Archives of Mental Health

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 21  |  Issue : 2  |  Page : 83--89

Depression and quality of life among family caregivers of Stroke Survivors in Ghana: The role of social support


Doreen Asantewa Abeasi 
 Lecturer, Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Abetifi, Ghana

Correspondence Address:
Ms. Doreen Asantewa Abeasi
Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Abetifi
Ghana

Abstract

Introduction: Stroke is a concern for global health policymakers because surviving stroke negatively affects the survivors and their caregivers. A good proportion of its survivors are left to battle with residual functional impairments, who often require long-term support care from family members who are usually ill-prepared for their caregiving role. Thus, this study examined depression and quality of life (QOL) among family caregivers of stroke survivors and the role of social support. Methods: A sample of 50 caregivers and 50 noncaregivers were conveniently selected using a cross-sectional research design at the Korle-Bu Teaching Hospital. Depression, QOL and social support were measured using Beck Depression Inventory-II, WHOQOL-BREF, and the Multidimensional scale of perceived social support. Multiple analyses of variance, independent t-test, and Pearson's r test were used to analyze data. Results: Caregivers of stroke patients reported higher levels of depression (M = 8.94, standard deviation [SD] = 5.34) than noncaregivers (M = 3.48, SD = 4.81) which was statistically significant at ρ < 0.05. Caregivers also reported poorer QOL (M = 79.52, SD = 12.04) compared to noncaregivers (M = 88.70, SD = 11.19) which was statistically significant at ρ < 0.05. There was a strong relationship between depression and QOL (r (48) = −0.66, ρ < 0.05), social support and depression (r (48) = −0.60, ρ < 0.05), social support and QOL (r (48) = 0.56, ρ < 0.05). Conclusion: Caregivers experienced significant depressive symptoms and low QOL than noncaregivers. There was a significant relationship between depression, quality of life, and social support.



How to cite this article:
Abeasi DA. Depression and quality of life among family caregivers of Stroke Survivors in Ghana: The role of social support.Arch Ment Health 2020;21:83-89


How to cite this URL:
Abeasi DA. Depression and quality of life among family caregivers of Stroke Survivors in Ghana: The role of social support. Arch Ment Health [serial online] 2020 [cited 2021 Apr 12 ];21:83-89
Available from: https://www.amhonline.org/text.asp?2020/21/2/83/306862


Full Text



 Introduction



Globally, about 38 million people die yearly due to noncommunicable diseases (NCD).[1] Thus, NCDs accounted for almost 70% of all deaths worldwide.[2] Furthermore, statistics show that 28 million NCD deaths are reported annually in low- and middle-income countries.[3],[4],[5] Besides, one-quarter of all NCD deaths in developing countries occur in Sub-Saharan Africa and this is projected to increase to 60% between 2020 and 2030.[6] Stroke, which is a NCD is a high-priority area for world health because it leads to a substantial socioeconomic and emotional impact on the survivors and their families.[7] Although comprehensive strokes surveillance data for Africa are lacking,[8] the available data show that the case fatality and prevalence of disability stroke in Africa are similar to or higher than those in most high-income regions.[9] Research suggests that 8% of all first-ever strokes occur in Africa and that 5% of the 30 million stroke survivors worldwide live in Africa.[10] Stroke is the second-leading cause of death and third-leading cause of disability.[11] In the West Africa sub-region, stroke is the cause of adult neurological admissions.[12] A study conducted in Ghana showed that stroke constituted 9.1% of total adult hospital admissions.[8] This is suggestive of the fact that stroke is a major burden in Ghana.[13]

Prompt intervention at the onset of a stroke has been cited as one of the ways to decrease case fatality among people who are affected by stroke. Unfortunately, the lack of such services, especially in low- and middle-income countries, may mean that most people may arrive late at health centers to receive the appropriate treatment. Delay in treatment can contribute to the severity of brain injury subsequently leading to serious functional and cognitive deficits[7] and survivors may need long-term care. In other words, after being discharged from the hospital, they still need to be provided with care at home. The responsibility of providing care usually falls on family members. Formal caregivers (health workers) receive specialized training which makes them better equipped to handle the demands of caring for individuals with complex conditions such as stroke. On the contrary, lack of awareness or education about stroke and its management may make informal caregivers more confused.[14] Consequently, family caregivers may have difficulty adjusting to their new roles, which may lead to increased strain or burden. The prevalence of burden is high in caregivers of stroke survivors.[15],[16] Recent studies have reported very specific psychological disorders that are associated with caring for a stroke survivor, especially depression.[17],[18] Besides the reported depressive symptomatology, quality of life (QOL) of caregivers of stroke survivors is affected. Some studies have reported that increased burden is significantly related to decreased health-related QOL among stroke caregivers, particularly in mental health and social functioning domains.[18],[19]

The above findings are important because a caregiver's physical, social, emotional, and cognitive functioning can be impaired by depression[20],[21],[22] and subsequently affect the QOL. Depression in the caregiver can also influence poststroke depression in the survivor.[23] Research has linked depression to inflammatory/autoimmune conditions and may change the immune system of the caregiver.[24] People with depression may have decreased libido, have trouble becoming aroused, no longer have orgasms, or have pleasurable orgasms or sexual dysfunction.[25] Caregivers with depression may have difficulty in sleeping,[26] which can leave them exhausted, making it difficult to manage both physical and mental health. This can also affect the care that is to be rendered to stroke survivors and may threaten the sustainability of home care as well as the rehabilitation process.

Does social support have a role in mitigating the negative effects of caregiving on the caregiver? Review of studies suggests that social support is a significant predictor of depression and life satisfaction at the onset of the caregiver's role.[27] Furthermore, these benefits may extend long term, generating better energy, mental health, physical function, general health, quality of life, and less pain.[28] Other researchers have observed that caregivers' perceptions of available social support can influence their health.[29] The absence of social support has been associated with stress in stroke survivors as well as their caregivers.[30],[31]

Although studies done on depression and QOL and the role of social support in the caregiving process provide some insights, there are gaps in reviewed studies that need to be addressed. The current study adds to literature in four main ways. First, this study will address the phenomenon as applied in the Ghanaian context as there is no study that have looked at both depression and QOL of caregivers of stroke survivors in Ghana. Second, this work will compare the depressive symptoms and the QOL of both caregivers of stroke survivors and noncaregivers. The noncaregivers will serve as a control for comparing with the caregivers. Third, the study considers both depression and QOL of these family caregivers and noncaregivers. This will help establish whether a relationship exists between depression and the quality of life of the caregiver. The reviewed literature does not clearly state whether depression affects the QOL of the caregiver and if it does in which way? Finally, the study will examine the role of social support on caregiving outcomes. Based on the above premise, the aim of this study was to examine depression and QOL among family caregivers of stroke survivors in Ghana and also determine the influence of social support.

 Materials and Methods



Research design and setting

The study employed a descriptive cross-sectional design and was conducted at the Korle Bu Teaching Hospital.

Sample size and sampling technique

One hundred respondents comprising 50 family caregivers and 50 noncaregivers were selected conveniently. Family caregivers who accompanied their stroke survivors to the Physiotherapy and Stroke Units of the hospital were contacted and screened to find out if they met the inclusion criteria. Noncaregivers were also chosen from the same settings. These were administrative staff of the hospital.

Family caregivers

Inclusion criteria

The caregiver should be a family member who is 18 years and aboveThe person should be the primary caregiver who assists the stroke survivor in ADL as well as other things like taking the stroke survivor to the hospitalShould have provided care for at least 1 month.

Exclusion criteria

Below 18 yearsWith any past psychiatric illness, severe physical illnessRefusal to willfully participate or offer consent.

Noncaregiver group

Inclusion criteria

The noncaregiver should be 18 years and aboveShould not be a primary caregiver providing care for a family member with disabilityNot from the same family as the caregivers. This is because in a family with persons with disability, more than one person may be assisting but may not be the primary caregiver.

Exclusion criteria

Less than 18 yearsWith any past psychiatric illness, severe physical illnessRefusal to willfully participate or offer consent.

Data collection tools

The Beck Depression Inventory-II, WHO Quality of Life BREF, multidimensional scale of perceived social support (MSPSS) were used.

The Beck Depression Inventory (BDI) is a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression. Internal consistency for the BDI ranges from 0.73 to 0.92 with a mean of 0.86. The BDI demonstrates high internal consistency, with alpha coefficients of 0.86 and 0.81 for psychiatric and nonpsychiatric populations, respectively.

The WHOQOL-BREF is cross-culturally comparable quality of life measure developed collaboratively and field-tested across a number of cultural contexts. The instrument comprises 26 items. The WHOQOL-BREF is a shorter version of the original instrument that may be more convenient for use in large research studies or clinical trials. It addresses 4 QOL domains: physical health (7 items), psychological health (6 items), social relationships (3 items), and environment (8 items). Two other items measure overall QOL and general health. Items are rated on a 5-point Likert scale (low score of 1 to high score of 5) to determine a raw item score. Cronbach's alpha values for each of the four domains scores range from 0.66 to 0.84.

MSPSS is a short 12-item social support scale that assesses the adequacy of a person's perceived social support from family, friends, and significant others. Respondents use a Likert-type scale to rate each item from very strongly agree to very strongly disagree. The questions are all positively worded, but it has been reported that MSPSS is relatively free from social desirability bias. For the Significant Other, Family, and Friends subscales, the internal are 0.91, 0.87, and 0.85, respectively. The reliability of the total scale is 0.88.

The instruments were administered by a research assistant who was blinded to the caregiver status of the participants.

Ethical consideration

Consent was sought from the participants before commencing the study.

Statistical analysis

The Statistical Package for Social Sciences version 21.0. To analyze data, IBM SPSS Statistics for Windows, version 21.0 (Arrmonk, NY: IBM) was used. Following all the assumptions required for parametric test selection and usage, the independent t-test, one-way multivariate analysis of variance (MANOVA), and Pearson correlation were used. The independent t-test was used to assess the differences between the caregiver group and the noncaregiver group on depression and QOL levels. MANOVA was used to establish the difference after the participants were divided into two groups based on their overall mean score on social support and measured on depression and QOL. Pearson correlation was used to examine the relationship between depression, QOL, and social support.

 Results



Demographic characteristics of caregivers and noncaregivers

Descriptive statistics for the demographics of the sample are shown in [Table 1]. The sample was 76% and 68% of female caregivers and noncaregivers, respectively, majority of caregivers (52%) were spouses of the stroke survivors, majority of them (78%) had provided care for <6 months{Table 1}

Depression among caregivers

From [Table 2], it was found out that a significant difference exists between caregivers of stroke patients and noncaregivers on their depression scores (t (97) = 5.37, ρ = 0.000; equal variances not assumed). Further analysis of the means of the two groups reveals that caregivers of stroke patients reported higher levels of depression (M = 8.94, SD = 5.34) than noncaregivers (M = 3.48, SD = 4.81) which was statistically significant at the 0.05 level of significance.{Table 2}

Quality of life among caregivers of stroke survivors

[Table 3] shows that a significant difference exists between caregivers of stroke patients and noncaregivers on their quality of life (t (98) = −3.95, ρ = 0.000; equal variances assumed). Examination of means shows that caregivers of stroke patients reported poorer quality of life (M = 79.52, SD = 12.04) compared to noncaregivers (M = 88.70, SD = 11.19), which was significant at the 0.05 level of significance.{Table 3}

Further analysis was performed to find out how caregivers and noncaregivers differed on the various domains of quality of life; physical, psychological, social, and environmental using MANOVA [Table 4]. Results revealed that caregivers reported poorer quality of life on all domains than noncaregivers except environmental domain of quality of life (F (1, 98) = 9.05; ρ = 0.003); (F (1, 98) = 23.45; ρ = 0.000); (F (1, 98 = 33.61; ρ = 0.000)); (F (1, 98) = 2.74; ρ = 0.101) for physical, psychological, social and environmental, respectively. It was also found out that the social domain of quality of life was the most affected as it had the highest effect size (η2 = 0.26), followed by psychological domain (η2 = 0.19) and then physical (η2 = 0.09).{Table 4}

Relationship between depression, quality of life and social support

[Table 5] showing result from Pearson correlation reveals that a strong relationship exists between; depression and QOL (r (48) = −0.66, ρ < 0.01), social support and depression (r (48) = −0.60, ρ < 0.01), social support and QOL (r (48) = 0.56, ρ < 0.01).

The MANOVA shows that a significant difference exists between the two groups being compared on both depression and quality of life (F (1, 48) =27.24, ρ = 0.000; η2 = 0.36); (F (1, 48) = 20.37, ρ = 0.003; η2 = 0.30), respectively. The participants were divided into two groups based on their overall mean score on social support (~45). The results show that caregivers of stroke patients with high social support reported a lower level of depression (M = 5.88 < M = 12.25) and better quality of life (M = 85.77 > M = 72.75) than those with low social support and these differences were significant at the 0.05 level of significance. The results are presented in [Table 6].{Table 5}{Table 6}

 Discussion



Depression among caregivers of stroke survivors

The findings of the current study showed that caregivers were more depressed more than noncaregivers. Depression is one of the most reported psychological outcomes of caregiving of stroke survivors in the literature.[32],[33] The finding of the present study is consistent with other studies who reported higher rates of depression among caregivers than noncaregivers.[34] The sudden onset of stroke renders caregivers mostly unprepared but still have to take on the care of survivors and cope with the situation. As most survivors become dependent on their family caregivers for their day-to-day activities depending on the severity of the stroke, it puts strain on the physical and psychological well-being of the caregivers, which noncaregivers do not experience. Sometimes, the stress level could be overwhelming and result in other serious psychological problems, including depression. Caregivers of stroke survivors would therefore have an elevated level of depression compared to the general population; however, the severity may depend on other factors.

Quality of life of caregivers of stroke survivors

The current study found that the overall quality of life of caregivers was poorer as compared to noncaregivers. Other studies have also reported poor QOL of caregivers of stroke survivors.[35],[36] On the contrary, Ganjiwale et al. reported that that caregivers in their study had better QOL. Though in that study comparison of QOL was between the stroke survivors and their caregivers.[37] In this study, caregivers and noncaregivers differed on all the domains except for the environmental domain. The finding that caregivers and noncaregivers did not differ significantly on the environmental domain is quite understandable. This is because the environmental QOL is not particularly linked to stroke caregiving but the general living conditions of the caregivers. Consequently, the environmental experiences of a caregiver may not differ significantly from a noncaregiver. However, physical, psychological, and social domains of quality of life differed significantly between the two groups with noncaregivers reporting better quality of life in those domains.

Caregivers may experience increased workload, fatigue, or exhaustion, sleep disturbance, headaches, and body pains and sometimes already existing medical conditions such as hypertension and diabetes may be exacerbated as a result of the demands of caregiving.[38] This would interfere in their daily functioning and lead to poor physical QOL. In addition, caregiving in disabling conditions may come with certain psychological burdens, which mostly result from burdens in other domains of a person's life such as social and physical. Caregivers may experience psychological distress associated with caregiving, such as depression, anxiety, stress, frustration, feelings of helplessness, despair among others which may impact their psychological QOL negatively.[21] Finally, social domain of QOL was found to be the most affected by caregiving in the present study. In stroke caregiving, there is burden on the time and the finances of the caregivers and hence, may not be able to go to social functions or spend time with people who matter in their social circles. Consequently, the caregiver may experience a restricted social life, withdrawal from social activities, stigma, family conflicts, dissatisfaction and instability in social relationships, limited family mobility, and rejection.[38] The physical and psychological impact of caregiving can also affect an individual's social life. For instance, caregivers experiencing depression, hopelessness, frustration, and poor physical health may lose interest in their social life. With time social relationships may begin to strain and they feel isolated. Contrary to the findings in the present study,[39] reported in their study that emotional well-being was the most affected domain of quality of life among caregivers of stroke survivors. It is possible that among the sample used in the present study, social relationships are more important to them than emotional or psychological needs. Hence, their quality of life is most affected by social burdens compared to others. However, it could also be because the participants are more aware of their social difficulties compared to the other domains of QOL.

Social support, depression, and quality of life among family caregivers of stroke survivors

The study also sought to assess whether social support influence depression and QOL among caregivers of stroke survivors and to find out the relationship between depression and QOL. The findings revealed that caregivers who had high social support reported lower levels of depression and better QOL compared to caregivers who had low social support. This is consistent with a study done Wan-Fei et al.[40] It was also found out that depression had a significant negative relationship with QOL. The outcomes of a stressful event depend highly on the coping resources available.

It is plausible in this case, therefore, that social support serves as one of the effective coping mechanisms caregivers may use in coping with the stressors associated with caregiving. This may, in turn, influence their mental health and QOL positively. This explains why people with high social support reported less depression and better QOL than those with low social support. It has been shown that the perception of availability of social support has the potency to make a person perceive a stressful situation as less stressful[41] and the actual supportive acts of significant others may boost a person's coping ability. This implies that a caregiver of a stroke survivor who perceives that social support is available would interpret the burden of care as less stressful. This enhances the individual's capacity to cope with the situation and in turn, has beneficial effects on both physical and psychological well-being.

The influence of caregiving among caregivers of stroke survivors is found to have both direct and indirect impact on QOL.[42] As found in this study, one of the indirect pathways through which caregiving could influence QOL of caregivers is through depression or emotional distress.[43] As level of depression increases in caregivers, their QOL is bound to be affected. Studies have reported that depression is a major predictor of QOL in both patients and caregivers of stroke survivors.[30],[44],[45] However, the mere presence of clinically significant emotional symptoms is not indicative of reduced QOL.[46] This is not consistent with the findings of the present study.

 Conclusion



Being an informal caregiver of a stroke survivor has been shown to be associated with psychological morbidities such as anxiety, depression, and psychological distress, among others.

This study examined depression and QOL among family caregivers of stroke survivors and noncaregivers as well as the role of social support on those variables. The outcome demonstrated that caregivers were more depressed than noncaregivers and reported poorer QOL. Social support was found to be a predictor of QOL and depression.

The above findings call for the following recommendations:

Caregivers should be routinely screened for depression and their QOL also assessed. This is to identify those caregivers who are at risk and the necessary interventions provided for themCaregivers should seek for support in managing their new roles. Support can be in many forms and also sought from different categories of people. One way of support is to be informed about their caregiving roles. This can be achieved by joining support groupsIn addition, caregivers' social domain of QOL was found to be the most affected. Consequently, centers should be established where caregivers can leave their survivors for some hours to pave the way for them to engage in necessary social activities. In doing this, caregivers will not feel too isolated as a result of their caregiving responsibilities, which will translate into improved social QOLFuture studies should explore on the positive outcomes of caregiving since a lot more needs to be explored in that dimension. Again, future studies should explore more survivor characteristics since they are likely to predict depression and poorer quality of life in informal caregivers. Different types of stroke may present with different challenges both for the survivor and the caregiver; hence, other studies should examine the mental health of caregivers based on the type of stroke of the survivor. Longitudinal studies should also be carried out to examine to long-term effects of caregiving.

Limitations and strengths

The present study bears the limitations that it is characterized by cross-sectional research, therefore one cannot derive any conclusions on the causality of the associations observed between the variables. Furthermore, the study employed self-reported measures which relied solely on the accuracy of the information provided by respondents. Caregivers who are at home and are unable to report for reviews with the patients and those who seek medical care in other hospital settings are not represented in the present study. These notwithstanding, the study makes important contributions to our understanding of the impact of caregiving among caregivers of stroke patients in the present sample and population at large. It is also among the few studies that have used a control group in examining the mental health of the caregivers. The study also has the strength in which the relationship between depression and QOL among caregivers of stroke survivors was established. The evidence gathered from this study makes it necessary for conclusions to be drawn.

Acknowledgment

Many thanks to the staff and caregivers at the outpatient department of the Stroke Unit and Physiotherapy Unit of the Korle-Bu Teaching Hospital for their support during the data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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