Caregiver Burden and the Related Factors Among Family Caregivers of Older Persons With Schizophrenia: A Mixed Methods Study

ABSTRACT

Background

Schizophrenia is a chronic health condition that poses unique challenges for patients and their family caregivers. This study assessed the association between caregiver burden, sociodemographic characteristics and psychological factors among family caregivers of older persons with schizophrenia.

Methods

A mixed methods design was employed in this study. Three hundred and forty respondents were purposively selected to participate in the quantitative aspect of the survey, whereas 20 caregivers were purposively selected to participate in the qualitative phase. The Zarit Burden Interview Scale and Hospital Anxiety and Depression Scale were used to collect quantitative data from family caregivers, and qualitative data were collected through face‐to‐face, in‐depth interviews using a semi‐structured interview question guide. The qualitative responses were audio‐recorded and transcribed, and the cleaned transcribed data were transferred to Atlas.ti Scientific version 24 for coding the themes and subthemes. SPSS version 29 was used to analyse the cleaned, sorted and coded quantitative data at a statistically significant level of p ≤ 0.05.

Results

The results showed that most family caregivers (60%) were female, aged between 17 and 64 years. Over half (52.6%) of the caregivers experienced severe caregiver burden. An ordinal logistic regression analysis to predict caregiver burden found that several factors were linked to lower caregiver burden, including older age (OR = 0.75, p = 0.042), certain living arrangements (OR = 0.51, p = 0.037) and longer caregiving duration (OR = 0.65, p < 0.001). In contrast, higher burden was strongly associated with depression (OR = 10.39, p < 0.001), anxiety (OR = 2.99, p < 0.001) and being married (OR = 1.65, p = 0.028). Qualitative findings revealed that caregivers experienced profound emotional distress, including anxiety and depression, and significant financial strain due to medication costs and transportation expenses. Qualitative interviews have highlighted emotional distress, financial strain and social isolation as core challenges.

Conclusion

There is a need to provide psychological and social support for family caregivers of older persons with schizophrenia. The government should consider subsidising medication and care costs, similar to existing models for TB and HIV treatments in Nigeria.

Implications for Practice

Family caregivers, especially women and those aged 53–64 years, experience a severe burden. Providing psychological support services, such as counselling and stress management, can help mitigate emotional distress.

Summary.

• What does this research add to existing knowledge in gerontology?

  • ○
    This study highlights the unique challenges faced by caregivers of older persons with schizophrenia in a low‐resource setting such as Southwest Nigeria.
  • ○
    A key finding was the significant financial strain experienced by caregivers, suggesting that socio‐economic disadvantages may outweigh protective factors like education.
  • ○
    This study challenges conventional caregiving paradigms by demonstrating that caregiving burdens in low‐income settings differ markedly from those in high‐resource environments, particularly in terms of financial and emotional stress.
• What are the implications of this new knowledge for nursing care for and with older persons?

  • ○
    Nurses should recognise that family caregivers, especially women and those aged 53–64 years, are vulnerable to emotional, financial and physical stress.
  • ○
    Caregivers should be supported by nursing programs that offer emotional counselling, stress management and financial assistance.
  • ○
    Community‐based education and training for caregivers can also improve their capacity to manage schizophrenia effectively.
• How could the findings influence practice, education, research and policy?

  • ○
    The study findings highlight the essential need for clinical practice involving holistic caregiver support for the financial and emotional well‐being of both patients and family caregivers.
  • ○
    The findings also offer evidence to guide policymakers in Nigeria towards developing mental health reforms, including subsidised treatment and respite services for caregivers.
  • ○
    Training programs should be developed with content tailored to the specific needs of caregivers, particularly female and middle‐aged family members.
  • ○
    Future studies should evaluate the effectiveness of intervention models developed to reduce the caregiver burden.

1. Introduction

Family members of people with schizophrenia play a crucial yet often unrecognised role in community‐based care, as they provide essential support to their loved ones (Yu, Tang, et al. ²⁰¹⁸). The shift from institutional to family‐based care has increased the caregiving responsibility, especially in regions with limited mental health infrastructure (Rahmani et al. 2022; Rosato et al. ²⁰¹⁹; Yu, Tang, et al. ²⁰¹⁸). Family caregivers face a range of physical, psychological, social and financial challenges that may compromise their biopsychosocial well‐being. Caregiver burden is a multidimensional strain (psychological, emotional, social, financial and physical) experienced by caregivers in their role (Secinti et al. 2023). Physical challenges may arise from the severe side effects of certain psychotropic medications, such as antipsychotics, which restrict or impede the patient's ability to engage in self‐care and mobility, necessitating additional physical assistance from caregivers (Iseselo and Ambikile 2017; Morrison and Stomski ²⁰¹⁷; Zhou et al. ²⁰²²). Psychological challenges include emotional detachment, compassion fatigue, emotional exhaustion, hopelessness, feelings of inadequacy and loss of identity and motivation. Caregivers may feel trapped in multiple roles or scapegoated by other family members (Iswanti et al. 2023; Peng et al. ²⁰²²; Rahmani et al. ²⁰¹⁸; Soni et al. ²⁰²⁴). For example, studies of female spousal caregivers revealed that women caring for husbands with schizophrenia often experience significant emotional distress (Liu et al. 2020; Rahmani et al. ²⁰¹⁸; Sharif et al. ²⁰²⁰).

Socially, caregivers report disrupted family relationships, social withdrawal and stigma. They often feel powerless and unsupported (Mata et al. 2023; Sharifi et al. ²⁰²³). The extent of caregiver burden is influenced by factors such as the severity of the patient's symptoms, satisfaction with healthcare services, communication dynamics within the family, coping strategies and the availability of social support (Cechnicki et al. 2023; Kumar and Saini ²⁰¹³; Sharifi et al. ²⁰²³; Yu et al. ²⁰¹⁷). Demographic factors, including age, sex, occupation, income, marital status, relationship to the patient and illness duration, are also associated with caregiver burden (Mata et al. 2023; Tabassum et al. ²⁰²⁴; Yu, Tang, et al. ²⁰¹⁸). In many studies, financial hardship consistently emerges as a significant source of strain, often reducing caregivers' quality of life (QOL) (Tabassum et al. 2024; Yu, Zhou, et al. ²⁰¹⁸).

In Nigeria, cultural norms place the burden of long‐term care on families due to limited access to public mental health services, increasing the stress on caregivers (Lasebikan and Ayinde 2013; Oloniniyi et al. ²⁰¹⁹). The high cost of psychotropic medications and transport to healthcare facilities imposes financial pressure, especially on families caring for older adults who may also experience age‐related decline (Oloniniyi et al. 2019). Mental illness stigma in Nigerian society further isolates caregivers and exacerbates their burden (James et al. 2019). Previous Nigerian studies have documented various types of burden experienced by caregivers of people with schizophrenia (Inogbo et al. 2017; Ofovwe and Osasona ²⁰²²; Okafor and Monahan ²⁰²³; Onuorah et al. ²⁰²³). Reported prevalence rates for caregiver burden in Nigeria are among the highest globally, 85.3%–90% for objective burden and 84.2%–88% for subjective burden (Lasebikan and Ayinde 2013; Okafor and Monahan ²⁰²³). These rates are much higher than those reported in middle‐ and high‐income countries, which range from 38% to 66% (Durmaz and Okanlı 2014; Rahmani et al. ²⁰²²; Tabassum et al. ²⁰²³; Yu et al. ²⁰¹⁷). This disparity highlights the influence of limited mental health infrastructure, out‐of‐pocket healthcare costs, and cultural expectations in low‐resource settings.

These factors create a unique caregiving environment that differs from high‐resource settings, where formal support and insurance frequently ease caregiver burden. Therefore, this study aimed to assess the burden experienced by family caregivers of older persons with schizophrenia and to explore the factors associated with this burden. We employed a convergent parallel mixed methods design, integrating quantitative surveys to measure burden levels and qualitative interviews to capture the experiences of caregivers. The study addressed the following questions: What are the types of burdens experienced by family caregivers of older persons with schizophrenia in Nigeria? What is the level of caregiver burden experienced by the family caregivers of older persons with schizophrenia in Nigeria? We examined the associations between caregiver burden, socio‐demographic characteristics and psychological factors (specifically anxiety and depression) among family caregivers of older adults with schizophrenia.

2. Materials and Methods

2.1. Research Design

We employed a convergent parallel mixed methods design to assess caregiver burden among family caregivers of older persons with schizophrenia in Southwest Nigeria. This design integrated quantitative and qualitative approaches to address the research questions (Creswell and Clark 2017). The quantitative component measured the level of caregiver burden and its association with sociodemographic factors using standardised scales, while the qualitative component explored caregivers' experiences and the types of burdens they faced through in‐depth interviews. We selected this approach to capture both measurable levels of burden and the contextual, personal experiences of caregiving. Quantitative methods addressed the level and factors of caregiver burden, while qualitative methods explored the types and experiences of burden. Data were collected concurrently, analysed separately and integrated during the interpretation phase to corroborate findings and enhance the depth of the results. The qualitative sample comprised a subset of the quantitative sample to ensure consistency.

2.2. Research Setting

The study was conducted in three randomly selected states in Southwest Nigeria, Lagos, Ogun and Ondo, with mental healthcare facilities. Nigeria is divided into six geo‐political zones, each with distinct ethnic and cultural characteristics: Southwest, Southeast, South–South, North Central, Northeast and Northwest. The Southwest zone includes the states of Oyo, Ogun, Osun, Ekiti, Ondo and Lagos. Mental health facilities included in this study were designated as Hospital A, Hospital B and Hospital C.

2.3. Study Population

The study population consisted of family caregivers of older individuals (aged 60 years or older) diagnosed with schizophrenia for at least 3 months, as confirmed by medical records in the selected mental health facilities. Caregivers were eligible if they were 18 years or older, provided unpaid care (as spouses, adult children or other relatives), and could read and speak English. We excluded caregivers of individuals younger than 60 years, those caring for patients with other psychiatric disorders and those receiving payment for caregiving.

2.4. Sample Size and Sampling Method

The sample size was estimated with the Cochrane formula n = Z ² _(1‐a/2) pq/d ² (where Z(1 − a/2) = 1.96 at 95% confidence; p = proportion of caregivers with moderate–severe burden, q = 1 − p; and d = absolute allowable error (precision)). We assumed the proportion of family caregivers of older people with schizophrenia who were moderately to severely burdened, maximum variability, p = 0.5, q = 0.5 and a precision (d) of ±6%. This resulted in a final sample size of 360 respondents for the quantitative component. For the qualitative aspect of the study, 20 participants were selected across the study areas. The study participants were selected through a diverse case sampling method to ensure a wide range of perspectives (Suri 2011), as they provided unique insights unavailable from other sources (Polit and Beck 2021).

2.5. Research Instrument

A self‐designed instrument to elicit demographic information about the participants and two standardised instruments was used.

2.5.1. Socio‐Demographic Questionnaire

The socio‐demographic questionnaire was a self‐designed instrument to gather key background information from family caregivers. It included structured questions on variables such as gender, age (categorised into ranges), level of education, marital status, living situation, relationship to the care recipient, ethnicity, duration of caregiving (in years) and monthly income (in Nigerian Naira). Responses were primarily collected via categorical options to facilitate ease of completion and analysis.

2.5.2. Zarit Burden Interview Scale (ZBI‐22)

The primary outcome was measured using the Zarit Burden Interview Scale (ZBI‐22), a self‐reported instrument developed by Zarit et al. (1980). It consists of 22 items scored on a 5‐point Likert scale ranging from 0 (never) to 4 (nearly always). The total score ranged from 0 to 88, with higher scores indicating a higher burden. As Zarit et al. (1980) recommended, the sum of the responses should be used to determine caregiver burden. Scores of 0–20 indicate little or no burden, 21–40 indicate mild to moderate burden, 41–60 indicate moderate to severe burden, and 61–88 indicate severe burden.

2.5.3. Hospital Anxiety and Depression Scale (HADS)

Psychological distress, including symptoms of anxiety and depression, was measured using the HADS to explore its associations with burden levels. The Hospital Anxiety and Depression Scale (HADS) consists of seven items measuring anxiety and depression (Snaith and Zigmond 1994). This scale assesses the emotional well‐being of family caregivers. It is a 4‐point Likert scale that was used for each subscale, ranging from 0 (‘not at all’) to 3 (‘most of the time’). Items with positive wording (e.g., ‘I still enjoy the things I used to enjoy’) received reverse scoring, and a higher score indicated a more severe disorder, ranging from 0 to 21. As defined by Snaith and Zigmond (1994), a score of 8–10 is considered mild, 11–15 is moderate and ≥ 16 is severe. We utilised standardised tools with established validity: the Zarit Burden Interview scale (ZBI‐22) and the Hospital Anxiety and Depression Scale (HADS). Each scale showed good internal consistency, with Cronbach's alpha of 0.95 for ZBI‐22, 0.92 for HADS‐Depression and 0.89 for HADS‐Anxiety, indicating high reliability.

2.5.4. Semi‐Structured Interview Guide

We also used a semi‐structured interview guide for qualitative data collection. Questions explored caregivers' experiences, challenges and burdens. For example, one core question was ‘Can you share your experience as you care for your loved one?’ Follow‐up questions were asked to gain deeper insights (see Data S1: Interview Guide).

2.6. Ethical Consideration

The Humanities and Social Sciences Research Ethics Committee of the University of KwaZulu‐Natal approved the study with ref. no: HSSREC/00006651/2024. Clearance to carry out the study was also secured from all three hospitals used in the study: the Neuropsychiatric Hospital, Aro, ref. no: NHREC/FNPH‐HREC/29/08/2023; the Neuropsychiatric Hospital, Ondo, ref. no: the OSHREC 05/07/2023/565 and the Federal Neuropsychiatric Hospital, Yaba, ref. no: FNPHY/HREC/2023/001/08/105. All participants received detailed study information and provided written informed consent. They were assured of their right to withdraw at any point without penalty. To maintain confidentiality, we anonymised and secured the data using password‐protected software. No participant reported psychological harm during data collection.

2.7. Data Collection Process

Data collection occurred over 5 months and was carried out by two trained psychiatric nurse research assistants at each site. These assistants reviewed patients' medical records to confirm schizophrenia diagnoses and identify eligible caregivers. For the quantitative phase, 360 caregivers were approached during clinical follow‐up visits, and 340 returned complete questionnaires (response rate: 94.4%). For the qualitative phase, 20 caregivers were selected from the survey pool to represent diverse caregiving experiences. Interviews were conducted by the lead researcher, a psychiatric nurse trained in qualitative methods, using a semi‐structured guide. Sessions lasted 20–25 min and took place at hospitals or participants' homes, based on their preference. Interviews were audio‐recorded with consent and later transcribed verbatim for analysis.

2.8. Data Management

2.8.1. Quantitative Data Management

We manually checked complete questionnaires and entered data into SPSS version 29. Two independent researchers performed double‐entry verification to ensure accuracy. Incomplete responses (20 out of 360) were excluded. We anonymised all data, removed identifiers and secured the electronic database with password protection. Paper records were stored in locked cabinets at the host institution.

2.8.2. Qualitative Data Management

We transcribed all 20 interviews verbatim and cross‐verified them with audio recordings. Identifiers were removed from transcripts before analysis. We uploaded the cleaned data into Atlas.ti version 24.0.0 for coding. All qualitative files were securely stored on an encrypted drive, with backup copies kept offsite. An audit trail documented transcription, coding and theme development.

2.9. Trustworthiness of Qualitative Data

Trustworthiness ensures that the results of qualitative studies are reliable and valid (Bryman 2016). Credibility, confirmability, dependability and transferability are standards of trustworthiness (Lincoln and Guba 1985). To ensure credibility, we used expert peer reviews, member checks and reflexivity. Participants were also asked to attest to the information gathered during the data‐gathering interviews. Data triangulation and precise reporting of participants' exact words were used to ensure the validity of the data. Two expert researchers who were not involved in the study evaluated the suitability of the methodology. The study design is detailed, and the data analysis method and a thorough explanation of the study settings are provided. Comprehensive details about transferability were provided, such as an explanation of the study design, methods, study areas, and participants.

2.10. Data Analysis

2.10.1. Quantitative Data Analysis

The quantitative data were screened for cases and variables to avoid missing data and outliers. We coded and scored the cleaned data by adding numbered responses to individual items. Descriptive statistics (frequency and percentages) were used to present the sociodemographic characteristics of the caregivers. The study hypothesis was analysed using an ordinal logistic regression at a significance level of 0.05. Statistical Package for the Social Sciences (SPSS version 29; IBM Corp. ²⁰²²) was used to analyse the cleaned, sorted and coded quantitative data at a statistically significant level of p ≤ 0.05.

2.10.2. Qualitative Data Analysis

Content analysis was performed to analyse the data, and data management was performed using Atlas.ti Scientific Version 24.0.0 (ATLAS.ti Scientific Software Development GmbH ²⁰²⁴). The qualitative data analysis was conducted by a trained psychiatric nurse with expertise in qualitative research methods. The recorded interviews were transcribed verbatim, supplemented by notes taken during the interview sessions. The researcher was thoroughly familiarised with the data through repeated listening to audio recordings and reading transcripts. To ensure anonymity, the participants' identities and location details were removed from the transcripts before analysis. The cleaned transcripts were uploaded into qualitative data analysis software for exploration, allowing the researcher to become acquainted with the data and understand how participants responded to the interview questions. Interview questions were reorganised for each participant to facilitate coding. Initial codes were systematically generated based on the research questions and participants' narratives. Related codes were then synthesised into broader themes, with subthemes identified to capture essential aspects of the data. Themes and subthemes were subjected to iterative review and refinement throughout the analysis to ensure accuracy and coherence. To ensure the credibility of the findings, member checking was conducted, where participants were invited to review and confirm the accuracy of the themes derived from their interviews. The co‐author independently reviewed the identified themes and subthemes, providing feedback to validate the analysis. Also, the researcher maintained a detailed audit trail, documenting all coding and theme development steps to enhance transparency and replicability.

2.10.3. Mixed Analysis

Quantitative and qualitative data were analysed separately, then integrated during the interpretation phase to address the research questions comprehensively. Quantitative findings on burden levels (e.g., ZBI‐22 and HADS scores) were triangulated with qualitative themes (e.g., psychological impact, financial burden) to validate and contextualise the results.

3. Results

3.1. Demographic Characteristics of the Respondents

Of the 360 questionnaires distributed, 340 were returned fully completed, yielding a response rate of 94.44%, and 20 were returned as invalid. The results showed that most family caregivers of older people with schizophrenia were female (60%) and aged between 17 and 64 years. Most were middle‐aged, 29–40 years old, almost three‐quarters (71.5%) had attained higher education, and over half were married and living with a partner (58.8%). Most family caregivers cared for the patients for 1–5 years and had a monthly income between ₦100,001 and ₦500,000 (Table 1). The qualitative data involved 20 family caregivers aged between 17 and 68, with various occupations, including students, teachers, traders and retirees. The caregiving duration varied widely, ranging from 3 months to over 30 years, and the participants had different educational backgrounds, from secondary school to PhD level. Eleven caregivers lived with the care recipients, reflecting varying caregiving involvement and intensity (Table 2).

TABLE 1.

Socio‐demographic characteristics of participants (N = 340).

Variables	f	%
Gender
Male	136	40
Female	204	60
Age
18–28	120	35.3
29–40	160	47.1
41–52	13	3.8
53–64	47	13.8
Level of education
Higher education	243	71.5
Secondary	86	25.3
Below secondary	11	3.2
Marital status
Single	127	37.4
Married living with a partner	200	58.8
Separated/divorced	7	2.1
Widowed	6	1.8
Living situation
Lives alone	76	22.4
Lives with others	264	77.6
Caregiver relationship
Spouse	64	18.8
Children	169	49.7
Friend	11	3.2
Co‐resident	5	1.5
Other relatives	91	26.8
Ethnicity
Yoruba	187	55.0
Igbo	41	12.1
Delta	43	12.6
Hausa	28	8.2
Edo	21	6.2
Other	20	5.9
Period of care (year)
1–5	291	85.6
6–10	43	12.6
11–16	6	1.8
Monthly income
10,000–100,000	141	41.5
100,001–500,000	196	57.6
> 500,000	3	0.9

TABLE 2.

Participant characteristics.

Participant	Age	Location	Relationship	Occupation	Duration of care	Level of education	Living situation
P1	26	Ilaje	Mother	Student	12 years	Undergraduate	Not living with the patient
P2	32	Irele	Grandma	Trader	2 years	Tertiary	Not living with the patient
P3	37	Ondo	Mum	Auxiliary Nurse	1 year	Tertiary	Not presently living with the patient
P4	68	Abeokuta	Senior Brother	Retiree	3 years	Secondary school	Living with the patient
P5	43	Ogun	Grandma	Company Worker	6 ½ months	technical college	Living with the patient
P6	44	Ogun	Mother	Pop	more than 30 years	HND	Living with the patient
P7	38	Nigeria	Mother	Student	6 months	Secondary school	Living with the patient
P8	34	Ogun	Sister	Business	15 years	Secondary	Living with the patient
P9	20	Ogun	Sister	Student	2 years	Undergraduate	Not currently living with the patient
P10	21	Oka Okoko	Father's Patient	Student	4 years	Tertiary	Living with the patient
P11	61	Ogun	Mother	Civil Servant	4 years	Tertiary	Not living with the patient
P12	68	Yoruba	Younger Sibling	Retiree	25 years	Graduate	Not living with the patient
P13	40	Ogun	Mother	Teacher	30 years	Graduate	Not living with the patient
P14	40	Ondo Town	Daddy	Fashion Designer	16 years	Secondary	Not living with the patient
P15	39	Ile Oluji	Mother	Bag Making	3 years	HND	Not living with the patient
P16	17	Eti Osa	Grandpa	Student	20 years	Secondary school	Living with the patient
P17	60	Edo State	Husband	Teacher	3 months	Secondary school	Living with the patient
P18	52	Delta	Mother	Teacher	6 years	Tertiary	Not living with the patient
P19	63	Yoruba	Spouse	Lecturer	4 years	PhD	Living with the patient
P 20	28	Ibadan	Father	Trader	5 years	Tertiary	Living with the patient

3.2. Levels of Caregiver Burden

Findings revealed that family caregivers of older people with schizophrenia reported moderate to high levels of burden across all domains. Financial strain (M = 3.67, SD = 1.37), emotional burden (M = 3.72, SD = 1.06) and relationship burdens (M = 3.77, SD = 1.02) were particularly pronounced (Table 3). Caregiver burden levels were assessed using the ZBI‐22, while psychological distress (anxiety and depression symptoms) was evaluated with the HADS as potential predictors of burden. Based on the Zarit Burden Interview (ZBI‐22), 52.6% of caregivers experienced severe burden. Moderate levels of psychological distress, 57.6% anxiety and 37.6% depression indicate emotional symptoms that strongly predict a higher burden (Table 4).

TABLE 3.

Types of burden experienced by the family caregivers (N = 340).

Domain	Item	M	SD
Relationship burden	I feel I should do more for my relative	3.77	1.02
	Relatives expect to depend only on me	3.55	1.29
	Having less privacy than I would like	3.37	1.3
	The relative asks for more help than needed	3.36	1.18
Emotional well‐being	Feel I could do a better job caring for my relative	3.72	1.06
	Feel strained when with my relative	3.30	1.33
	I don't have enough time for myself	3.33	1.18
	Overall feeling of burden	3.31	1.13
Financial burden	Don't have enough money to care for my relative	3.67	1.37
Loss of control	Feel uncertain about how to care for my relative	3.53	1.3
	Worried about what the future holds for my relative	3.51	1.2
	Feel I can't continue caregiving much longer	3.43	1.29
Social burden	My social life has suffered due to caregiving	3.43	1.42
	Feel uncomfortable having friends over	3.30	1.37
	Caregiving negatively affects my other relationships	3.24	1.38
Psychological	Hospital Anxiety and Depression Scale
Anxiety	f (%)	275 (80.8)
Depression	f (%)	263 (77.3)

Note: Items are ordered by mean score (M) within domains.

Abbreviation: SD, standard deviation.

TABLE 4.

Levels of caregiver burden and psychological distress among family caregivers.

	Normal		Mild		Moderate		Severe
	f	%	f	%	f	%	f	%
Zarit caregiver burden	64	18.8	54	15.9	43	12.6	179	52.6
Psychological distress
Anxiety	65	19.1	50	14.7	196	57.6	29	8.5
Depression	77	22.6	70	20.6	128	37.6	65	19.1

3.3. Predictors of Caregiver Burden

This study tested the hypothesis that there was a significant association between caregiver burden, sociodemographic characteristics and psychological factors (specifically anxiety and depression at p ≤ 0.05). An ordinal logistic regression analysis was conducted to identify predictors of caregiver burden levels. The Brant test confirmed that the proportional odds assumption was satisfied, χ²(20) = 23.99, p = 0.243, indicating that the effects of the predictors were consistent across all burden category thresholds. Variance inflation factor (VIF) values for all predictors were below 2, which suggests the absence of multicollinearity. The model demonstrated excellent fit, explaining 30% of the variance in caregiver burden levels (McFadden's pseudo‐R ² = 0.30). The likelihood ratio test indicated a statistically significant improvement over the null model, χ²(10) = 248.74, p < 0.001, with favourable parsimony indices (AIC = 597.80, BIC = 647.57; log‐likelihood = −285.90). All threshold parameters were statistically significant (p < 0.05), confirming that the burden categories were appropriately differentiated.

Psychological factors emerged as the most influential predictors. Higher depression scores were strongly associated with increased odds of elevated burden (β = 2.34, SE = 0.27, z = 8.78, p < 0.001, OR = 10.39, 95% CI [6.16, 17.53]), such that each one‐unit increase in depression symptoms was linked to more than a tenfold increase in the odds of reporting a higher burden category. Similarly, higher anxiety levels significantly increased the likelihood of greater burden (β = 1.09, SE = 0.23, z = 4.74, p < 0.001, OR = 2.99, 95% CI [1.90, 4.69]). Among demographic variables, older age was significantly associated with lower odds of higher burden (β = −0.29, SE = 0.14, z = −2.03, p = 0.042, OR = 0.75, 95% CI [0.56, 0.99]), suggesting a potential protective effect. Being married, compared to being single, predicted a higher burden (β = 0.50, SE = 0.23, z = 2.20, p = 0.028, OR = 1.65, 95% CI [1.05, 2.57]). Living apart from the care recipient was also associated with reduced odds of higher burden (β = −0.68, SE = 0.33, z = −2.09, p = 0.037, OR = 0.51, 95% CI [0.27, 0.96]).

In contrast, gender (β = 0.34, SE = 0.26, z = 1.30, p = 0.194, OR = 1.41, 95% CI [0.84, 2.35]) and educational attainment (β = −0.02, SE = 0.24, z = −0.09, p = 0.927, OR = 0.98, 95% CI [0.61, 1.57]) were not statistically significant predictors. Monthly income also did not reach significance (β = 0.18, SE = 0.12, z = 1.47, p = 0.141, OR = 1.20, 95% CI [0.94, 1.52]). Within caregiving context variables, longer duration of the caregiving role was significantly associated with lower odds of higher burden (β = −0.44, SE = 0.12, z = −3.59, p < 0.001, OR = 0.65, 95% CI [0.51, 0.82]). However, the caregiver's relationship with the patient was not a significant predictor (β = −0.21, SE = 0.15, z = −1.42, p = 0.155, OR = 0.81, 95% CI [0.61, 1.08]). These results indicate that depression and anxiety are the predominant predictors of caregiver burden, with selected demographic and caregiving context variables such as age, marital status, living situation and caregiving duration also contributing meaningfully. Other factors, including gender, education, monthly income and caregiver relationship, appear to have limited influence in this model (see Table 5).

TABLE 5.

Ordinal logistic regression predicting caregiver burden levels.

Predictor	β (SE)	z	p	OR [95% CI]	VIF
Socio‐demographics
Age	−0.29 (0.14)	−2.03	0.042	0.75 [0.56, 0.99]	1.49
Gender	0.34 (0.26)	1.3	0.194	1.41 [0.84, 2.35]	1.18
Education	−0.02 (0.24)	−0.09	0.927	0.98 [0.61, 1.57]	1.29
Marital status	0.50 (0.23)	2.2	0.028	1.65 [1.05, 2.57]	1.42
Living situation	−0.68 (0.33)	−2.09	0.037	0.51 [0.27, 0.96]	1.28
Monthly income	0.18 (0.12)	1.47	0.141	1.20 [0.94, 1.52]	1.25
Caregiving role	−0.44 (0.12)	−3.59	< 0.001	0.65 [0.51, 0.82]	1.15
Caregiver relationship	−0.21 (0.15)	−1.42	0.155	0.81 [0.61, 1.08]	1.28
Psychological factors
Anxiety level	1.09 (0.23)	4.74	< 0.001	2.99 [1.90, 4.69]	1.43
Depression level	2.34 (0.27)	8.78	< 0.001	10.39 [6.16,17.53]	1.44

Model fit statistics
Log‐likelihood	McFadden's pseudo‐R 2	Likelihood ratio	AIC	BIC
−285.90	0.30	χ2 (10) = 248.74, p < 0.001	597.80	647.57

3.4. Types of Burden Experienced

Qualitative interviews with 20 family caregivers revealed three main themes describing the types of burdens experienced: (1) Psychological and Emotional Impact of Caring, (2) Financial Burden and (3) Caregiving Satisfaction. Each theme included subthemes that provided deeper insight into caregivers' experiences Table 6.

TABLE 6.

Themes and supporting extracts on the burden of care experienced by caregivers.

Themes	Subthemes	Supporting participant extracts	Participant ID
Psychological and emotional impact of caring	Impact on Mental Health	‘I get stressed at times, and it is hard to stay calm’ ‘She can just continue to talk for about one hour non‐stop’	P1
		‘The experience is traumatic because you know your sister is living somehow’	P6
		‘Sometimes, her behaviour affects my mood, and I get frustrated’.	P4
		‘Sometimes I feel depressed and embarrassed’.	P5
	Emotional distress	‘The experience is traumatic because you know your sister is living somehow’	P6
		‘Caring for her is demanding. Sometimes she shouts or relapses’	P4
		‘When she doesn't sleep, I can't sleep’	P12
	Constant worry	‘I always think, “How is she now? What is she doing now?”’	P17
		‘I'm always afraid about the outcome of her illness’	P3
	Social sacrifices	‘It restricts my social life. I always have to stay with her’	P10
		‘I miss spending time with friends because I am always looking after her’	P3
Financial burden	Cost of treatment	‘The hike in drugs is killing… Without the medication, there's no rest’	P19
		‘Every hospital visit costs at least 50,000 Naira’	P19
		‘Private hospital admission drained our savings’	P5
		‘Between the hospital bills and medication, it's a lot of money’	P11
	Systemic barriers	‘If drugs were subsidised like HIV treatment’	P14
		‘The financial aspect is the most challenging… Over 25 years’	P6
Caregiving satisfaction	Positive aspects	‘I enjoy singing for her. It brings us joy and strengthens our bond’	P11
		‘Seeing her improvement gives me hope. My children learn compassion by watching me care for her’	P17
		‘Caring for him taught me love and patience. He's educated and friendly—we share stories’	P 8
	Relationship building	‘My children learn compassion by watching me care for her’	P17
		‘He's educated and friendly, we share stories’	P8

3.4.1. Theme 1: Psychological and Emotional Impact of Caring

Caregiving profoundly shapes the mental and emotional well‐being of caregivers, leading to stress, frustration and persistent anxiety. This theme comprised four subthemes: Impact on Mental Health, Emotional Distress, Constant Worry and Social Sacrifices, which collectively illustrate the psychological burden and social trade‐offs of caregiving.

3.4.1.1. Sub‐Theme 1.1: Impact on Mental Health

Caregivers frequently described caregiving as a source of significant stress, caused by their loved ones' unpredictable and demanding behaviours. These behaviours, such as incessant talking or unpredictable actions, led to frustration, mood disruptions and depressive symptoms. For example, one caregiver shared, ‘I get stressed at times, and it is hard to stay calm’ (P1). The participant added, ‘She can just continue to talk for about one hour non‐stop’ (P1), highlighting the mental strain. Similarly, another caregiver expressed, ‘Sometimes, her behaviour affects my mood, and I get frustrated’ (P4), and one admitted, ‘Sometimes I feel depressed and embarrassed’ (P5), underscoring the emotional weight on their mental health.

3.4.1.2. Sub‐Theme 1.2: Emotional Distress

The emotional burden of caregiving was marked by trauma, exhaustion and distress, particularly during relapses or disruptive episodes. Caregivers struggled with a sense of loss for their loved one's former self, as one articulated, ‘The experience is traumatic because you know your sister is living somehow’ (P6). Another described the physical and emotional toll of sleeplessness, stating, ‘When she does not sleep, I can't sleep’ (P12). The demands of managing relapses further intensified distress, with one caregiver noting, ‘Caring for her is demanding. Sometimes she shouts or relapses’ (P4).

3.4.1.3. Sub‐Theme 1.3: Constant Worry

Caregivers lived with ongoing anxiety about their loved one's immediate well‐being and long‐term prognosis. One caregiver explained this pervasive worry infiltrated their daily lives: ‘I always think, How is she now? What is she doing now?’ (P17). Another expressed fear about the future, saying, ‘I'm always afraid about the outcome of her illness’ (P3), reflecting the relentless concern that defined their caregiving experience.

3.4.1.4. Sub‐Theme 1.4: Social Sacrifices

The time‐intensive nature of caregiving restricts participants' social lives, limiting friendships and community engagement opportunities. Caregivers felt bound to their responsibilities, with one stating, ‘It restricts my social life. I always must stay with her’ (P10). Another echoed this sentiment, stressed, ‘I miss spending time with friends because I am always looking after her’ (P3), highlighting the social isolation that accompanied their role.

3.4.2. Theme 2: Financial Burden

The economic demands of caregiving posed a significant challenge, with costs straining their financial resources over prolonged periods. Two subthemes, Cost of Treatment and Systemic Barriers, support this theme, highlighting the direct financial burden and structural challenges caregivers face.

3.4.2.1. Sub‐Theme 2.1: Cost of Treatment

Caregivers consistently reported the high costs of medications and hospital visits, which often depleted personal savings and strained household budgets. The escalating price of drugs was a significant concern, as one caregiver noted, ‘The hike in drugs is killing… Without the medication, there is no rest’ (P19). Another quantified the expense, stating, ‘Every hospital visit costs at least 50,000 Naira’ (P19), while a third shared, ‘Private hospital admission drained our savings’ (P5). The cumulative financial burden was further emphasised by one caregiver, who said, ‘Between the hospital bills and medication, it is a lot of money’ (P11).

3.4.2.2. Sub‐Theme 2.2: Systemic Barriers

Caregivers expressed frustration with the lack of affordable treatment options and inadequate systemic support, drawing comparisons to subsidised programs for other conditions. One participant remarked, ‘If drugs were subsidised like HIV treatment’ (P14), highlighting the disparity in healthcare access. Another reflected on the long‐term financial strain, stating, ‘The financial aspect is the most challenging… Over 25 years’ (P6), underscoring the persistent economic challenges of caregiving.

3.4.3. Theme 3. Caregiving Satisfaction

Despite the significant challenges, caregivers found meaning, joy and personal growth in their roles, deriving fulfilment from their efforts. This theme includes two subthemes, Positive Aspects and Relationship Building, which capture the rewarding dimensions of caregiving.

3.4.3.1. Sub‐Theme 3.1: Positive Aspects

Caregivers highlighted moments of joy, hope and emotional connection that sustained them through difficulties. Shared activities, such as singing, fostered closeness, as one caregiver shared, ‘I enjoy singing for her. It brings us joy and strengthens our bond’ (P11). Observing improvements in their loved one's condition provided hope, with one caregiver noting, ‘Seeing her improvement gives me hope’ (P17). Another reflected on the broader influence, stating, ‘Caring for him taught me love and patience’ (P8), emphasising the personal growth of caregiving.

3.4.3.2. Sub‐Theme 3.2: Relationship Building

Caregiving heightened connections with loved ones and imparted valuable lessons to caregivers and their families. One participant observed, ‘My children learn compassion by watching me caring for her’ (P17), illustrating how caregiving experiences transcend generations. Another valued the mutual engagement with their loved one, saying, ‘He's educated and friendly, we share stories’ (P8), highlighting how caregiving fostered meaningful relationships.

3.5. Integration of Quantitative and Qualitative Findings

The integration of quantitative and qualitative findings provides a comprehensive understanding of the caregiver burden.

3.5.1. Types and Levels of Burden

The qualitative themes of psychological/emotional impact and financial burden corroborated the quantitative findings of severe burden (52.6% on ZBI‐22) and moderate anxiety/depression (57.6% and 37.6% on HADS). For example, qualitative reports of stress and financial strain aligned with high ZBI‐22 scores in emotional and financial domains.

3.5.2. Associated Factors

Quantitative associations between burden and gender, age, marital status and caregiving duration were supported by qualitative narratives, particularly from female caregivers and those with long‐term responsibilities, who described intense emotional and financial challenges.

3.5.3. Positive Aspects

The qualitative theme of caregiving satisfaction, highlighting fulfilment and relationship building, provided context for understanding resilience despite high burden levels observed in the quantitative data.

This integrated approach confirms that family caregivers of older persons with schizophrenia in Southwest Nigeria experience significant emotional, financial and social burdens, with specific demographic factors exacerbating these challenges, while also finding meaning in their roles.

4. Discussion

This study examined the types, levels and predictors of caregiver burden among family caregivers of older persons with schizophrenia in Southwest Nigeria using a convergent parallel mixed‐methods design. The integration of quantitative (ZBI‐22, HADS) and qualitative data revealed a high prevalence of burden, significant associations with selected demographic and psychological factors and multiple dimensions of burden—psychological, financial, social and relationship—alongside reported positive caregiving experiences. These findings support and expand the existing literature, especially within low‐resource settings.

4.1. Levels of Caregiver Burden

This study found that caregivers of older people with schizophrenia experienced severe burden, moderate anxiety and moderate depression. These findings are consistent with previous research in similar contexts. Lasebikan and Ayinde (2013) reported objective burden rates of 85.3%–90% and subjective burden rates of 84.2%–88% among Nigerian caregivers, whereas Ofovwe and Osasona (2022) attributed the elevated burden in Nigeria to limited mental health infrastructure.

However, the prevalence of severe burden in this study exceeds the 38%–66% reported in middle‐ to high‐income countries (Durmaz and Okanlı 2014; Rahmani et al. ²⁰²²). This discrepancy highlights the increased challenges in Nigeria, including out‐of‐pocket healthcare expenses and cultural norms that prioritise familial caregiving. The higher prevalence of anxiety may reflect caregivers' constant worry about unpredictable patient behaviours and uncertainty about the future outcomes, as qualitative narratives emphasised persistent anxiety over patient well‐being (e.g., ‘I always think, “How is she now?”’ [P17]). This suggests that anxiety may be a more immediate emotional response to caregiving demands, which calls for targeted psychological interventions alongside burden‐reduction strategies.

4.2. Predictors of Caregiver Burden

Ordinal logistic regression analysis revealed that psychological variables, particularly depression and anxiety, were the strongest predictors of caregiver burden. Each unit increase in depression symptoms was associated with more than a 10‐fold increase in the odds of experiencing a higher burden, while elevated anxiety nearly tripled these odds. These results align with Cechnicki et al. (2023) and Liu et al. (2022), who found that emotional distress amplifies the subjective experience of caregiving difficulty, particularly in resource‐constrained environments. Older age was associated with lower odds of higher burden among demographic variables, suggesting a possible protective effect due to accumulated coping strategies or adjusted expectations (Sharifi et al. 2023). Conversely, marriage predicted a higher burden, possibly reflecting increased family responsibilities and societal expectations of spousal caregiving (Qalb‐I‐Hyder et al. ²⁰²³). Living apart from the care recipient was linked to lower burden, potentially due to reduced daily exposure to caregiving demands.

Gender, educational attainment, monthly income and caregiver relationships to the patient were not significant predictors. This contrasts with studies reporting gender differences (Benallel et al. 2023; Ofovwe and Osasona ²⁰²²), which attributed a high burden among women to traditional gender roles in caregiving and protective effects of education (Sharif et al. 2020). In the Nigerian context, systemic barriers such as high medication costs and scarce mental health resources may diminish the influence of these factors. Findings revealed that longer caregiving duration predicted lower odds of higher burden, contradicting literature suggesting cumulative stress over time (Tabassum et al. 2023; Sharifi et al. ²⁰²³). This pattern may indicate adaptation, improved coping mechanisms or survivor bias, whereby only those who have successfully adjusted remain in caregiving roles for extended periods.

4.3. Types of Caregiver Burden

4.3.1. Psychological and Emotional Burden

Quantitative findings revealed a high psychological and emotional burden, with 52.6% of caregivers reporting severe burden, 57.6% moderate anxiety and 37.6% moderate depression. Qualitative data highlighted stress, frustration and trauma during patient relapses (e.g., ‘The experience is traumatic because you know your sister is living somehow’ [P6]). These findings corroborate Cechnicki et al. (2023) and Liu et al. (2022), who linked emotional burden to patient symptoms and limited social support, is also consistent with Mbadugha et al. (2023), who described similar struggles among Nigerian caregivers and reinforced the notion that persistent worry and emotional exhaustion are common in contexts where mental health services and respite care are limited.

4.3.2. Financial Burden

Financial strain emerged as a significant theme, with caregivers reporting high costs for medications and hospital visits (e.g., ‘Every hospital visit costs at least 50,000 Naira’ [P19]). This is consistent with Onyia et al. (2024) and Tabassum et al. (2024), who identified economic hardship as a critical factor in low‐income settings. The frequent comparisons to subsidised HIV treatment programs (e.g., ‘If drugs were subsidised like HIV treatment’ [P14]) mirror James et al. (2019), who noted that inadequate policy support exacerbates financial challenges for mental health care in Nigeria. The absence of subsidies for schizophrenia treatment intensifies the financial burden and may indirectly worsen psychological distress.

4.3.3. Social and Relationship Burden

Caregivers reported social isolation and disrupted family dynamics, with quantitative data showing high ZBI scores for relationship burden and qualitative narratives describing restricted social lives (e.g., ‘I miss spending time with friends’ [P3]). This corroborates Zhou et al. (2022), who found limited social interactions among schizophrenia caregivers in China. The dependency of patients on caregivers, noted in both quantitative and qualitative data, strained family relationships, aligning with Peng et al. (2022), who reported loss of personal freedom due to caregiving demands. However, the study's focus on older patients may amplify relationship burden, as age‐related comorbidities increase caregiving complexity, a factor less emphasised in studies of younger patients.

4.4. Positive Aspects of Caregiving

Despite the burdens, caregivers reported satisfaction through personal growth and strengthened relationships (e.g., ‘Caring for him taught me love and patience’ [P8]). This aligns with Peng et al. (2022) and Han et al. (2022), who identified resilience and compassion as positive caregiving outcomes. The finding of caregiving satisfaction in a low‐resource setting is notable, as it suggests that cultural values of familial duty may foster resilience, even amidst significant challenges. These mixed experiences of both burden and fulfilment show that caregiving is complex. Liu et al. (2022) described caregiver burden as a dynamic process influenced by personal views, environment and coping skills.

4.5. Relevance to Clinical Practice and Policy

These findings suggest that reducing psychological distress, particularly depression and anxiety, should be a central focus of caregiver support interventions. Strategies could include accessible counselling services, psychoeducation and structured peer‐support programs tailored to low‐resource environments. Financial aid, including subsidies for medications and transportation, is critical to reduce economic strain, as highlighted by caregivers' comparisons to HIV treatment programs. Psychiatric nurses should advocate for policy reforms to integrate mental health care into subsidised healthcare frameworks, addressing systemic barriers noted in the qualitative findings. Community‐based education programs to reduce stigma and peer support groups could mitigate social isolation and relationship burdens, enhancing caregivers' social support networks. The observed protective effects of older age and longer caregiving duration point to the potential utility of mentorship models, whereby experienced caregivers support and guide those newly assuming caregiving responsibilities.

4.6. Strengths and Limitations of the Study

This study has several strengths and limitations. The use of a mixed methods design provides a more complete understanding of caregiver burden by integrating quantitative tools (ZBI‐22 and HADS) with qualitative data, allowing for both statistical rigour and depth of context. The high response rate (94.4%) and a diverse sample of 340 caregivers across three states in Southwest Nigeria enhance the representativeness of the findings. The focus on older adults with schizophrenia fills a gap in existing literature, which often focuses on younger populations. However, the regional focus may limit the transferability of our findings to other settings with different sociocultural or healthcare dynamics. Self‐reported measures, like the ZBI‐22 and HADS, may have introduced social desirability bias, as some caregivers might underreport burden due to cultural norms around family responsibility. The exclusion of patient data, such as symptom severity, means an important factor influencing caregiver burden was not examined. Though rich in detail, the qualitative sample may not represent the full range of experiences, especially from caregivers in rural areas or those outside the formal healthcare system. The fact that qualitative and quantitative data collection were done simultaneously limited the opportunity to adapt interview questions based on emerging survey results. Future research should include patient characteristics, target rural caregivers and consider sequential mixed methods designs for greater flexibility.

5. Conclusion

This study adds to the growing body of knowledge on family caregiver burden in older persons with schizophrenia, especially in the Nigerian setting. This mixed methods study presents important and practical perspectives about family caregiver burden among family caregivers of older persons with schizophrenia, revealing significant emotional, financial and social challenges. The integration of quantitative findings showed that 52.6% of caregivers experienced severe burden, with qualitative narratives of psychological distress and financial strain, highlighting the urgent need for targeted support in low‐resource settings. While the study's geographical focus and reliance on self‐reported data may limit generalisability and introduce social desirability bias, the insights are relevant for research, education, practice, policy and sustainability. Future research should expand into other regions, incorporate patient demographic information and assess longitudinal burden trends and intervention outcomes. Educational programs tailored to caregivers and integrated into the health curriculum can improve caregiver competence and professional support. Clinically, psychiatric nurses should prioritise interventions for high‐burden groups, offering psychological services and fostering social support through community‐based initiatives. Policy responses are needed to reduce out‐of‐pocket healthcare expenses and promote access to mental health services, including subsidised medication and respite care programs. Although not a direct focus, the study also raises sustainability concerns, as limited healthcare infrastructure and frequent hospital visits contribute to caregiver stress and environmental burdens; expanding community‐based or telehealth models could support equitable and sustainable caregiving.

Author Contributions

O.J.M., W.B.N. (Supervisor): Conceptualization of the study. O.J.M.: Designed and wrote the draft with input and advice from W.B.N. O.J.M., W.B.N.: Contributed to the design and methodology. O.J.M., W.B.N.: Contributed to the design and reviewed the draft. O.J.M., W.B.N.: Contributed to the methodology and analysis. All authors read and approved the final draft.

Ethics Statement

The Humanities and Social Sciences Research Ethics Committee of the University of KwaZulu‐Natal approved the study with ref. no: HSSREC/00006651/2024. Clearance was also secured from all three hospitals used for the study: the Neuropsychiatric Hospital, Aro, with ref. no: NHREC/FNPH‐HREC/29/08/2023, the Neuropsychiatric Hospital, Ondo, ref. no: OSHREC 05/07/2023/565 and the Federal Neuropsychiatric Hospital, Yaba, with ref. no: FNPHY/HREC/2023/001/08/105.

Consent

Written and verbal consent was obtained from each respondent before the data collection. All authors have reviewed and consented to this publication.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: opn70047‐sup‐0001‐Supinfo1.docx.

Makanjuola, O. J. , and Ngcobo W. B.. 2025. “Caregiver Burden and the Related Factors Among Family Caregivers of Older Persons With Schizophrenia: A Mixed Methods Study.” International Journal of Older People Nursing 20, no. 5: e70047. 10.1111/opn.70047.

Data Availability Statement

The data for the study are available either in the manuscript or as a Data S1 accompanying this manuscript. However, further requests for data in the future should be directed to the corresponding author, who will gladly share it.