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Keywords:

  • care management;
  • caregiver burden;
  • gender;
  • home-visit nursing;
  • long-term care insurance

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Background:  Japan is presently experiencing a growth in the number of male caregivers and this situation has given rise to some concerns over gender differences. Previous studies have suggested that there are gender differences in caregiver burden in home care, however, it is still unclear whether or not gender differences exist. We therefore conducted this study to attain a better understanding of the Japanese male caregiver burden in home care, using data from the Nagoya Longitudinal Study of Frail Elderly (NLS-FE).

Methods:  NLS-FE is a large prospective study of community-dwelling elderly persons eligible for public long-term care insurance who live in Nagoya city and use the services of the Nagoya City Health Care Service Foundation for Older People, which comprises 17 visiting nursing stations and corresponding care-managing centers, from November to December 2003. Data used in this study included the Japanese version of the Zarit Caregiver Burden Interview, caregivers’ and dependents’ characteristics, and the caregiving situation. The differences in dependent and caregiver characteristics between male and female caregiver groups were assessed using the χ2-test for categorical variables or the unpaired t-test for continuous variables. Multiple logistic regression was used to examine the association between dependent and caregiver characteristics and caregiver burden.

Results:  A total of 399 male caregivers and 1193 female caregivers were included in our analysis. Before and after controlling baseline variables, we did not detect a difference between male and female caregivers with respect to caregiver burden.

Conclusion:  Our study suggests that differences in caregiver burden may not necessarily exist between male and female caregivers in Japan.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

In Japan, the proportion of elderly persons in the population has steadily increased in recent years.1 The growth of the aging population has triggered an increase in the demand for services and a rise in costs which, in turn, have brought about social and economic burdens to the society.2,3 Thus, in recent years, there has been growing interest in home care in Japan,4 especially after the introduction of the public long-term care insurance system in April 2000.1

Meanwhile, the structure of families has changed significantly and consequently young family members now tend to live apart from their aging parents and are thus unable to care for them personally.3–5 While daughters and daughters-in-law have traditionally played a significant role in caring for disabled elderly persons in Japan, male caregivers are now growing in number, as the frequency of spouse care-giving rapidly increases.3,5

In Western countries, a number of studies have suggested that there are gender differences in caregiver burden in homecare.6–10 In Japan, however, it is still unclear whether or not gender differences exist because very few studies have so far been conducted on the topic.3,5,11

In order to expand our knowledge of the Japanese male caregiver burden in homecare, we conducted a subanalysis study of the Nagoya Longitudinal Study of Frail Elderly (NLS-FE), which is a large prospective study of community-dwelling elderly.

METHOD

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Study design and subjects of NLS-FE

The NLS-FE consisted of a cross-sectional analysis of a total of 1875 subjects (632 men, 1243 women). The study subjects were community-dwelling elderly (aged 65 years or older) eligible for the public long-term care insurance who lived in Nagoya city (central Japan), and were provided with various home care services from the Nagoya City Health Care Service Foundation for Older People, which comprises 17 visiting nursing stations and corresponding care-managing centers. During the registration period (1 November 2003–31 December 2003), 1875 out of 3630 elderly users agreed to take part in this study. Informed consent for participation was obtained verbally from the patients or, for those with substantial cognitive impairment, from a surrogate, and from the caregivers according to procedures approved by the institutional review board of the Nagoya University Graduate School of Medicine.

Data collection and instruments

A total of 56 nurses and 48 care-managers visited the users’ homes and collected data from standardized interviews with patients or surrogates and caregivers, as well as from medical and visiting nursing station records. The abstractors were blinded to the study hypothesis or anticipated study results. Data we used in this analysis included the following items about the caregiver and the dependent.

Caregiver

Age, kinship of caregiver, use of care service, nurse’s judgment of use of care service, family care provision, caregiver’s state of health, use of care services in detail, family care sufficiency, caregiver burden (Japanese version of the Zarit Burden Interview (J-ZBI), nurse’s assessment of caregiver burden), and depression (Geriatric Depression Scale (GDS-15)).

Dependent

Age, sex, spouse, number of family members, family relationship, ease of access to the house, financial state, nutrition, degree of care needed, sight, hearing, communication with family, dementia, activities of daily living (ADL) scale of demented elderly, behavioral disorder, depression (GDS-15), ADL scale of disabled elderly, ADL (mobility on bed, transfer, walking inside, walking outside, dressing the upper half of the body, dressing the lower half of the body, feeding, toilet use, grooming, bathing, use of stairs), instrumental ADL (IADL) (preparing meals, housework, washing, money management, medication, telephone use, shopping, transportation use), illness, pressure ulcer, person in charge of medication.

Depressive mood was assessed by the Japanese short version of the GDS-15,12 in which high scores are characteristic of subjects who are in a greater depressive mood. Subjective caregiver burden was assessed by the Japanese version of the J-ZBI,13 which is a 22-item self-report inventory that examines the burden associated with functional behavioral impairments in the home care situation.

The Japanese long-term care system is a public and mandatory long-term care insurance for the frail and elderly. The insurance system is financed by premiums from everyone aged 40 years and older and a government subsidy. Everyone aged 65 years and older is eligible for benefits based strictly on physical and mental disability, in six levels of need ranging from ‘not applicable’ to ‘5’ (completely dependent in ADL).1 Also, Japan’s Ministry of Welfare identifies four ranks of ADL of disabled elderly ranging from J (independent in ADL) to C (bed-ridden).14

Statistical analysis

We excluded from our analysis those caregivers whose sex had not been specified and divided the study caregivers into two gender groups. Consequently, a total of 399 male caregivers and 1193 female caregivers were included in the analysis. The differences in dependent and caregiver characteristics between male and female caregiver groups were assessed using the χ2-test for categorical variables or the unpaired t-test for continuous variables. Multiple logistic regression was used to examine the association between dependent and caregiver characteristics and the caregiver burden, adjusting for age, sex and other factors associated with P < 0.05 on bivariate analyses between female and male caregivers. Data was analyzed using Statview-J5.0.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Caregivers’ gender differences in characteristics of dependents

The distribution of dependent characteristics is shown in Table 1. Significantly more dependents of male caregivers were female or married, and fewer of their dependents had residents compared to female caregivers. Dependents of male caregivers were less likely to have close relations with other family members. No significant differences were found between male and female caregivers in the ease of access to their houses, financial hardship, nutrition, or intravenous hyperalimentation. Dependents of male caregivers had better hearing ability than those among female caregivers. In cognitive function, behavioral disorder or ADL, no statistical differences were found between male and female caregivers (Table 2). In IADL, no statistical differences were found except in food preparation, home maintenance and laundry, with which men are less accustomed. In illness, dependents of female caregivers were more likely to have congestive heart failure, ulcer disease, peripheral vascular disease, or cerebrovascular disease. Among the male caregivers, dependents were more likely to be independent in taking medication.

Table 1.  Differences between male and female caregivers in dependents’ characteristics
VariableCategoryMale caregiver N %, mean ± SD (range)n = 399Female caregiver N %, mean ± SD (range)n = 1193P-value
  1. The χ2-test for categorical variables or the unpaired t-test for continuous variables was conducted between male and female caregiver groups. ADL, activity of daily living; GDS, geriatric depression scale.

Age (years) 78.2 ± 7.8 (53–97) 81.6 ± 8.0 (56–104) <0.001
Sex (females) 32280.770158.8<0.001
Marital statusMarried25263.255346.4<0.001
Bereaved13734.361151.2 
Divorced30.8121.0 
Not married51.3171.4 
Number of residents   1.7 ± 1.5 (0–12) 2.1 ± 1.5 (0–10) <0.001
Quality of family relationshipClose10325.837431.3<0.001
Average27067.778665.9 
Estranged235.8302.5 
Not at all30.800.0 
Suffering from financial hardshipNot at all8421.130025.1NS
Low28872.282869.4 
Rather frequently143.5484.0 
Very frequently112.8161.3 
NutritionPer oral38095.2112394.1NS
Parenteral184.5665.5 
Intravenous hyperalimentation20.520.2NS
Degree of care requiredNot applicable10.310.1NS
Assistance required225.5564.7 
Degree 110827.129724.9 
Degree 27819.525521.4 
Degree 36416.020417.1 
Degree 44711.816714.0 
Degree 57619.021017.6 
DementiaPresent12731.842635.7NS
Behavioral disorderPresent7218.024020.1NS
Depression
 GDS-15 5.7 ± 4.1 (0–15) 5.7 ± 4.0 (0–15) NS
ADL scale of disabled elderlyIndependent164.0413.4NS
J1287.0826.9 
J25513.814312.0 
A17518.821117.7 
A27017.525421.3 
B14711.815513.0 
B2358.81189.9 
C1256.3574.8 
C24310.812610.6 
IllnessIschemic heart disease389.514712.3NS
Congestive heart failure235.81109.2 0.030
Ulcer disease20.5242.0 0.039
Peripheral vascular disease41.0363.0 0.026
Liver disease133.3342.8NS
Cerebrovascular disease13433.649741.7 0.004
Connective tissue disease205.0534.4NS
Diabetes5413.513811.6NS
Dementia12832.144137.0NS
Chronic pulmonary disease215.3857.1NS
Hemiplegia11528.833428.0NS
Renal failure123.0544.5NS
Neoplasia287.01079.0NS
Leukemia/lymphoma10.300.0NS
Metastatic solid tumor20.540.3NS
Hypertension10025.127122.7NS
Pressure ulcer266.5917.6NS
Person in charge of medicationOneself17644.140333.8<0.001
Family18546.471660.0 
Others194.8282.3 
Table 2.  Differences in dependents’ ADL and IADL between male and female caregivers
VariableCategoryMale caregiver n%n = 399Female caregiver n%n = 1193P-value
  1. The χ2-test was conducted between male and female caregiver groups. ADL, activity of daily living; IADL, instrumental activity of daily living; NS, not significant.

ADL
Mobility on bedIndependent26065.278165.5NS
Partly dependent7518.823119.4 
Dependent6416.017915.0 
TransferIndependent21453.660050.3NS
Partly dependent10426.135529.8 
Dependent8120.323819.9 
Walking insideIndependent22556.467256.3NS
Partly dependent8421.126222.0 
Dependent9022.625921.7 
Walking outsideIndependent8621.624120.2NS
Partly dependent16340.949941.8 
Dependent14937.345338.0 
Dressing the upper half of the bodyIndependent19348.454845.9NS
Partly dependent11328.336730.8 
Dependent9323.327823.3 
Dressing the lower half of the bodyIndependent18446.150142.0NS
Partly dependent10526.334929.3 
Dependent11027.634328.8 
FeedingIndependent26566.479766.8NS
Partly dependent8922.323819.9 
Dependent4511.315813.2 
ToiletIndependent22355.961951.9NS
Partly dependent8621.628824.1 
Dependent8922.328624.0 
GroomingIndependent16441.147740.0NS
Partly dependent14035.141434.7 
Dependent9523.830225.3 
BathingIndependent9122.825921.7NS
Partly dependent16842.150142.0 
Dependent14035.143336.3 
Using stairsIndependent8621.627222.8NS
Partly dependent14636.641634.9 
Dependent16641.650442.2 
Visual acuityAdequate27869.782569.2NS
Difficulty reading small characters9624.128924.2 
Blind11 2.823 1.9 
Unknown14 3.556 4.7 
Auditory capacityAdequate31378.476364.0<0.001
Difficulty hearing a low voice8020.139533.1 
Completely impaired2 0.511 0.9 
Unknown4 1.023 1.9 
Communication with familyPossible35689.2106589.3NS
Impossible4310.812810.7 
IADL
Food preparationIndependent27 6.893 7.8<0.001
Mostly independent8521.316814.1 
Fairly dependent9122.820817.4 
Completely dependent19649.172460.7 
Home maintenanceIndependent14 3.529 2.4 0.003
Mostly independent8822.121618.1 
Fairly dependent9323.321317.9 
Completely dependent20451.173561.6 
LaundryIndependent35 8.8107 9.0<0.001
Partly dependent7819.515312.8 
Fairly dependent7819.517414.6 
Completely dependent20852.175863.5 
Money managementIndependent10726.831026.0NS
Mostly independent7518.819416.3 
Fairly dependent5814.517114.3 
Completely dependent15839.651843.4 
MedicationIndependent14937.338932.6NS
Mostly independent4711.814812.4 
Fairly dependent6516.320817.4 
Completely dependent13734.344737.5 
TelephoneIndependent13834.640934.3NS
Mostly independent7017.518015.1 
Fairly dependent5012.515613.1 
Completely dependent14135.344837.6 
ShoppingIndependent30 7.584 7.0NS
Mostly independent5614.016213.6 
Fairly dependent9423.624120.2 
Completely dependent21954.970659.2 
Transportation useIndependent28 7.084 7.0NS
Mostly independent4812.016313.7 
Fairly dependent9924.823719.9 
Completely dependent22456.170959.4 

Caregivers’ gender differences in characteristics of caregivers and caregivers’ burden

The distribution of caregiver characteristics is shown in Table 3. Male caregivers were more likely to be older and generally the spouse of the dependent. About one-quarter (26.1%) of female caregivers were daughters-in-law, while a few male caregivers were sons-in-law. In formal care services, female caregivers were more likely to use a day care/service, while male caregivers were more likely to use home help or home-visit nursing care. No significant differences were noted between them in depressive mood according to the GDS-15. According to the nurse’s subjective assessment, male caregivers were less likely to use sufficient formal or informal support or to have good health. No differences were found between male and female caregivers in levels of burden according to the J-ZBI or nurse’s subjective assessment.

Table 3.  Gender differences in main caregiver characteristics
VariableCategoriesMale caregiver N %, mean ± SD (range)n = 399Female caregiver N %, mean ± SD (range)n = 1193P-value
  1. The χ2-test for categorical variables or the unpaired t-test for continuous variables was conducted between male and female caregiver groups. GDS, geriatric depression scale; NS, not significant.

Age (years) 68.3 ± 12.7 (31–91) 62.5 ± 12.1 (31–93) <0.001
KinshipSpouse23458.641735.0<0.001
Child14335.841935.1 
Daughter/son-in-law51.331126.1 
Sibling82.0272.3 
Other92.3181.5 
Unknown00.010.1 
Types of care service useDay care/service16641.658649.1 0.009
Home-visit rehabilitation317.8907.5NS
Home-visit bathing4611.516513.8NS
Short stay379.314211.9NS
Home help21152.945137.8<0.001
Family physician home-visit25664.270759.3NS
Home-visit nursing care23258.160951.0 0.014
Housing adjustments9323.329724.9NS
Care implements rental23759.477064.5NS
Depressive mood
 GDS-15 5.5 ± 4.0 (0–15) 5.1 ± 3.9 (0–15) NS
Nurse’s assessment
Use of care service by caregiverSufficient15739.353144.5NS
Average18947.454545.7 
Insufficient5313.31159.6 
Unknown00.000.0 
Caregiving by familySufficient16741.965655.0<0.001
Average18345.944637.4 
Insufficient4711.8857.1 
Unknown20.500.0 
Caregiver’s healthExcellent14135.352243.8<0.001
Normal19348.452944.3 
Below standard6315.813511.3 
Unknown20.500.0 

Multivariable analyses

A multiple regression analysis was carried out to more systemically examine the relations between sex and J-ZBI while adjusting for differences in baseline variables, in which statistically significant differences were detected between the male and female caregiver groups. The multivariable-adjusted results of the J-ZBI are shown in Table 4. Even after adjusting for these baseline variables, there were no significant differences between the two groups in the J-ZBI.

Table 4.  Gender differences in caregiver burden and depressive mood
VariableCategoryMale caregiver n%, mean ± SD (range)n = 399Female caregiver n%, mean ± SD (range)n = 1193POdds ratio unadjusted95% CIOdds ratio adjusted for age95% CIOdds ratio adjusted for age and other variables95% CI
  • Controlling for dependent’s age, marital status, number of residents, quality of family relationship, cognitive heart failure, ulcer disease, peripheral vascular disease, cerebrovascular disease person in charge of medication, auditory capacity, food preparation, home maintenance, laundry, caregiver’s age, kinship, use of daycare/service, use of home help, use of home-visit nursing care, caregiving by family, and caregiver’s health status.

  • The χ2-test for categorical variables or the unpaired t-test for continuous variables was conducted between male and female caregiver groups. Multiple logistic regression was used to examine the association between dependent and caregiver characteristics and the Japanese version of the Zarit Burden Interview (J-ZBI). CI, confidence interval; NS not significant.

Caregiver burden
J-ZBI 26.0 ± 18.5(0–81) 27.3 ± 17.6(0–84) NS1.0040.997–1.0111.0050.998–1.0121.0040.995–1.012
Nurse’s assessment
 Severe11328.327423.0NS      
 Moderate21553.971559.9       
Light 6917.319616.4       

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Characteristics of the study population

The findings of the present study were similar to a few previous studies,3,5 namely that the dependents of female caregivers were more likely to be men and older. In addition, they had more residents than the male caregivers’ dependents. In the caregivers’ characteristics, daughters-in-law constituted 26.1% of the female caregiver group, while spouses constituted the majority of the male caregiver group. It is possible that the kinship difference was related to the differences between the two groups in dependents’ age, sex or number of residents.

Cognitive function is a major predictor of caregiver burden.15–18 A few studies have suggested that male caregivers are less competent at providing care for elderly people with dementia and are more likely to reject the idea of doing it at home.15,19 Thus, we estimated that male caregivers cared for fewer cognitively impaired elderly with problematic behaviors than female caregivers.3 However, in our study, there was no significant difference between the two caregiver groups in terms of dependents’ cognitive impairment and behavioral disorders.

In addition, some studies have suggested that there is a strong relation between depression and sex.20,21 However, no significant differences were found in the dependents. The dependents in the female caregiver group had graver illnesses and greater difficulty in taking medicine by themselves, but this may be due to the fact that they were generally older than the dependents under the care of male caregivers.

The ADL of the dependents in the male and female caregiver groups were matched, except for auditory capacity. Dependents in the female caregiver group were more dependent in IADL. A good explanation for this is that the male dependents were generally unskilled22 and more female caregivers cared for a male dependent than male caregivers.

As for the characteristics of the caregivers, consistent with previous studies,3–5 male caregivers were more likely to be older than their female counterparts. Also, as mentioned earlier, there was a kinship difference between the male and female caregiver groups. According to previous studies,17,23 the differences in age and kinship should be taken into account in analyzing our results.

In items of care services, consistent with previous studies, the male caregiver group was more likely to use home help.3,19 It is generally believed that men are less experienced with housework3,7 and our results probably reflect this situation. In addition, female caregivers were more likely to use a day care/service in our study. Sugiura et al. and Colline et al. previously explained that women tended to prefer respite care.3,6,22 Our results seem to support their suggestions. Contrary to what might be expected, more frequent use of home-visit nursing care by male caregivers was observed in this study. Male caregivers were less likely than female caregivers to help an older person with different types of illnesses who may need more nursing care. However, to our knowledge, few studies have so far dealt with this issue.7 Additional studies are needed to obtain a more accurate appraisal of the gender differences in the use of in-home care.

Inconsistent with earlier studies,3,24 which found that female caregivers showed a higher depression rate than male caregivers, we detected no significant difference in GDS-15 in this study. In addition, the nurses’ subjective assessment in this study showed that male caregivers used less formal or informal care, and that male caregivers were in worse health. It is possible that this had a negative effect on the male caregivers, resulting in a higher depressive mood, because there is a strong relation between caregiver burden and depression.20,21,25 However, the GDS-15 was developed to assess the depressive mood of the elderdy26 and not that of a younger population. We should think of this result only as a suggestion.

Gender differences in caregiver burden

This study focused on differences in caregiver burden according to gender. Our results, regardless of adjusting, did not reveal any difference between male and female caregivers with respect to caregiver burden. This finding supports the result of Aoki et al.’s study5 and differs from various other studies which suggested that female caregivers showed more caregiver burden than their male counterparts.3,6–11 Our results suggest that further studies are needed to prove the gender difference in caregiver burden, at least in Japan. In Japan, the public long-term care insurance system which was implemented in 2000 provides a care-management system by professional care managers.27,28 Care management facilitates the selection of appropriate care services for elderly people among available care services provided in the community based on a care need assessment.28 A care manager needs to monitor a dependent’s physical and mental condition to assess the latest care need as occasion demands.27,28 Therefore, the system provides for a high level of care and helps caregivers cope with stress, giving them relief from caregiver burden.29 It is possible that the care management system lessened the female caregiver burden and narrowed the gender gap in caregiver burden. Moreover, female caregivers reportedly tend to seek informal support from family and neighbors.3,5 We did not investigate the use of informal care, except family care, and therefore we were unable to determine the extent to which caregivers were given informal support by care providers except family.

Study limitation

The current study has several limitations. Although the NLS-FE is a large-scale observational study, it does not include the complete spectrum of elderly patients in the Nagoya area. In addition, the selection of subjects was somewhat biased because the participants were groups of users of home nursing stations using home visiting nurses or care planning services.

Another limitation is that we requested that each station perform its own evaluation due to a shortage of staff and the large quantity of settings. This may have biased the assessors’ evaluation and limited the validity of the results, including the nurses’ subjective assessment.

Finally, this study is an analysis of data from a large-scale study. Therefore, our database does not always capture the full extent of the dependents’ and caregivers’ characteristics needed to obtain a precise analysis. A lack of data concerning caregiving period, caregiving hours per day or details of required care weakened the impact of our findings.23,30

CONCLUSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

We conducted a subanalysis of a large scale observational study in Japan. Our results indicated that there were no differences in caregiver burden between male and female caregivers. Further studies are needed to confirm whether or not gender differences do in fact exist.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

We are grateful to all participants in this study. We also thank Ms. N. Sano for her editorial work.

Conflict of interest declaration

The authors declare that they have no competing interests.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES
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    Morimoto T, Schreiner AS, Asano H. Caregiver burden and health-related quality of life among Japanese stroke caregivers. Age Ageing 2003; 32: 218223.
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