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Gender differences in burden of care and coping strategies among caregivers of schizophrenia patients

1 Psychiatry Department, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Psychiatry Department, Rohilkhand Medical College & Hospital, Bareilly, Uttar Pradesh, India
3 Department of Psychiatry, Dr D Y Patil Medical College, Hospital & Research Centre, Pune, Maharashtra, India

Date of Submission14-Mar-2022
Date of Acceptance29-Mar-2022
Date of Web Publication14-Sep-2022

Correspondence Address:
Suprakash Chaudhury,
Department of Psychiatry, Dr D Y Patil Medical College, Dr D Y Patil Vidyapeeth, Pimpri, Pune - 411018, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipj.ipj_44_22


Background: Caregivers of patients with schizophrenia have a considerable burden of care and develop different coping strategies to deal with the caregiving burden. Aim: The aim of this article is to assess gender differences in the burden of care and coping strategies used among caregivers of clinically stable patients with schizophrenia. Methods: In this cross-sectional study, a total of 57 caregivers (33 males and 24 females) of the patients with schizophrenia attending a psychiatric outpatient setting were included by purposive sampling. The caregivers were assessed with the Burden Assessment Schedule 20 items (BAS-20) and Brief Approach/Avoidance Coping Questionnaire (BACQ) to assess the burden of care and coping strategies, respectively. Results: Average BAS-20 score was comparable between the male and female caregivers. If the patient was a spouse, the male caregivers had a significantly higher burden of the marital relationship than the female caregivers. On the BACQ, the socio-emotional approach subscale was significantly higher in female caregivers. The avoidance-oriented coping score and socio-emotional avoidance subscale were significantly higher in male caregivers. A significant positive correlation was found between BAS-20 score and avoidance-oriented coping scores in all caregivers except the females where a significant negative correlation was found between BAS score and socio-emotional avoidance type of coping. Conclusion: There are no gender differences in the burden of care in caregivers of clinically stable patients with schizophrenia except the male caregivers have a higher burden in the domain of marital relationship. The socio-emotional approach type of coping is higher in females while the socio-emotional avoidance type of coping is lower in male caregivers.

Keywords: Burden, caregiving, coping, gender, India, schizophrenia

How to cite this URL:
Kumar S, Dixit V, Ali R, Chaudhury S. Gender differences in burden of care and coping strategies among caregivers of schizophrenia patients. Ind Psychiatry J [Epub ahead of print] [cited 2023 Feb 6]. Available from: https://www.industrialpsychiatry.org/preprintarticle.asp?id=355947

   Introduction Top

Schizophrenia is a serious psychotic disorder that has a significant impact on the life of not only the patients but also their caregivers. Its severe and characteristic manifestations with disorganized behavior and long term course,[1],[2] along with associated social stigma produce a considerable challenge to the caregivers in the form of multiple responsibilities such as financial costs, physical care of the patient, and compromises on the personal freedom and leisure activities.[3],[4] The term “caregiver burden” has been used to define the multidimensional response to physical, psychological, emotional, social, and financial stressors associated with the caregiving experience.[5],[6] This caregiver burden is often the outcome of a stressful and negatively perceived experience of providing care.[7]

To deal with the caregiver burden, caregivers develop different kinds of coping strategies by which they either approach the challenge finding a reasonable solution, looking for support from friends or other near ones, or they start trying to avoid the situation by indulging in activities like smoking or substance abuse.[8],[9] Caregivers experience higher levels of burden when they have limited positive coping resources,[10],[11] and there has been a reduction in the perceived burden if they adopt less emotion-focused coping strategies.[8] The caregivers of the patients with schizophrenia may develop psychological disturbances and poor quality of life if they find difficulty in coping with the caregiving distress.

In a developing country like India, family members are the main pillars to the caregiving of the patients with chronic medical and psychiatric conditions in the family. Across the world, women have been the predominant caregivers for family members with chronic medical conditions or disabilities and mental illnesses.[12],[13],[14] A recent review on gender differences in caregiving among family-caregivers of people with mental illnesses suggests that women form the bulk of those who provide care for people with physical and mental illnesses. This article, however, presents an equivocal and inconsistent role of gender in differentiating the evident distress and burden of caregiving in the context of caregivers of elderly people with physical illnesses and hesitates to give such opinion in the context of caregivers of mental illnesses like schizophrenia as numbers of such studies are scarce.[15]

The issue of gender differences in family-caregiving in psychiatric disorders like schizophrenia has not been examined as comprehensively as in the elderly with physical problems. Some individual studies have found higher levels of caregiver burden, stress, burnout, psychological morbidity, and poorer quality of life among female caregivers of those with schizophrenia.[16],[17],[18],[19],[20],[21] However, several other studies have not reported any differences in caregiver burden across male and female caregivers.[22],[23],[24],[25]

In this regard, some Indian studies are worth mentioning. Examination of the gender difference of caregiving experiences of 100 couples (i.e., the mothers and fathers of a son or daughter with schizophrenia) showed that men and women were equally vulnerable to caregiving stressors.[22] Caregivers of patients with schizophrenia and caregivers of patients with bipolar affective disorder suffered nearly similar level of burden and used similar pattern of coping strategies.[26] However, none of these Indian studies have studied gender differences in the burden of care and coping strategies of the caregivers. In 70 spousal caregivers of patients with schizophrenia, it was reported that female spouses experienced significantly higher total burden and burden in the areas of external support, caregivers' routine, patients' support, patients' behavior, and caregivers' strategies.[21]

In the context of the family caregivers of the elderly, gender differences in coping have been reported in several studies.[27],[28] It was observed that women use emotion-focused coping and other ineffective coping styles such as fantasy, wishful thinking denial, escape, or avoidance while men use more effective coping strategies such as problem-solving, acceptance, detachment, or distancing. Such differences in coping strategies have been found to explain the higher levels of caregiver burden and psychological morbidity among female caregivers of patients with physical illnesses.[12],[27],[29] Similar gender differences in coping have occasionally been reported in the context of the caregivers of patients with psychiatric disorders like schizophrenia.[21],[30]

Review of the existing literature reveals that the exploration of gender differences in caregiving burden and coping strategies of the caregivers of patients with schizophrenia is important but the volume of research works in this regard is low. Few Indian studies of the issue have ended up with different conclusions. Keeping all these points in mind, this study was undertaken to assess gender differences in the burden of care and coping strategies used by the caregivers of patients with schizophrenia.

   Materials and Methods Top

This was a hospital-based cross-sectional study. After the approval of the institutional ethics committee (IEC/25/17/SEP dated 06/11/2017), this study was carried out in the outpatient setting of a tertiary care hospital. The sample comprises 57 caregivers (33 males and 24 females) of the patients with schizophrenia, chosen with the help of the purposive-sampling technique. The patients were diagnosed as per ICD-10 diagnostic criteria for research. The caregiver was defined as a person, living with the patient and intimately involved in the care of the patient for a minimum duration of 1 year, that is, looking after her/his day-to-day needs, medication intake, and accompanying the patient during the hospital visits.[31] Only the caregivers giving written informed consent were enrolled for the study. They had to be between the age group of 18 and 65 years, either parent, spouse, or sibling, free from an intellectual disability or other comorbidity affecting their cognitive or mental functions. The patients with schizophrenia had to be in the age range of 18–65 years and must be accompanying a caregiver as defined above. A minimum duration of illness of 1 year and clinical stability of the illness (as defined as major changes in medication and no hospitalization in the 3 months preceding the intake of the patients in the study) for a minimum period of 3 months before the study was required. Patients with any significant co-morbidities, physical or other mental disorders including substance use disorders, were excluded. Persons having any living family member suffering from psychiatric illness and staying in the same household were also excluded.

On a self-prepared sociodemographic and clinical data sheet, sociodemographic details like name, age, sex, marital status, education level, and so on of both the patients and their caregivers as well as patients' clinical details like duration of illness and age of onset of illness were recorded. The caregivers were assessed on the Burden Assessment Schedule 20 items (BAS-20) scale and Brief Approach/Avoidance Coping Questionnaire (BACQ) to evaluate their burden of care and coping strategies, respectively.

Burden Assessment Schedule 20 items scale

The BAS-20 measures the subjective burden of relatives of persons with a severe mental illness and takes into consideration both positive and negative sides of caregiving. It consists of five subscales: impact on well-being, appreciation for caring, impact on relations with others, perceived severity of the disease, and impact on marital relationship (when relevant). Each subscale has four items with a three-point response scale (not at all, to some extent, and very much).[32],[33] A few items of the scale did not apply to most caregivers (i.e., four items, 3, 4, 5, and 6, are applicable only if the patient is the spouse of the interviewed caregiver). As this would influence their total score, we used the average BAS score for statistical analysis. The average BAS score was calculated by dividing the total BAS score by 16 in non-spouse caregivers and by 20 in caregivers who were also spouses. A higher score indicates a greater burden on the caregiver.

Brief Approach/Avoidance Coping Questionnaire

The BACQ consists of 12 items measuring approach coping (6 items; e.g., I make an active effort to find a solution to my problem), and two forms of avoidance coping: (1) resignation and withdrawal (3 items; e.g., I withdraw from other people when things get difficult) and (2) diversion (3 items; e.g., I try to forget my problems). It has also been organized in six different categories of coping strategies, reflecting the approach versus avoidance dimension in the cognitive, socio-emotional, and action-related domains, respectively. It uses a five-point Likert-type scale (1 = “completely agree” to 5 = “completely disagree”). The coping strategy sum scores are calculated by summing up the item scores with a BACQ sum score ranged from 12 to 60. The BACQ has an internal consistency of Cronbach's α =0.68.[34]

Statistical analyses

The collected data were analyzed using SPSS software (IBM, Atlanta, USA). Descriptive statistics like means and standard deviations for continuous variables and frequency for categorical variables were calculated for the study participants. Chi-square test, Independent-sample t-test, Mann–Whitney U test, and Spearman's correlation examined the relationships between characteristics of the study participants. A P value of ≤0.05 was considered to be statistically significant.

   Results Top

A total of 57 primary caregivers (33 males and 24 females) and their corresponding 57 patients with schizophrenia (36 males and 21 females) were evaluated in the study. Patients had a mean age of 31.60 ± 9.98 years and a mean education duration of 7.77 ± 2.06 years. Patients developed schizophrenia at a mean age of 25.21 ± 9.97 years and their mean duration of illness was 6.38 ± 5.52 years. The majority of the patients (31, 54.4%) were unmarried (either never married or separated or divorced or widowed). The majority of caregivers were married, Hindu, employed, and came from a rural socioeconomic status, nuclear family type, and rural background. More than half of caregivers were parents (56.1%) and the rest of them were either spouses (22.8%) or other relatives (21.1%) of the patients.

The caregivers' variables are shown in [Table 1] with their comparison between two groups of caregivers based on gender. There was no statistically significant difference between male and female caregivers in terms of all sociodemographic details except employment. Significantly more female caregivers were unemployed than their male counterparts. The mean duration of caregiving was significantly more in females. Both groups were comparable in terms of the overall burden of care (i.e., average BAS 20 score) and its all domains except the burden in marital relationships [Table 2]. If the patient was a spouse, the male caregivers had a significantly higher mean score of the burden of the marital relationship than the female caregivers. The mean score of BACQ total score as well as the mean of the approach-oriented total score was comparable in the two groups but the mean of the avoidance-oriented total score was significantly higher in males. Male caregivers appeared distinct from their female counterparts in terms of the use of socio-emotional coping strategies. They had a significantly lower mean score of socio-emotional approach-oriented coping and a higher mean score of socio-emotional avoidance-oriented coping.
Table 1: Gender differences in caregivers' sociodemographic details

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Table 2: Gender differences in caregivers' scores on BAS-20 and BACQ

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In [Table 3], a correlation has been sought between the coping strategies used and the burden of care of the caregivers (overall as well as based on gender). There was no significant correlation observed of the burden of care to either total BACQ score or to the approach-oriented coping scores among all caregivers. However, a significant positive correlation was observed between the burden of care and avoidance-oriented coping strategy used across all caregivers but not in male or female caregivers separately. A significant negative correlation of the burden of care to the socio-emotional type of avoidance-oriented coping was observed in female caregivers only. The action-oriented avoidance type of coping had a significant positive correlation to the burden of care in all caregivers together and in both genders separately. The cognitive avoidance type of coping had a significant positive correlation to the burden of care in all caregivers together and in female caregivers separately but not so in male caregivers.
Table 3: Correlation of burden of care (average BAS-20 Score) with coping strategies

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   Discussion Top

In India, this study was the first of its kind to assess gender differences in the burden of care as well as coping strategies used in caregivers of patients with schizophrenia. Caregivers of both genders were comparable in terms of sociodemographic details like age, education, marital status, socioeconomic status, religion, living background, family type, relationship with their patients, and duration of caregiving. However, more females were unemployed. Since the majority of the caregivers belonged to the rural background and lower socioeconomic status, higher unemployment in females can be easily understood. In fact, in India, females are less employed than males.[35],[36] Females are still homemakers in the majority and are supposed to take care of sick persons lying in the house while male members of the family are mainly involved in earning their livelihood.[36]

A major finding of the study was that the male caregivers had a higher burden in the domain of marital relationships in the caregiving of their spouses with schizophrenia. As per the BAS-20,[32] the domain of burden in marital relationships includes (a) patient's poor cooperation with family responsibilities, (b) patient's unaffectionate attitude toward the caregiver, (c) patient's inability to satisfy caregiver's needs for intimacy, and (d) decline in quality of marital relationship since the onset of patient's illness. A higher burden in the domain of marital relationships indicates male caregivers experience one or more of these issues significantly more in comparison to female caregivers while taking care of their spouses with schizophrenia. This can be due to female respondents being hesitant to admit these personal marital experiences, considering the background they belonged to, and thereby they appeared less burdened. In the remaining domains of caregiving burden, an absence of gender differences indicates that, be it a male or female caregiver, there was a similar impact on their well-being, that they were appreciated for their caregiving roles in similar ways, that caregiving had a similar impact on their relationship with others, and that their perceived severity of caregiving the patients with schizophrenia was similar. These findings are somewhat different from those of another Indian study done which found that females have a greater burden in multiple areas as assessed with BAS-40 item-scale.[21],[33]

The male and female caregivers of patients with schizophrenia differed in terms of different coping strategies used. Male caregivers appeared distinct from their female counterparts in terms of the use of socio-emotional coping strategies. Conceptually, avoidance-oriented coping is opposite to approach-oriented coping.[34] In the present study, while the socio-emotional approach-oriented coping was higher in female caregivers, the socio-emotional avoidance-oriented coping was higher in male caregivers. Further, a significant negative relationship of the socio-emotional avoidance-oriented coping was found with the burden of care in female caregivers only. It meant that, when things got difficult, the male caregivers tried to withdraw from other people emotionally or started feeling to give up while the female counterparts coped with the stress oppositely, that is, they liked to talk to few chosen people or to say so if felt angry or sad. While the socio-emotional domain of coping reflects psychological constructs like social support seeking and emotional expression to deal with the stressor, the cognitive domain of coping reflects the attitude of the individual to deal with the problems.[34] In the present study, a significant positive relationship of the cognitive avoidance-oriented coping with the burden of care in only female caregivers indicated that they displayed poorer mental strength to deal with a rising burden of care in comparison to the male caregivers.

These gender-related differences in coping of the caregivers of this study are in line with the existing literature on the role of gender in the behavioral stress response. In a systematic review,[37] it is apparent that although individuals of both genders may have a physiological experience of fight or flight, the women have a more typical behavioral experience of “tend and befriend,” for example, engaging in nurturing activities designed to protect the self and offspring, and maintenance of social networks, and this sex difference is likely to be related to sex differences in oxytocin and estrogen and parenting requirements. In a meta-analysis[38] about sex differences in coping behavior, it has been found that females are more likely than males to use coping strategies that are emotion-focused (that alter the response to a stressor) as opposed to problem-focused (which are aimed at altering the stressor). For example, it appears that females tend to cope with stress by talking about their feelings more than males do.

Conceptually, an avoidance-oriented coping is opposite to approach-oriented coping and the construct of avoidance is not unidimensional, rather it has been conceptualized in two different ways historically, either as a passive or disengaged way of relating to stressful events or as an active orientation away from the stressor, such as denial, diversion, or escape.[39] Logically, approach-oriented coping strategies appear better to handle ongoing stress than avoidance-oriented coping strategies. However, which subtype of either type of coping strategy will be beneficial to handle caregiving stress of schizophrenia patients is not known. A 1-year follow-up study by Magliano et al.,[8] regarding family burden and coping strategies in schizophrenia has found that a reduction of family burden was evident over time among relatives who adopted less emotion-focused coping strategies.

A recent review article from India suggests that different coping mechanisms, as assessed on different tools to assess coping, are associated with various caregiving-related outcomes like the burden, caregiving experience, expressed emotion, illness perception, quality of life, and psychological morbidity among the caregivers of patients with schizophrenia. In general, the relationship of caregiving outcome is clearer with problem-focused or adaptive coping mechanisms than with emotion-focused coping mechanisms. However, this article does not focus on gender-related differences in coping of caregivers of schizophrenia patients as sought in our study.[40]

Several theories have been advanced to explain gender differences among caregivers of either physical conditions or psychiatric disorders like schizophrenia. In the “role-socialization” theory, the social traditions are given importance and thereby the women are expected to adopt the role of a caregiver and not the man. This leads to dissimilar approaches toward caregiving across the gender. However, the empirical support of this theory is lacking.[41],[42],[43] In the “stress-coping” theory, it has been argued that gender differences in caregiving burden arise because female caregivers have greater exposure to caregiving stressors and differ in their appraisal, coping, and availability of social support while managing these demands.[5],[42],[43] Despite these theoretical underpinnings, the relationship of coping strategies used with different domains of the burden of care is not straightforward if the person- and family-related other factors are taken into account. Viewing the same through the lens of gender makes the issue further complex.

There are certain limitations of this study. It utilizes cross-sectional design and purposive sampling techniques. Factors like personality characteristics, gender-related biological differences, and family and social dynamics, which are supposed to influence both the burden of care and coping among the caregivers, should be taken into consideration while interpreting the overall findings. Future studies are suggested to handle these limitations and to employ a larger sample size with participants from both clinical settings and the community for the sake of better generalization of the findings.

The findings of this study can have multiple implications. The clinicians dealing with the caregivers of patients with schizophrenia must systematically assess the coping mechanisms of caregivers. The gender-related differences in the burden of care and coping of the caregivers can be utilized to train the clinical psychologists and other psychological therapists. The clinicians can learn to improve the success of their practice by taking the gender of clients into account. The study further emphasizes the need for policymakers to address the gender-related issues in the caregiving of patients with schizophrenia.


This was a hospital-based study with a modest sample size. Hence, the findings may not be generalizable.

   Conclusion Top

There are no gender differences in the burden of care in the caregivers except the male caregivers to have a higher burden in the domain of marital relationships. The socio-emotional approach type of coping is higher in females while the socio-emotional avoidance type of coping is lower in male caregivers. The relationship between caregiver burden and coping is complex.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3]


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