of stroke caregivers.
Similarly, Kamel et al. (2012) implemented a cross-sectional study in caregivers of Jordanian patients with stroke. The researchers recruited 116 stroke patients and their caregivers to study the correlation of caregiver burden, caregiver depression and caregiver’s health. The finding showed that health of caregivers was related to caregiver burden and caregiver depression. In the current study, the result showed that caregiver burden was negative correlated to health status of stroke caregivers (see Table 4.10). It was congruent with studies of Ogunlana et al. (2014) and Caro et al. (2017).
According to Nelson and colleagues (2008) found that declining patient’s functioning predicted greater objective and subjective burden relating to consequences for caregiver’s personal lives. In this study, the functional status of stroke patients
(mean = 49.32) indicated that they required great assistance in daily living activities.
This leads to more burden experienced by stroke caregivers. Caregiver burden was high negatively associated with patient’s functional status (r = -.643, p < .001) (see Table 4.11). In addition, study of Hayashi et al. (2013) said that the caregivers lacked of information about preventing future for strokes, local services accessible to stroke survivors, training skills for take care stroke patients when the stroke patient discharged from hospital to community. Similarly, Tsai and colleagues (2015) reported that although the needs of stroke caregivers were different in each stage, health information, professional support, and community networks were the leading need domains in all stages. Furthermore, currently in Vietnam, there are little community services or long-term care services for the elderly and chronically ill patients as stroke, which makes it difficult for older adults and their families to afford care tasks. This may leading to more burden for caregivers when providing care for the stroke patients in their home.
The burden of caregiving is often evident in the decline of the health status of stroke caregivers. After having started taking caregiving of the stroke patients, the health status of caregivers was significantly worse than before. Greenwood and colleagues (2008) conducted a systematic review of stroke family caregivers and found that the burden of caregiving negatively impacted and predicted their physical and psychosocial well-being (Greenwood et al., 2008). This finding was similar to finding in previous studies (Carod-Artal, et al., 2009; Clay et al., 2013; King et al., 2010; Tellier, Rochette, & Lefebvre, 2011; Yang et al., 2012). In this study, caregiver burden was the strongest predictor which explained 70.3% of variation in health status of stroke caregivers. Thus, the research hypothesis was supported. In addition, caregiver burden was strong negatively associated with health status of stroke caregivers (Beta = -.567, p < .0001). This indicated that more burden experienced by the caregivers would develop more health problems. This finding was consistent with the finding of Ogunlana et al. (2014) and Duggleby et al. (2016).
5.4.2 Patient’s functional status
Severity of stroke was determined by activities of daily living (ADL). It was measured by the Modified Barthel Index (MBI) in this study. Mean scores of MBI
of the stroke patients were 49.32 (SD = 11.76). According to Shah and colleagues (1989), the MBI scoring is interpreted as “total dependence: 0 - 20”, “severe dependence: 21 - 60”, “moderate dependence: 61 - 90”, “slight dependence: 91 - 99”, and “fully independence: 100” for classifying the independent survivor. Based on the mean score of MBI, the stroke patients participating in the current study had a high level of functional dependency. In fact, almost stroke patients 80.2% had MBI scores between 21 and 60, indicating that these stroke patients needed much assistance. The current finding was consistent with a study published in Vietnam of Le (2015). The Vietnamese stroke patients in that study had a greatly dependent in perform regular activities, with a mean MBI score of 49.11 (SD = 31.35). Previous studies also have reported that stroke patients living in the community have high levels of physical disability and need much assistance in perform regular activities of daily living from family members (Costa et al., 2015; Em et al., 2017; Ganjiwale, Ganjiwale, & Parikh, 2016; Kaneko & Kanekawa, 2015; Nelson et al., 2008; Othman et al., 2014; Persson et al., 2015; Yu et al., 2013).
There were inter-correlations between patient’s functional status measured by MBI, caregiver burden and health status of stroke caregivers. MBI had negative relationships with caregiver burden (r = -.643, p < .001) and positive relationships with health status of stroke caregivers (r = .717, p < .001). These findings created questions about whether or not caregiver burden mediated the relationship between MBI and health status of stroke caregivers. After controlling for the influence of caregiver burden on health status, the association between MBI and health status was significantly reduced, indicating that the relationship between MBI and health status of stroke caregivers was mediated by caregiver burden. Taking care of stroke patients with higher dependencies increased caregiving burden and led to lower physical and mental health of the caregivers. This finding was similar to the result of Chatcheydang (2005) who conducted a study related to HRQoL of women caregivers of elderly stroke survivors in Thailand.
In this study, the result found that the functional dependency of stroke patients was significant impacted on the health status of stroke caregivers. Our finding was consistent with the existing literature that patients' functional status was significantly related to caregivers' psychosocial burden and was linked to health status
of caregivers (Carod-Artal, et al., 2009; Clay et al., 2013). The results of existing literature shown that caring for the stroke patients with low daily living abilities was associated with caregivers’ poor physical and mental health (King et al., 2010; Tellier et al., 2011). Caregivers caring for the stroke patients with high functional dependency engaged in more physical expenditure more stressful. Therefore, the degree of dependency for assistance in daily living can well predict physical and mental well- being of caregivers. Further interventions to improve health status of stroke caregivers should target at improving poorer functioning status of the stroke patients. Ogunlana and colleagues (2014) found that stroke survivors' level of disability and duration of the stroke had a significant influence on the physical and mental health of caregivers leading to reduce the quality of life of caregivers.
In the current study, patient’s functional status was the significant predictor, in addition to caregiver burden, to predict health status of stroke caregivers.
These two variables could explain 75.5% of variation in health status of stroke caregivers. Thus research hypothesis was supported. Moreover, patient’s functional status had a positive relationship with health status of stroke caregivers (Beta = .249, p
< .001). This means that the higher independent of stroke patients, the increasing health status of stroke caregivers. Most findings from other researchers were consistent with this result (Em et al., 2017; Persson et al., 2015; Vincent et al., 2009;
Yu et al., 2013).
5.4.3 Caregiver’s age
In this study, Spearman’s Rho correlation analyses showed that caregiver’s age had a negative relationship with health status of stroke caregivers (r = -.303, p <
.001). This finding is consistent with previous studies (Akosile et al., 2011; Carod- Artal et al., 2009; Choi-Kwon et al., 2005; Huang et al., 2009). Huang and colleagues (2009) examined the relationships among stressors, social support, depressive symptoms and the general health status of Taiwanese caregivers of individual with stroke disease. They found that stressors (caregiver’s age, gender, patient’s behavioral problems) were significantly associated with general health status of stroke caregivers (F
(5, 97) = 7.764, p < .001). Similarly, Akosile et al. (2011) stated that caring for stroke
survivors in Nigeria seems to have adverse effects on the quality of life of health of
older relatives. However, Pai and Tsai (2016) conducted a research in Taiwan found that caregiver’s age was negative associated with PCS (r = -.39, p < .01) but not associated with MCS. This was consistent with finding of Chen and colleagues (2010) and Chatcheydang (2005).
A study of Wu and colleagues (2013) focused on the prevalence of major chronic diseases among older Chinese adults between 50 and 79 years. They said that the majority of the respondents were between 50 and 59 years old (44.9%) and 49.8%
of respondents reported at least one chronic condition, 18.9% reported having two conditions. The most common chronic diseases reported by the respondents were hypertension, arthritis, backache, heart diseases (Wu et al., 2013). Therefore, caregiving also plays a part in worsening health status of older caregivers who already have their own health problems.
Age was a significant predictor of the health status of caregivers in the literature. Studies in the American on stroke caregivers (Clay et al., 2013; McPherson et al., 2011; Neugaard et al., 2008) and Chinese stroke caregivers in Hong Kong (Chen et al., 2010; Greenwood & Ross, 2012) and Japan stroke caregivers (Morimoto et al., 2003) claimed that older age was associated and predicted worse physical health of stroke caregivers. The number of diseases among caregivers may explain the relationship between their age and health status of stroke caregivers. Significant correlations between age and number of diseases, and between the number of diseases and health status of stroke caregivers, were found in the current study. These analyses supported that the older caregivers, the more diseases they reported the poorer their health. In addition, older caregivers had higher stress from caregiving, probably due to older age, which may reduce adaptation and psychomotor function (Louie, Liu, &
Man, 2009). Thus, it is reasonable to understand that the age of caregivers be associated with their health.
Older caregivers are at a greater risk of experiencing depression due to boredom, financial problems and role overload, thus, causing a decline in their physical wellness (Chow et al., 2007). In this study, we also found that living with the stroke patients was a significant predictor of health status. The reason may be that, the caregivers living with the stroke patients, have to manage more stressful and difficult
circumstance of caring, as well as spend more time and vigor undertaking the care tasks, which would compromise health status.
In the current study, caregiver’s age was a significant predictor of health status of stroke caregivers. Caregiver’s age, caregiver burden, and patient’s functional status accounted on 78.8% of variation in health status of stroke caregivers. Thus research hypothesis was supported. Moreover, caregiver’s age had a significantly negative relationship with health status of stroke caregivers (Beta = -.170, p < .0001).
This means that increasing age of caregivers leads to decreasing health status of stroke caregiver. Most findings from other researchers were consistent with this result (Huang et al., 2009; Lui et al., 2012; Kaneko & Knaekawa, 2015).
5.4.4 Social support
Perceived social support was usually considered a protective factor for stressful life situations, helping to maintain an individual’s physical and psychological health (Gottlieb & Bergen, 2010). Inadequate social support perceived by stroke caregivers leads to higher levels of caregiver burden and lower levels of physical and mental health, and well-being (Clay et al. 2013; Shyu et al., 2010). In this study, actual range score of social support was between 21 to 68 with a mean of 41.97 and a standard deviation of 10.77. The meaning of variable was moderate social support.
The finding was consistent with previous studies (Cameron et al., 2014; Cameron et al., 2016; Clay et al., 2013; Han et al., 2011; Lui et al., 2012).
Furthermore, finding in this study showed that mean scores of social support in three domains “family subscale”, “friends subscale”, and “significant others subscale” were 3.91 (SD = 1.81), 3.34 (SD = 1.62), and 3.24 (SD = 1.60), respectively (see Table 4.7b). This reflected that the caregivers have support from the family was higher than friends and others support. Similarly, Han and colleagues (2011) conducted a study related to depression and social support among family caregivers of stroke survivors in China. The researchers used MSPSS to measure perceived social support of caregivers. Their finding shown that family support in six months after post-discharge was higher than support from friends and others at any stage on a 7- point scale of MSPSS. Both Yeh et al. (2009) and Yeh and Chang (2012) affirmed that family support was a significant predictor of caregiver’s health in Taiwan. Han et al.
(2011) indicated that family support is a key element of perceived social support in Chinese culture. This is consistent with traditional values of Vietnamese lifestyle were deeply affected by Confucian philosophy as Chinese culture. Children taking care of a parent who has had a stroke accept this task, because taking care of parents has been accepted in Vietnamese culture as one of the prime responsibilities of the children (Meyer et al., 2015; Pham, 2011).
Perceived social support, one of the most important resources for family caregivers, significantly predicts health status of stroke caregivers. Many caregivers could identify positive aspects of caregiving, such as rewards, gratifications or gains (Savini et al., 2015) through support from family members, friends, and others.
Similar to Chappell and Reid (2002) study, social support was conceptualized as the caregivers’ perceptions of support and resources from others and was found positively to affect rewords of caregiving. Park and Lee (2007) similarly found that social support might be a potentially modifiable factor associated with positive aspects in caregiving, particularly psychological levels in older family caregivers. Moreover, social support has been found positively to affect family caregiver’s HRQoL by reducing their stressors and enhancing their rewords of caregiving (Chappell & Reid, 2002). Nurses and health care providers should appropriately assess caregiver’s needs and help support and provide sufficient resources required to enhance confidence in knowledge and skills for caregiving roles. As social support also included the provision for attachment, the social integration, and the availability of information, emotional and material assistance, training programs and discharge plans are needed to develop caregivers’ knowledge and to build caregiving skill for enhancing caregiver’s perceived social support. Study of Hayashi and colleagues (2013) in Vietnam found that the caregivers most frequently cited a need was information on how to prevent stroke recurrence (83.7%, n = 93), followed by which drugs are most effective in preventing a relapse (72.1%), how long recovery would take (70.9%), and availability of hospitals in the patient’s hometown (69.8%).
In the current study, social support was a significant predictor of health status of stroke caregivers. Social support, caregiver burden, patient’s functional status, and caregiver’s age accounted on 80.3% of variation in health status of stroke caregivers. Thus research hypothesis was supported. Moreover, this variable also had a
significantly positive relationship with health status of stroke caregivers (Beta = .150, p
< .0001). It means that higher social support could increase health status. This is consistent with previous studies of Cameron and colleagues (2016), Grant and colleagues (2006).
5.4.5 Caregiver’ income
Caregiver’s income was found to be negatively correlated with caregiver burden and family conflict in this study (see Table 4.11). This finding was similar to previous studies; those with higher income levels reduce burden and decreasing family conflict (Roopchand-Martin & Creary-Yan, 2014). In this study, although discharged to home, most stroke survivors went to the hospital regularly to receive medical treatments or rehabilitation. Caregiver’s income must be sufficient for the stroke survivor to receive these constant treatments. Stroke family caregivers need to deal with expenses incurred for hospitalizations due to check-up or rehabilitation process of stroke patients. For example, they had to pay for some medicines with no insurance converge and also cost for transportation, support tools for stroke patients such as a cane or a wheelchair. Such financial problems may create strain/burden for the caregiver. This is consistent with past stroke literature, which indicates that caregivers of stroke survivors often have financial problems (Lutz et al., 2011; Mishra et al., 2016).
Noticeably, caregivers with lower income levels frequently have to work harder to pay for their daily living expenses and tend to perceive caregiving as a burden (Yang et al., 2012). Caregivers with lower incomes are apt to have fewer actual and potential support options for themselves and their care recipients. They are less likely to utilize paid care providers, therefore potentially increasing the pressure on other family members to assist with care provision and creating opportunities for disagreements regarding the amount and adequacy of care provision (Scharlach, Li, &
Dalvi, 2006). Caregivers with lower incomes also are less likely to utilize counseling, respite care, and other social and emotional support services for themselves, potentially increasing their reliance on family members for social and emotional support and increasing their sensitivity to disagreements, interpersonal slights, and other signs of family conflict (Scharlach, Li, & Dalvi, 2006).
In this current study, although income of caregivers was negatively correlated with caregiver burden, no association between caregiver’s income and health status of stroke caregivers was found. Interestingly, previous researchers have reported association between income and health of caregivers. In the stroke literature, Jeong and colleagues (2015) reported that caregiver’s income, spouse caring for patients and duration of hospitalization was identified as significant predictors of health status with a mediating effect of caregiver burden. Costa and colleagues (2015) conducted a study about health status of caregivers for patients of a cerebrovascular accident. They found that caregiver with lower income showed lower scores for mental health and vitality of stroke caregivers. Bakas and Burgener (2015) investigated a study related to emotional distress, general health, and caregiving outcomes in family caregivers of stroke survivors. They found that predictors of poorer health (R2 = .25, p < .001) were not living with patients, low household income, and high threat appraisal. Findings from those investigators contrasted with findings from the current study. One of the reasons might be because a majority of stroke caregivers were retired, and they received benefits from a retirement pension. Also, primary caregivers in this study received financial support from other family members.
In addition, approximately 70.6% stroke patients were paid for their treatment by universal coverage card (see Table 4.3). Furthermore, in this study the majority of stroke caregivers (88.1%) reported having a monthly income of more than 1.3 million VNĐ (US$59). This was considered the minimal level for Vietnamese people’s daily living in urban areas when benchmarking with the medium household of a monthly per capita income in urban areas in period 2016-2020 (MOJ, 2016). Moreover, these stroke caregivers might have less financial pressure from hospital costs of care stroke patients because 70.6% health insurance supported for stroke patients and 88.1%
stroke caregivers had average income higher than 1.3 million per month. The financial status was not related with health status of stroke caregivers also reported by previous studies (Ogunlana et al., 2014; Yu et al., 2013).
In current study, caregiver’s income was not a significant predictor of health status of stroke caregivers. Thus research hypothesis was not supported. The findings from other researchers were consistent with the result of previous studies of Chatcheydang (2005) and Gbiri et al. (2015).