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EMP IR ICAL STUD IES
Quality of life of Nigerian informal caregivers of community-dwelling stroke survivors
Grace Vincent-Onabajo PhD (Lecturer)1, Aisha Ali BMR (Physiotherapist)1 and Talhatu Hamzat PhD
(Professor)2
1Department of Medical Rehabilitation (Physiotherapy), University of Maiduguri, Maiduguri, Nigeria and 2Department of Physiotherapy,
University of Ibadan, Ibadan, Nigeria
Scand J Caring Sci; 2013; 27; 977–982
Quality of life of Nigerian informal caregivers of
community-dwelling stroke survivors
Background: Caregivers play important roles in the collab-
orative efforts that characterize successful stroke rehabili-
tation, and their quality of life (QoL) may have
implications for outcome of care.
Aim: This study explored the QoL of caregivers of commu-
nity-dwelling stroke survivors in north-eastern Nigeria.
Methods: Fifty-nine caregivers of community-dwelling
stroke survivors attending physiotherapy out-patients
departments of two government hospitals in the city of
Maiduguri participated in the study. Information on par-
ticipants’ age, gender, employment status, educational
background, relationship with the stroke patient, and
time after onset of stroke were obtained through inter-
view, while their QoL was assessed with WHOQoLBREF
questionnaire. Demographic and QoL data were summa-
rized with descriptive statistics, and influence of caregiv-
ers and care recipients’ factors on QoL was analysed
using Kruskal–Wallis test.
Results: Majority of caregivers were males (55.9%) and
provided care for their parents (69.5%) who had suffered
stroke within 1 year prior to study (72.9%). Mean scores
on all QoL domains were above average with the physi-
cal domain recording the lowest scores. Caregivers’ fac-
tors of age, educational background and employment,
and duration poststroke onset were significantly associ-
ated with domains of QoL.
Conclusion: Although QoL of stroke caregivers was fair
across domains, the physical domain recorded the lowest
mean scores. Older age, lack of formal education, unem-
ployment and caring for stroke patients within the sec-
ond year poststroke were associated with lower QoL
scores. Information from this study may aid in identifying
those caregivers who require support programmes and
care the most.
Keywords: stroke, caregivers, quality of life, Nigeria,
family.
Submitted 22 March 2012, Accepted 19 October 2012
Background
Stroke is a common neurological disease with high
rates of mortality and morbidity worldwide (1).
Although recent advances in health care have enabled
more people to survive a stroke, many of these survi-
vors experience persistent motor function deficits and
require assistance with activities of daily living (2).
Oftentimes, the assistance and care required by stroke
survivors is provided by their family and friends. The
physical and psychological well-being of these informal
caregivers has however been reported to be negatively
affected by the various care-giving services they render
(3). Caregivers of stroke survivors also experience
diminished Quality of Life (QoL) as a result of the
physical, emotional, financial and psychological burden
of stroke (4, 5).
Quality of life is defined as an individual’s perception
of their position in life in the context of their cultural
and value systems by which they live and in relation to
their goals, expectations, standards and concerns (6). It
also refers to a person’s subjective well-being and life sat-
isfaction which includes mental and physical health,
material well-being, interpersonal relationships within
and outside the family, work and other activities in the
community, personal development and fulfilment of
active recreation (7). The impact of care giving on the
caregiver’s QoL can be influenced by the demographic
attributes of the caregiver. Factors such as age, gender
and caregiver’s relationship with stroke survivor have
been identified by some studies as predictors of QoL
among stroke caregivers (8–10).
Correspondence to:
Dr. Grace Vincent-Onabajo, Department of Medical Rehabilitation
(Physiotherapy), University of Maiduguri P.M.B., 1069 Maiduguri,
Nigeria.
E-mail: [email protected]
© 2012 The Authors
Scandinavian Journal of Caring Sciences © 2012 Nordic College of Caring Science 977
doi: 10.1111/scs.12017
Due to the centrality and immense benefits of infor-
mal care giving among the components of health care
(11), supporting the caregiver serves as a critical aspect
of rehabilitating and reintegrating stroke survivors into
the community (12). Furthermore, with the shift in
emphasis from institutional to home-based care, research
interest in the QoL of caregivers of stroke survivors has
significantly increased in high-income countries (3).
However, only a few studies have been carried out on
this important subject matter in African countries (9,
13). Paradoxically, the informal care of stroke survivors
after hospital discharge in many African communities is
often the preserve of caregivers in the community and
home settings due to the shortage or nonexistence of
institutional care facilities. Furthermore, the cultural
structure in many African countries encourages commu-
nity and family care rather than institutional and nurs-
ing home care. This present study was designed to assess
the QoL of caregivers of stroke survivors in the Kanuri-
Hausa community of Maiduguri, North-Eastern Nigeria
with the aim of evaluating the influence of age, gender,
educational and employment status of the caregivers
and time after stroke of the care recipients, on the care-
givers’ QoL.
Based on observations from previous studies (4, 8–10),
we hypothesized that personal factors such as caregivers’
age, gender, employment and educational status, rela-
tionship with stroke survivor and duration of care giving
(estimated by poststroke duration) will significantly influ-
ence caregivers’ QoL.
Methods
Study location
This cross-sectional study was conducted at two govern-
ment hospitals (a tertiary and a secondary care hospital)
located in the city of Maiduguri, the capital of Borno
state, one of the six states in north-east region of Nigeria.
The approval of the Research and Ethical Committee of
the University of Maiduguri Teaching Hospital was
obtained prior to the commencement of the study.
Participants
Fifty-nine informal caregivers who accompany commu-
nity-dwelling stroke survivors for out-patients physio-
therapy sessions at the two hospitals participated in the
study. A caregiver was included in the study if he or she
had the informal responsibility of looking after a stroke
survivor in the home; gave verbal/written informed con-
sent and understood written and verbal information in
English language due to the unavailability of translated
and validated versions of the main measure utilized in
the study, namely the World Health Organization Quality
of Life brief version questionnaire (WHOQoLBREF), in
the two predominant indigenous languages (Hausa and
Kanuri language) of the population in the study location.
Information on the caregivers’ age, gender, educational
background, employment status and relationship with
stroke survivors, and poststroke duration was obtained
using an information data form while quality of life was
assessed with WHOQoLBREF.
Measure
The WHOQoLBREF contains 26-items that assess general
health and QoL status, and QoL in psychological, physi-
cal, social relationship and environmental domains. The
questionnaire was self administered by respondents with
the required ability, otherwise it was interviewer admin-
istered (6). Scores were calculated in a positive direction
and raw score on each domain of the WHOQoLBREF
was transformed to a scale of 0–20 with higher scores
denoting better QoL. The internal consistency of the
WHOQoLBREF ranges from 0.70 to 0.77 of Cronbach’s
alpha for the four domains.
Data analyses
Descriptive statistics of mean, standard deviation, fre-
quency and percentages were used to summarize the
socio-demographic data and QoL scores. To test the
study’s hypotheses, Kruskal–Wallis test was used to ana-
lyse the influence of caregivers’ socio-demographic char-
acteristics and poststroke duration on their QoL scores.
For this purpose, caregivers were categorized by age group
(14–30 and 31–55 years), educational background (pri-
mary, secondary, postsecondary and none), employment
(employed, unemployed and schooling) and poststroke
duration (1–12, 13–24 and above 24 months). Caregivers’
relationship with stroke survivors was also categorized
into family and acquaintance (specific relationship such
as spouse, sibling and child were however utilized for
purposes of descriptive statistics). Data analyses were per-
formed with the SPSS version 15 (SPSS Inc., Chicago, IL,
USA) with level of statistical significance at p = 0.05.
Results
Fifty-nine stroke caregivers participated in the study.
Majority of the caregivers were males (55.9%), and chil-
dren of stroke survivors (69.5%) and their ages ranged
from 14 to 55 years with a mean of 29.2 � 9.6 years.
Data on educational and employment status also showed
that majority of the caregivers were undergoing or had
completed postsecondary education (61%) and were
employed (45.8%). Mean poststroke duration for the
care recipients was 11.9 � 11.26 months. Socio-demo-
graphic data of caregivers are presented in Table 1.
978 G. Vincent-Onabajo et al.
© 2012 The Authors
Scandinavian Journal of Caring Sciences © 2012 Nordic College of Caring Science
QoL of caregivers
Caregivers’ mean score for each of the four QoL domains
assessed, namely physical, psychological, social relation-
ships and environment domains, was above average
(Table 1). The mean score for the physical domain was
however lowest (14.75 � 3.12), while the highest mean
score was obtained in the environment domain
(15.58 � 2.26).
QoL and caregivers’ gender
Quality of life of the caregivers was not significantly
influenced by their gender. Female caregivers however
had slightly higher mean scores in all four domains of
QoL (Table 2).
QoL and caregivers’ age
Caregivers were categorized into two age groups; those
aged 14–30 years, and those in the 31–55 years group.
Caregivers in the younger age group had significantly
higher mean scores in the physical (15.5 � 3.1), social
relationship (16.2 � 3.2) and environment (16.0 � 2.4)
domains (Table 2). Psychological QoL domain mean score
was also higher for caregivers in 14–30 years age group,
although without statistical significance.
QoL and educational status of caregivers
Significant association was observed between the physical
domain of QoL and educational background of caregivers.
Highest physical domain mean score (16 � 3.2) was
obtained by caregivers with not more than secondary
education while those without formal education scored
lowest (10.5 � 0.7). Although without statistical signifi-
cance, caregivers without formal education however had
highest mean scores in the psychological (15.5 � 0.7)
and environment (16 � 0.0) domains of QoL.
QoL and employment status of caregivers
Employment status was significantly associated with the
physical and environment QoL domains, with caregivers
who were schooling having higher mean scores
(15.8 � 3.1 and 16.4 � 1.8, respectively). Unemployed
caregivers had the lowest mean scores in all the four QoL
domains (Table 2).
QoL and relationship with stroke survivor
Table 2 shows that QoL of caregivers in this study was
not significantly influenced by being either family or
acquaintance of stroke survivors. However, caregivers
who were acquaintances of stroke survivors had higher
mean scores in the physical (16.8 � 1.3) and social
relationship (17.8 � 2.2) QoL domains than family
caregivers.
QoL and poststroke duration
The only care recipient variable assessed was time after
onset of stroke, and it was found to significantly influ-
ence the environment domain of caregivers’ QOL. Care-
givers of individuals who had survived a stroke for a year
or less had highest mean score in environment QoL
(15.9 � 2.2). Also in the physical (15.1 � 3.0), psycho-
logical (15.1 � 2.0) and social relationship (15.9 � 3.3)
domains of QoL, these caregivers had highest mean
scores although with no statistical significance (Table 2).
Discussion
Mean scores for all the QoL domains in this study was
above average. However, normative data representative
of the demographic characteristics of our participants are
not available in the literature for purposes of comparison.
Of the four domains of QoL, caregivers rated the physical
domain lowest although findings from previous studies
showed that the psychological and social QoL domains
were the most severely compromised in stroke caregivers
(8, 14–16). Our finding appears to reflect the negative
effect of physical aspects of caring for stroke patients on
Table 1 Characteristics of the stroke caregivers (N = 59)
Variable n %
Gender
Male 33 55.9
Female 26 44.1
Age (years)
Mean (SD) 29.24 (9.68)
Range 14–55
Employment
Employed 27 45.8
Unemployed 17 11.9
Schooling 15 42.4
Educational background
Primary 9 15.3
Secondary 12 20.3
Postsecondary (Completed/Ongoing) 36 61.0
None 2 3.4
Relationship
Child 41 69.5
Sibling 10 16.9
Spouse 4 6.8
Acquaintance 4 6.8
QOL domain scores, Mean (SD)
Physical 14.75 (3.12)
Psychological 14.85 (2.16)
Social relationship 15.56 (3.15)
Environment 15.58 (2.26)
QoL of stroke caregivers 979
© 2012 The Authors
Scandinavian Journal of Caring Sciences © 2012 Nordic College of Caring Science
caregivers’ physical well-being (4). Poststroke functional
limitations often leave the responsibility of helping the
stroke survivor with transfers as well as basic and instru-
mental activities to the caregiver (2). Furthermore, in
this community of Nigerians, caregivers traditionally
accompany stroke survivors for physiotherapy sessions
and are taught to administer and assist stroke survivors
with home exercises which may increase the physical
demands of care giving.
The predominance of male caregivers in this present
study contrasts findings from studies of caregivers of
stroke survivors in developed countries (4, 17). Our find-
ing is also inconsistent with the preponderance of female
caregivers reported in a study carried out in south-
eastern Nigerian (9). The gender difference observed
between our study and previous studies may be indica-
tive of the comparatively secluded lives the Kanuri-Hausa
females of the northern part of Nigeria lead. This in effect
leaves the duty of accompanying patients to the hospital
to males while females administer care from the home
fronts. The fact that our study was hospital based there-
fore calls for cautious generalization of the male predom-
inance observed. Gender however did not significantly
differentiate QoL of caregivers in this study in contrast
with previous reports (4, 9, 17).
The influence of age on QoL of caregivers observed in
this present study, with older caregivers having lower
scores in almost all QoL domains, is consistent with
Table 2 Kruskal–Wallis test for difference in caregivers’ quality of life by selected variables
Variable
QOL domains – mean (SD)
Physical Psychological
Social
relationship Environment
Gender
Male 14.7 (3.2) 14.8 (2.1) 15.5 (3.2) 15.5 (2.0)
Female 14.8 (3.0) 14.9 (2.2) 15.7 (3.1) 15.7 (2.6)
KW 0.001 0.50 0.01 0.62
p-value 0.97 0.47 0.92 0.43
Age group (years)
14–30 15.5 (3.1) 15.1 (2.1) 16.2 (3.2) 16.0 (2.4)
31–55 12.9 (2.3) 14.3 (2.3) 14.1 (2.7) 14.6 (1.4)
KW 8.94 0.64 5.92 6.16
p-value 0.00* 0.42 0.02* 0.01*
Educational background
Primary 13.2 (3.0) 14.1 (1.6) 14.0 (3.4) 14.7 (2.3)
Secondary 16.0 (3.2) 14.2 (1.8) 16.3 (3.0) 15.1 (1.8)
Postsecondarya 14.9 (2.9) 15.2 (1.8) 15.8 (3.1) 15.9 (2.4)
None 10.5 (0.7) 15.5 (0.7) 13.5 (2.1) 16.0
KW 7.94 5.36 4.63 4.93
p-value 0.05* 0.15 0.20 0.18
Employment
Employed 14.5 (2.9) 14.6 (2.3) 15.5 (3.2) 15.3 (2.6)
Unemployed 11.7 (2.1) 14.3 (2.8) 13.9 (2.9) 13.9 (1.3)
Schooling 15.8 (3.1) 15.3 (1.8) 16.0 (3.1) 16.4 (1.8)
KW 9.82 1.60 2.81 8.87
p-value 0.01* 0.45 0.24 0.01*
Relationship
Family 14.6 (3.2) 14.9 (2.2) 15.4 (3.2) 15.6 (2.3)
Acquaintance 16.8 (1.3) 14.0 (2.4) 17.8 (2.2) 14.8 (1.7)
KW 1.90 0.87 1.92 0.84
p-value 0.16 0.34 0.16 0.36
Post stroke duration (months)
1–12 15.1 (3.0) 15.1 (2.0) 15.9 (3.3) 15.9 (2.2)
13–24 13.4 (3.4) 14.0 (2.7) 14.2 (2.5) 14.4 (1.1)
>24 14.4 (2.3) 14.6 (2.3) 15.2 (2.9) 15.4 (3.6)
KW 2.52 1.11 2.86 5.92
p-value 0.28 0.57 0.24 0.05*
aOngoing/completed postsecondary education KW = Kruskal–Wallis Chi-square.
*Significant at p = 0.05.
980 G. Vincent-Onabajo et al.
© 2012 The Authors
Scandinavian Journal of Caring Sciences © 2012 Nordic College of Caring Science
findings from previous studies (8, 14). However, a major
difference between our findings and majority of the pre-
vious studies is the young age of our participants. While
stroke caregivers studied in Canada, Japan, United King-
dom and Australia were in their 50s and 60s (4), the
average age of caregivers in our study was 29 years. The
age distribution of caregivers from these developed coun-
tries could be because majority of the caregivers were
spouses of the care recipients (4). Our study, like the
earlier one conducted in south east Nigeria (9), however
had younger caregivers with majority being children of
the stroke survivors. The culture of the Nigerian people
that often reserves the responsibility of care giving for
the offspring of an individual suffering ill-health is rein-
forced by these findings.
Majority of the caregivers in this study had completed
or were undergoing postsecondary education, a pattern
that could be due to the age distribution of the caregiv-
ers. Available data from the 2008 Nigeria Demographic
and Health Survey Statistics (NDHS) (18) show that
approximately 9.8% of Nigerians aged 25–34 years have
more than secondary education. There is also a growing
societal emphasis on further education in Nigeria with
the desire of younger generations of Nigerians to obtain
higher education on the increase, and this is more so
with establishment of more postsecondary educational
institutions in the country compared to what obtained in
the past. As this study was hospital based, the fact that
majority of the caregivers in this study had higher educa-
tion may have influenced the choice of medical care and
rehabilitation for their care recipients over alternative
and traditional treatments that are still very prevalent in
Nigeria.
Employment status and educational background of the
caregivers significantly influenced the physical and envi-
ronmental aspects of their QOL with the unemployed
and those with no formal education recording the low-
est mean scores. Generally, unemployment is linked
with poor QoL, and unemployed individuals are
reported to exhibit different degrees of dissatisfaction
with life (19). The low QoL among unemployed caregiv-
ers could therefore be considered as resulting from both
the adverse effect of unemployment and the responsibil-
ity of caring for stroke patients. However, one study
reported that unemployment had a positive effect on
the QoL of spousal caregivers of stroke survivors (20).
Although few studies have explored the influence of
educational background of caregivers on their QoL (4),
the significantly low physical domain scores observed
among caregivers with no formal educational back-
ground implies the need of this category of caregivers
for more information and enlightenment on the physical
aspects of care giving.
Caring for stroke patients who had suffered stroke
within 1 year was associated with better QoL compared
with longer poststroke periods. The ability of caregivers
to cope well with their role at the initial periods after
onset of stroke has been identified by previous studies
(5). The early period after onset of a disease is often char-
acterized by enormous support for the patient and his/
her caregivers which may help cushion the burden of
care giving at such times. However, following survival
and increasing time after a disease condition, support
often wanes leaving the primary caregivers with the sole
responsibility of providing informal care with a conse-
quent negative effect on their well-being. Results of a
longitudinal study of caregivers of stroke patients at dif-
ferent time points after stroke indicated that adverse psy-
chosocial consequences were more severe with increasing
time after stroke, and this was strongly associated with
lesser social support and network for the caregivers (21).
The only significant influence of time after stroke in this
present study was however on the environment domain
of QoL, a domain that entails availability of financial
resources, accessibility to health and social care and par-
ticipation in leisure activities.
There were some limitations in this study. Being a hos-
pital-based study, only caregivers of stroke survivors
receiving physiotherapy participated, and thus, the find-
ings might not be generalizable to all caregivers of stroke
survivors in the study location. This study also did not
obtain information on care recipients’ attributes such as
gender, age and level of functioning, all of which could
have influenced the QoL of the caregivers. Data collec-
tion took place during the therapy sessions for the stroke
survivors (caregivers were available to participate in the
study at these times) and stroke survivors’ information
could not be obtained during the sessions, especially
objective assessment of their functional status. Future
studies should be conducted in the community to elimi-
nate selection bias with consideration for the demo-
graphic and clinical data of the stroke survivors being
cared for.
Conclusion
Quality of life of stroke caregivers in this study, although
above average in all domains, was observed to be lowest
in the physical domain. Caregivers’ age, educational
background and employment status were observed to
significantly influence the physical, social relationship
and environmental domains of QoL, with unemployed,
uneducated and older caregivers recording lower scores.
Caregivers of patients who had suffered stroke from 1 up
to 2 years were also at increased risk of low QoL in the
environmental domain. Strategies such as education and
training of caregivers on the physical aspects of care such
as lifting and assisting with ADLs should be adopted and
routinely provided to reduce the impact of care giving on
the physical well-being of caregivers. The comparatively
QoL of stroke caregivers 981
© 2012 The Authors
Scandinavian Journal of Caring Sciences © 2012 Nordic College of Caring Science
lower QoL of older, uneducated and unemployed stroke
caregivers implies the need for provision of appropriate
intervention and support for this categories of caregivers.
Author contribution
Grace Vincent Onabajo designed the study, analysed
data, drafted and reviewed the manuscript for intellectual
content, and provided supervision. Aisha Ali collected
and analysed data, and drafted the manuscript. Talhatu
Hamzat drafted and reviewed the manuscript for intellec-
tual content. All the authors provided material support.
Ethical approval
The study was approved by the Research and Ethical
Committee of the University of Maiduguri Teaching Hos-
pital (UMTH), Nigeria.
Funding
The authors received no financial support for the
research.
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