HAWASSA UNIVERSITY

COLLEGE OF MEDICINE AND HEALTH SCIENCES

SCHOOL OF NURSING

CAREGIVER BURDEN AND ITS ASSOCIATED FACTORS AMONG FAMILY

MEMBERS OF PATIENTS DIAGNOSED WITH CANCER AND WHO HAD
TREATMENT / CARE FOLLOW-UP IN ONCOLOGY UNIT OF HAWASSA
UNIVERSITY COMPREHENSIVE AND SPECIALIZED HOSPITALS IN
HAWASSA, SOUTHERN ETHIOPIA

BY:
 AMANDA ESSAYAS
 AREGA TEGEGNE
 DAWIT KASSIE
 NAHOM GEBREMEDHIN
 NETSANET GEBEYEHU

A RESEARCH PROPOSAL SUBMITTED TO HAWASSA UNIVERSITY, COLLEGE

OF MEDICINE AND HEALTH SCIENCES, SCHOOL OF NURSING IN PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF BACHELOR
SCIENCE IN NURSING.

DECEMBER, 2019
HAWASA, ETHIOPIA

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CAREGIVER BURDEN AND ITS ASSOCIATED FACTORS AMONG FAMILY
MEMBERS OF PATIENTS DIAGNOSED WITH CANCER AND WHO HAD
TREATMENT / CARE FOLLOW-UP IN ONCOLOGY UNIT OF HAWASSA
UNIVERSITY COMPREHENSIVE AND SPECIALIZED HOSPITALS IN
HAWASSA, SOUTHERN ETHIOPIA

BY:
 AMANDA ESSAYAS
 AREGA TEGEGNE
 DAWIT KASSIE
 NAHOM GEBREMEDHIN
 NETSANET GEBEYEHU

ADVISORS:
 GEZAHEGN BEKELE (A.P ROFESSOR , MSc)
 MELESE GEBRIE (L ECTURER , MSc)

DECEMBER, 2019
HAWASSA, ETHIOPIA

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 ACKNOWLEDGMENT

First we would like to give deepest thanks to Hawassa University College of Medicine and
Health Science School of Nursing and Community Based Education (CBE) coordinating office
for the chance they gave us which potentially will enable us to appreciate the really health
problems of community and address it via research work.

Secondly we would like to forward heartfelt gratitude to our advisors Mr. Meless and Mr.
Gezahegnfor valuable guidance, feedback, encouragement and wholesome support on the subject
both theoretically and practically to do this research proposal.

Thirdly we would like to provide our appreciation for individuals those who help us by giving
important information for our research proposal.

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 APPROVAL SHEET

This is to certify that the student research project proposal entitled assessing "care burden and
its associated factors among family members of patients diagnosed with cancer and who had
treatment / care follow-up in oncology unit of Hawassa University Comprehensive and
Specialized Hospitals in Hawassa, southern Ethiopia" submitted in partial fulfillment of the
requirements for the degree of Nursing undergraduate program of the school of Nursing ,
College of Medicine and Health Sciences, Hawassa University, and is recorded as original work
carried out by students named .

The assistance and help received during the course of this work have been duly acknowledged.
Therefore I/we, advisor/s, recommends that it be accepted as fulfilling the requirements.

____________________________ _____________ __________________

Name of Advisor Signature Date

____________________________ _____________ __________________

Name of Advisor Signature Date

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 TABLE OF CONTENTS
ACKNOWLEDGMENT............................................................................................................................i
APPROVAL SHEET.................................................................................................................................ii
LIST OF TABLES....................................................................................................................................iv
LIST OF FIGURES...................................................................................................................................v
ABREVATION AND ACRONYMS........................................................................................................vi
ABSTRACT..............................................................................................................................................vii
CHAPTER ONE........................................................................................................................................1
1. INTRODUCTION.............................................................................................................................1
1.1. Background................................................................................................................................1
1.3. Significance of the study............................................................................................................7
CHAPTER TWO.......................................................................................................................................8
2. OBJECTIVE......................................................................................................................................8
2.1. General objective.......................................................................................................................8
2.2. Specific objective........................................................................................................................8
CHAPTER THREE...................................................................................................................................9
3. LITRATURE REVIEW....................................................................................................................9
CHAPTER FOUR...................................................................................................................................14
4. METHODS AND MATERIALS....................................................................................................14
4.1. Study design.............................................................................................................................14
A descriptive Institutional-based cross-sectional study design will be used to conduct this study.........14
4.2. Study Area and period............................................................................................................14
4.3. Population.....................................................................................................................................14
4.3.1 Source population.......................................................................................................................14
4.3.2. The study population.............................................................................................................14
4.3.3. Study Unit...............................................................................................................................15
4.4. Eligibility criteria..........................................................................................................................15
4.4.1. Inclusion criteria........................................................................................................................15
4.4.2. Exclusion criteria.......................................................................................................................15
4.5. Sample size determination and sampling technique..................................................................15
4.5.1. Sample size determination........................................................................................................15
4.5.2 Sampling method.....................................................................................................................16
4.6. Variables........................................................................................................................................16

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 4.6.1. Dependent variable................................................................................................................16
 Caregiver burden (Physical, psychological, emotional, economical and social)................................16
4.6.2. Independent variable.............................................................................................................16
4.7. Data Collection and Analysis Plan..........................................................................................16
4.7.1. Data collection tool...............................................................................................................16
4.7.2. Data collection plan.............................................................................................................17
4.7.3. Data quality control...................................................................................................................18
4.7.3. Data processes and analysis................................................................................................18
4.8. Ethical Consideration..............................................................................................................19
4.9. Operational definition.............................................................................................................19
4.10. Dissemination of the result..................................................................................................19
CHAPTER FIVE.....................................................................................................................................21
5. WORK PLAN..................................................................................................................................21
CHAPTER SIX........................................................................................................................................22
6. BUDGET PLAN..........................................................................................................................22
Reference:.................................................................................................................................................23
Reference...................................................................................................................................................24
Annexes:....................................................................................................................................................27
Annex I: Consent Form..........................................................................................................................27
Annex II: Questionnaire (English Version).............................................................................................27
Annex III: Questionnaire (Amharic Version)..........................................................................................27
Questionnaire............................................................................................................................................27
Annex : I Socio- demographic character for patients.................................................................................27
Annex :IISocio demographic character for familycaregivers.....................................................................29
Annex III: zarit burden interview..............................................................................................................31
Annex IV: Social support rating scale.......................................................................................................33

iv
LIST OF TABLES

LIST OF FIGURES

v
 ABREVATION AND ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

CBE Community Based Education
CI Confidence Interval
DNA Deoxyribonucleic Acid
DSM-IV Diagnostic and Statistical Manual of Mental Disorders
EC Ethiopian Calendar
ETB Ethiopian Birr
ENT Ear,Nose,Throat
GBD Global Burden of Disease
HUSCH Hawassa University Comprehensive Specialized Hospital
KM Kilometer
OPD Out Patient Department
SD Standard Deviation

SNNPR South Nation Nationalities and peoples Region

SSRI Social Support Rating Scale

US United State

WHO World Health Organization

ZBI Zarit Burden Interview Scale

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 ABSTRACT

Background:Cancer is a group of disease characterized by uncontrolled growth and spread of

abnormal cells, which can result in death. Worldwide, about 25 million people are living with
cancer. Each year, 7 million people die from it and 11 million new cases are diagnosed globally.
The burden of cancer is increasing in economically developing countries as a result of
population aging and growth as well as, increasingly, an adoption of cancer-associated lifestyle
choices including smoking, physical inactivity, and ‘‘westernized’’ diets. It frequently comprises
our patient’s vitality. In addition, itshould have emotional, economical, physical and
psychological burden on family, friends, significant others, community and other social
resource.Care burden is perceived by family is a stressful due to physical, psychological, social,
financial reaction that might emerge while providing care. The burden level of caregivers for
cancer patients is increased by payment type forgetting health care service and palliative care in
addition to their medical, surgical, radiation treatments.
Objective:The aim of this study is to assess the care burden and its associated factors of family
members of havingpatients diagnosed with cancer and who had treatment / care follow-up in
oncology unit of Hawassa University Comprehensive and Specialized Hospitals in Hawassa,
Southern Ethiopia.
Method: Institutional based cross sectional study will be conducted starting from January
20/2020 up to March 20/2020. Data will be collected from 141 randomly selected caregivers
/family members of cancer patients of having patients diagnosed with cancer and who had
treatment / care follow-up in oncology unit of Hawassa University Comprehensive and
Specialized Hospitals in Hawassa. We willuse structured questionnaire to collect the socio-
demographic data and also we use validated “ Zarit Burden Interview (ZBI) scale and SSRI”
measurement tool to determine the level of family care burden. Pre-test will be done in10 % of
sample before beginning the program in other site. The finding will be analyzed through using
SPSS version 22, presented by table and chart, and interpreted based on the collected data and
also the association b/n dependent & Independent variables will be discussed. Based on the
result identified, conclusion & recommendation will be given for responsible bodies to take
appropriate measure early as possible and improve the services. The total budget required for
this study will be _____________.
Key words: Cancer, Care Burden, Hawassa, Southern Ethiopia

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 CHAPTER ONE
1. INTRODUCTION
1.1. Background
Cancer is a group of disease involving abnormal cell growth with the potential to invade or
spread to other parts of the body(WHO 2010). It is a group of distinct diseases with different
causes, manifestations, treatments, and prognoses. Cancer nursing practice covers all age groups
and nursing specialties and is carried out in a variety of health care settings, including the home,
community, acute care institutions, outpatient centers, rehabilitation, and long-term care
facilities. The scope, responsibilities, and goals of cancer nursing, also called oncology nursing,
are as diverse and complex as those of any nursing specialty. Because many people associate
cancer with pain and death, nurses need to identify their own reactions to cancer and set realistic
goals to meet the challenges inherent in caring for patients with cancer. In addition, cancer
nurses must be prepared to support patients and families through a wide range of physical,
emotional, social, cultural, and spiritual crises.

Cancer is a disease process that begins when an abnormal cell is transformed by the genetic
mutation of the cellular DNA. This abnormal cell forms a clone and begins to proliferate
abnormally, ignoring growth-regulating signals in the environment surrounding the cell. The
cells acquire invasive characteristics, and changes occur in surrounding tissues. The cells
infiltrate these tissues and gain access to lymph and blood vessels, which carry the cells to other
areas of the body. (Suzanne C. Smeltzer, et.al ,2010)

There are two major types of cancer genes. The first type comprises genes that positively
influence tumor formation and are known as oncogenes. The second type of cancer genes
negatively impact tumor growth and have been named tumor-suppressor genes. Both oncogenes
and tumor-suppressor genes exert their effects on tumor growth through their ability to control
cell division (cell birth) or cell death (apoptosis), although the mechanisms can be extremely
complex ( Berhane Y, Mariam DH, Kloos H (2006))

The exact causes of cancer are not known and very often no single cause can be found. Findings
so far show that cancer causes are related to changes on genes. Such changes on genes are related
to living habit such as tobacco smoking, unhealthy diet and physical inactivity, and

1
environmental factors like exposure to infections and carcinogens, and longer life expectancy
(McSweeney PA, Niederwieser D, and Molina AJ, et al. (2001)

Cancer is a major public health problem in the world. This disease is one of the leading causes of
death worldwide. Based on the GLOBOCAN estimates, about 14.1 million new cancer cases and
8.2 million deaths occurred in 2012 worldwide. Lung and breast cancer are the most frequently
diagnosed cancers and the leading causes of cancer death in men and women, respectively, both
overall and in less-developed countries. Cancer imposes an enormous burden on society both in
more- and less-economically developed countries alike. The occurrence of cancer is increasing
because of the growth and aging of the population, as well as an increasing prevalence of
established risk factors, such as smoking, overweight, physical inactivity, and changing
reproductive patterns associated with urbanization and economic development [ CITATION Int12 \l
1033 ].

Multiple modalities are commonly used in cancer treatment. A variety of approaches, including
surgery, radiation therapy, chemotherapy, and targeted therapies, may be used at various times
throughout treatment. Understanding the principles of each and how they interrelate is important
in understanding the rationale and goals of treatment (Suzanne C. Smeltzer, et.al.2010)

Diagnosis of cancer and adoption of the caregiver role by family members are two parallel
stages. Caregiver is the key person who supports the patient and usually provides the biggest
care. A cancer patient in family forces the caregivers to face new circumstances into which they
have to adapt. The longevity of this sickness state which impacts the whole family, life
threatening effects of the ailment, inability of the patient to engage in work and social activities
are a few of the reasons further climbing the responsibilities of the caregiver and transforming
the roles within family (Oksuz et al. 2013; Akgul et al. 2014).

In Ethiopia, cancer accounts for about 5.8% of total national mortality. Although population-
based data does not exist in the country except for Addis Ababa, it is estimated that the annual
incidence of cancer is around 60,960 cases and the annual mortality over 44,000. or people
under the age of 75 years, the risk of being diagnosed with cancer is 11·3% and the risk of dying
from the disease is 9·4%. The most prevalent cancers in Ethiopia among the entire adult
population are breast cancer (30.2%), cancer of the cervix (13.4%) and colorectal cancer (5.7%).
About two-thirds of annual cancer deaths occur among women[ CITATION Fed15 \l 1033 ].

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In most cases, cancer treatment requires long-term medical care and support. Many patients with
cancer rely on family and friends to assist with cancer treatment needs, and their family members
often take the primary responsibility as the caregiver [ CITATION Ken16 \l 1033 ]. Due to the
upsetting nature of the illness, being a caregiver for a family member with cancer requires
multifaceted activities that are physically, emotionally, socially, and financially
demanding[ CITATION Ros13 \l 1033 \m Nig16] . Caregiving tasks include monitoring symptoms,
dealing with various side effects, tracking medical information;, and providing emotional and
clinical support.[ CITATION LiQ13 \l 1033 \m Abu11] . Daily routines are also negatively affected,
and many caregivers become isolated from their family and friends [ CITATION Nor12 \l 1033 \m
Blu10]. In addition, the caregiver’s performance influences the coping style of the patient with
cancer, such as managing depression that can originate from the ordeal of living with
cancer[ CITATION Lit15 \l 1033 \m Kim15] . Unfortunately, negative emotions (i.e., anxiety,
depression, and symptoms of postrraumatic stress) can be stressful for patients and ultimately
impact both patients’ and caregivers’ health [ CITATION Gri14 \l 1033 ].

Family involvement has significant influences on decision-making processes, the receiving and
sharing of information, and the provision of physical and emotional support for patients. This
role commonly causes a substantial burden and caregivers often experience negative
psychological, behavioral, and physiological effects on their daily lives and well-being. Caring
for people with cancer can have significant impacts on caregivers as well as caregivers’
outcomes, which in turn can have negative impacts on the people being cared for (Ly Nguyen
Thuy and Trang Ta Ngoc Dan, 2015). Despite the significance of their role towards better
outcome, the diverse needs of caregivers and their burdens are needed to overlooked by the
health care system and there are inadequate data showing approaches that are effective at easing
caregiving burden.

Worldwide, about 25 million people are living with cancer. Each year, 7 million people die from
it and 11 million new cases are diagnosed globally. In fact more people die from cancer than
from AIDS, malaria and tuberculosis put together where 12.5% of all deaths each year in the
world are due to cancer. The bad news is that the incidences of cancer in developing countries
like Ethiopia, which are not prepared to control, is rising at an alarming rate where as it is
declining in the developed world because they started timely to avert it(WHO,2010)

3
Similarly, global burden of disease (GBD) studies estimated age standardized death rates of 800
per 100,000 populations for non-communicable diseases in Ethiopia, of which higher death rates
(approximately 450 per 100,000) were attributed to cardiovascular disease and diabetes, 150
per100,000 attributed to cancer, and 100 per 100,000 to chronic obstructive pulmonary
disease(Horton R, Ortegon M, et al. (2014))

The burden of cancer is increasing in economically developing countries as a result of population

aging and growth as well as, increasingly, an adoption of cancer-associated lifestyle choices
including smoking, physical inactivity, and ‘‘westernized’’ diets. Regardless of all this, Cancer
has received low priority for health care services in Sub- Saharan Africa (Torre LA, et al.,2015)

Treatment options offered to cancer patients is based on treatment goals for each specific type of
cancer. The range of possible treatment goals may include complete eradication of malignant
disease (cure), prolonged survival and containment of cancer cell growth (control), or relief of
symptoms associated with the disease (palliation). The health care team, the patient, and the
patient’s family must have a clear understanding of the treatment options and goals. Open
communication and support are vital as the patient and family periodically reassess treatment
plans and goals when complications of therapy develop or disease progresses

1.2. Statement of problem

Cancer is an increasing public health burden for Ethiopia and Sub- Saharan Africa at large. In
Ethiopia, hospital records show that there are more than 150,000 cancer cases per year and
currently cancer accounts for 4% of all deaths. However, Cancer is the most neglected and least
prioritized health issue in Ethiopia. On the other hand, the WHO report which updated on
February 2015, shows Cancers figure is among the leading causes of morbidity and mortality
worldwide, with approximately 14 million new cases and 8.2 million cancer related deaths in
2012, with 5.3 million deaths a year in low income countries. According to this report, the
number of new cases is expected to rise by about 70% over the next 2 decades (Morhason-Bello
IO, et al. 2013).

As a result of population growth and increased life-span in both high- and low-income countries
(You W, et al. 2018).Before now, cancer is considered to be a disease of affluence that affects
the developed countries but has now cut across all socioeconomic levels with burden more in

4
developing countries such as Ethiopia. Cancer incidence increasing globally: the role of relaxed
natural selection (Asobayire A, et al. 2015).

Cancer affects not just those who have the disease but also their informal caregivers who provide
care. The informal caregivers perform many activities that used to be done in the health facilities
by health workers (Mitnick S, et al. 2010); they can help in drugs administration, counseling,
dressing, all through the different phases of managing the condition .(Lkhoyaali S, et al. 2015).
As most of them assume caregiving role without adequate training and are expected to meet up
with caregiving demands without much help, they experience psychological worries, increasing
rate of physiological illness, and social problems (Dionne-Odom JN, et al. (2016). Studies in
the developed countries had established that informal caregivers of patients with cancer are
vulnerable to all kinds of psychological (e.g., anxiety, stress, depression) and physical (e.g.,
burn-out, increased mortality, loss of weight, poor immune functioning, and insomnia) burden
(EffendyC,et al. 2015). However, little is known about problems facing the informal caregivers
of patients with cancer in sub-Saharan particularly in Ethiopia (Kent EE, et al. 2016).

Cancer affects the quality of life of family caregivers in many ways, but takes its greatest toll on
their psychological well-being. Family caregivers are expected to provide complex care in the
home with little preparation or support. When the demands placed on caregivers exceed their
resources, caregivers feel overwhelmed and report high stress. The stress has a negative effect
initially on the caregiver’s psychological wellbeing, but as the stress continues it can negatively
affect their physical well-being as well. The effects of stress on the psychological domain of
quality of life appear as increased emotional distress, anxiety, and/or depression; feelings of
helplessness and loss of control; and difficulty in coping with caregiving roles [ CITATION Lau12 \l
1033 ].

Caregivers themselves also go through certain physical, mental, social and financial troubles
during the time they provide care to their patients (Terakye 2011). According to research,
caregivers of cancer patients experience intense emotional and physiological stress during care-
giving process; hence they themselves become vulnerable to physiological and psychological
health problems (Yakar and Pinar 2013)

Assessments and initiatives focusing on this particular issue shall not only diminish the burden of
caregivers but also it will save them from the negative effects of this process to some extent. This

5
outcome shall reflect itself in the life-quality of the care giver as well as the patient. On accounts
of lighting a torch in the planning, implementation and assessment of initiative towards
decreasing caregivers’ burden that the results obtained from the study ( Kuscu et al., 2009).

Cancer research in Ethiopia is not commensurate with the magnitude of the problem. This is due
to inadequate funding and training facilities in cancer research. There is also no comprehensive
cancer surveillance system, and population-based cancer registry limited to the Addis Ababa
region at present[ CITATION Fed15 \l 1033 ]. In addition, Composite variables of family burden
towards support of cancer patient and pallative care standard based on WHO recommendation
are not studied in Ethiopia and as well in the study area. Accordingly, the objective of this study
will be to assess the caregiver burden and its associated factors among family members of
patients diagnosed with cancer and who had treatment / care follow-up in oncology unit
of Hawassa University Comprehensive and Specialized Hospitals in Hawassa, Southern
Ethiopia.

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1.3. Significance of the study

This study provides information for researcher. the study will be revile good information on the
burden level of caregivers for cancer patients by payment type, by forming good relationships to
patient administering drug , dressing and by giving palliative care in addition to their medical ,
surgical, radiation treatments

The significance of this study will be to provide valuable and important information on cancer
caregiver burden for policymakers, implementers and other responsible governmental and non-
governmental bodies.

Also this study will be helpful to HUCSH to know the burden levels of caregivers and important
to find solution for problems like those that have severe burden (economic impact, socio-
behavioural impact , psychological impact by link to psychiatric OPD).

The findings of this study will help to describe the care burden of families of cancer patioents
and reveal areas for further study and will assist health care professionals who are working in
oncology unit, community and the families to understand their burden in the study area and help
them to prioritize and focus their efforts. Additionally, since there is a limited research in the
study area, this study can be used as a benchmark for further studies.

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 CHAPTER TWO

2. OBJECTIVE
2.1. General objective
 To assess the caregiver burden and its associated factors among family members of
patients diagnosed with cancer and who had treatment / care follow-up in oncology
unit of hawassa university comprehensive and specialized hospitals in Hawassa,
Southern Ethiopia
2.2. Specific objective
 To determine the levels of the careging burden among family members of patients
diagnosed with cancer and who had treatment / care follow-up in oncology unit of
Hawassa University Comprehensive and Specialized Hospitals in Hawassa,
Southern Ethiopia
 To identify the factors associated with the level of caregiving burden among family
members of patients diagnosed with cancer and who had treatment / care follow-
up in oncology unit of Hawassa University Comprehensive and Specialized
Hospitals in Hawassa, Southern Ethiopia

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 CHAPTER THREE

3. LITRATURE REVIEW

3.1. Overview of Cancer and its Magnitude

3.2. Cancer care / palliative care
3.3. Determinant factors of cancer care burden
3.4. Conceptual framework

The hosipital based cross-sectional study involving 226 participants was conducted in Ahmadu Bello
University Teaching Hospital, Zaria, Kaduna State, Nigeria fromF ebruary 08, 2019 to march 01, 2019

Patient’s Characteristics

Among the 108 patients, the average age was 59.7 years (standard deviation [SD] = 14.9), and 96
patients (88.9%) were married. More than half of participants (55.6%) had less than secondary school
education. The majority (86.1%) pay for the medical bills. The cancer stage distribution among patients
ranged from stage II to stage IV; there were 12 stage II patients (11.1%), 77 stage III patients (71.3%),
and 19 stage IV patients (17.6%). The overall mean score on the cancer stage was 3.21 (SD= 0.57). More
than half (52.8%) had two hospitalization experiences within the past 6 months. The majority of patients
(74.1%) had at least one comorbidity .(Israel O. Gabriel et al 2019)

Caregiver characterstics

The average age of the informal caregivers was 41.9 years (13.8), and the age range was 18– 65 years.
Most of the caregivers were female (75.4%) and married (86.4%). The majority of caregivers (87.3%) had
an educational level of junior secondary school or above. The majority (89%) had a monthly family
income of less than US $500, which is a low-income level. Most of the caregivers (83.1%) had a full-time
or part-time job. The majority of caregivers (77.1%) were adult children of the patients, and (14.4%)
were the spouses/partners. Most caregivers (78%) spent more than 4 hours per day providing care for
the patients, and 55% had cared for the patients for more than one year. The majority of caregivers
(72.9%) lived with the patients. (Israel O. Gabriel et al 2019)

Caregiver burden by ZBI score among informal caregivers

And assess that informal caregiver burden by using ZBI score: the ZBI score was 13.3%(30 caregivers)
had “low” care burden and 86.7%(196 caregivers) had “high” care burden and their mean ZBI score is
37.1(12.3).(Nigeria)(Israel O. Gabriel et al 2019)

Factors related to caregiver burden

Theunivariate factor analysis showed that there were significant relationships between the caregiver
burden and patient characteristics, including educational status, number of hospitalizations in the past
six months, breast cancer staging, duration of illness, number of comorbidities, and payment type for
treatment. In addition, patients with a lower education level, more hospitalization experiences, a higher

9
breast cancer staging, longer duration of illness, more comorbidities, and self-support for treatment
demonstrated a higher caregiver burden. (Israel O. Gabriel et al 2019)

The univariate factor analysis revealed that there were significant relationships between the caregiver
burden and characteristics of caregivers (educational level, marital status, monthly family income,
employment status, relationship to the patient, duration of caregiving, and number of caregiving hours
per day) In addition, caregivers with a lower educational level, lower monthly income, longer duration of
caregiving, more caregiving hours per day, as well as adult-child caregivers also suffered higher level of
caregiver burden . Multivariate analysis was used to detect factors associated with the caregiver burden,
using the caregiver burden as the dependent variable and significant variables from the univariate and
correlation analysis as independent variables.(Israel O. Gabriel et al 2019)

The hospital based cross sectional study conducted in department of oncology, university hospital of
mohammed VI ,morooco, marakech from august 13 2015 to September 18 2015

Caregivers characteristics

A total of 150 participants were included from all Moroccan regions. The mean age was 44 years, the
majority was married, employed for full time, 53% of elderly patients lived with their families and 56%
with the children (sihamanelkhoyaali et al 2015)

Psychological impact

Depression according to DSM-IV [ 5] was found in 34 participants (22.7%) and 94 (62.7%) reported at
least one depressive signs. The depression was severe in four cases (2.7%).Anxiety was often associated
with depression, noted in 79.3% of cases and led to an anxiolytic taken in 15 caregivers (10%); it was
linked to the fear of losing their close in 57.3% of cases.Depression and anxiety were more common in
urban origin and female relatives and, maybe because of women are more vulnerable and close to the
relatives (Additional file 2 : Guilt was objectified in 57 relatives (38%) due to a delay of consultation in
9.3% or neglect of the patient’s symptoms in 15.3%.(sihamanelkhoyaali et al 2015)

Socio-behavioral impact of cancer in the family caregivers

Regarding the behavioral impact there were sleep disorders in 46% and loss appetite in 39.3% of cases.
The obsession of having a cancer was present in 29.3% and the fear of contagion in 10.7%. The fear of
contagion was more common in the rural illiterate populationFear of inheriting cancer was reported by
daughters of women suffering from breast cancer. More than 32 of relatives reported that they are less
socializing and neglect their families in 45% of cases. (sihamanelkhoyaali et al 2015)

Economic impact of cancer in relatives

The economic families’ resources were exceeded in 78.7%. Thus, 56% reported having recourse to
credits, 18.7% sale their goods, and 70.7% requested help from benefactors.In addition, the support for
these cancer patients caused the stoppage of work in 54% of cases; caregivers were obliged to quit their
jobs in order to help the cancerous relatives . (sihamanelkhoyaali et al 2015)

10
Participation in care and support benefits

Relatives play a vital role in the care of patients, they participated in making treatment decisions in 86%
of cases, 75.3% wanted a maximalist treatment for their relatives and only 10.7% desired to limit a care.
Despite the unfortunate consequences of cancer, 80% of families have reported a beneficial effect of
support in particular overestimates the self. (sihamanelkhoyaali et al 2015)

Hosipital based cross sectional study conducted in Ataturk Training and Research Hospital, Izmir
KatipCelebi University, İzmir, Turkey, by using ZBI score

67.4% of the caregivers constituting the scope of the current study are in the 35-64 age group (mean=
45±14.45), 67.5% are females, 73.7% are married. 37,4% of the caregivers are spouses and 37.4% of
them have been providing service for 1-2 years. 50% of the caretaker patients are in the 35-64 age group
and 51.2% are males. 42.6% of the patients were diagnosed with a hematologic malignity, 18.8% were
diagnosed with uterus, breast or ovary, 12.5% with lungs, 22.5% with prostate, colon or stomach
malignity.(FatmaKahriman andAytenZaybak2015 )

Care Burden Range n %

No care burden 0-20 15 18.7

Mild care burden 21-40 40 50

Medium care burden 41-60 19 23.8

Heavy care burden 61-88 6 7.5

Total 34.16±16.39 80 100

It was found that caregivers’ ZBI score means were 34.16±16.39. 50% had “mild” care burden, 23.8%
had “medium” care burden, 7.5% had “heavy” care burden. The ratio of caregivers with “no care
burden” was 18.7%.( FatmaKahriman and AytenZaybak 2015 )

2.2. The Conceptual Framework

The conceptual model of this study is based on the work of Lazarus and Folkman, which suggests that an
individual’s response to stress is affected by primary appraisal, secondary appraisal, and available
resources (Folkman S (1997). According to this model, primary appraisal, secondary appraisal, and

11
available resources interact and ultimately impact the individual’s stress response. The caregiver
assesses the effects of various aspects of care giving on himself/herself in the primary appraisal, which
include potential factors of patients and caregivers. The patient factors include demographic factors;
payment type for treatment; and disease characteristics. The caregivers’ characteristics include the
demographic features of caregivers, employment status, and family income. The transaction between a
person and his/her social or illness-related factors such a cancer can influence how individuals appraise
and cope with the illness (Shaw C (1999) )

12
Stressor primary appraisal secondary appraisal outcome

Characteristics of patient

Demographic factor

Duration of cancer

Cancer classification
Available resource
Number of hospitalization
Internal resource
Payment type for Caregiver
treatment External resource burden
Care giving Social support
Characteristics of caregiver

Demographic factor

Employment

Family income

Relationship to patient

Duration of caregiving

Figure 1 conceptual model of this study

13
 CHAPTER FOUR

4. METHODS AND MATERIALS

4.1. Study design
A descriptive Institutional-based cross-sectional study design will be used to conduct this
study
4.2. Study Area and period
Hawassa is a capital city of SNNPR with total area of 50 km2 and total population of
315,267 which located 275km away from Addis Ababa via bishoftu, 130 km east of sodo
and 75 km north of dilla. The town has an elevation of 1708 meters above sea level.

HUCSH is one of the teaching hospitals in our country and SNNPR, which is established
in 2005, in Hawassa town. This hospital serves more than 19 million people in SNNPR
regions and southern border of Oromia Region, like Sidama, Hagereselam, Arsi, Moyale
etc. It is accompanied with different serving units. This teaching hospital serves the
community with dental clinic, dermatology clinic, laboratory unit, pathology unit,
psychiatry clinic, ENT clinic, physiotherapy unit, surgical unit (general surgery,
neurosurgery, orthopedics, urology, and plastic surgery), internal medicine with sub-
specialty of cardiology and neurology, ophthalmology, radiology, oncology, gynecology
& obstetrics and pediatrics.

The study will be conducted from February, 2020 to April, 2020

4.3. Population
4.3.1 Source population
The source populations for this study will be all diagnosed cancer patient’s family caregivers
who residing in Hawassa Town

4.3.2. The study population

The study populations for this study will be all randomly selected family members of
patients diagnosed with cancer and who had treatment / care follow-up in oncology
unit of Hawassa University Comprehensive and Specialized Hospitals in Hawassa,
Southern Ethiopia

14
4.3.3. Study Unit
The study populations for this study will be all randomly selected family members of
patients diagnosed with cancer and who had treatment / care follow-up in oncology
unit of Hawassa University Comprehensive and Specialized Hospitals in Hawassa,
Southern Ethiopia and available during the study period

4.4. Eligibility criteria

4.4.1. Inclusion criteria
 All Family caregiver of cancer patient of those who had treatment / care follow-up in
oncology unit of HUCSH and who are available during the study period will be
included in the study.

4.4.2. Exclusion criteria

 All family caregiver of cancer patients who are not willing to give information
 All family caregiver of cancer patients whose age less than 18 years
 All family caregiver of cancer patients with severe functional or cognitive impairment
4.5. Sample size determination and sampling technique
4.5.1. Sample size determination
The sample size will be determined by using single population proportion formula,

Considering the following assumption:

o Since there was no similar study that shows caregiver burden among family
caregivers of patient with cancer at HUCSH, we took the Prevalence of family
caregiver burden - 50% ,
o Desired degree of precision of - 5 % and
o Zα/2 is the value of the standard normal distribution corresponding to a significant
level of alpha (α) of 0.05, which is 1.96.
Therefore, the calculated sample size is 384
Since the study cancer patients who had treatment follow-up is < 10,000, which are 150, we use
reduction formula as follows:

15
 Sample size = = =384× 192/384+192 =128
After adding 10% for non-response, the total sample size computed was 141

4.5.2 Sampling method

First, HUCSH will be selected from the existing based on the availability of cancer care
service. Then, lists of cancer patients who had treatment follow-up that will be identified by
research assistants / principal investigators from oncology unit registration book of HUCSH
used for a sampling frame. Finally, Study participants will be selected by simple random
sampling technique using random number computer generation method in the selected health
facility.

4.6. Variables
4.6.1. Dependent variable

 Caregiver burden (Physical, psychological, emotional, economical and social)

4.6.2. Independent variable
 Socio demographics factors of cancer patients: age, sex, educational status, Residential
place, marital status, Monthly income, occupational status, Patient’s independent level,
 Socio demographics factors of family caregivers of cancer patients: age, sex,
educational status, marital status, Monthly income, Types of patient-caregiver
relationship, Number of members in family, Number of financial dependent people,
occupational status, availability of other support,
 Disease related factors: types of cancer, Duration of disease(acute/chronic) since
diagnosis, treatment therapies used, duration of treatment modalities, payment for
medical service, stage of cancer, co-morbidities, any surgery, Health-related quality of
life (Physical, psychological, emotional, and social well-being)
 Care related factors: place of care, caring time, types of care, duration of care,

4.7. Data Collection and Analysis Plan

4.7.1. Data collection tool

16
A Semi-structured interviewer administered questionnaire will be adopted from different
literature and used to conduct this study. The questionnaire containing closed-ended and open-
ended questions that used to assess socio-demographic and economic characteristics of the
cancer patients and care givers. An outcome variable (presence of caregiver burden) will be
collected by zarit burden interview: defines caregiver burden as physical, psychological, social
and financial reaction that might emerge while providing care. Zarit Burden Interview - ZBI (22
items). The items are worded subjectively, focusing on the affective response of the caregiver.
Each question is scored on a 5-point scale ranging from - never to nearly always present. Total
scores range from 0 (low burden) to 88 (high burden). If ZBI total score of <21: “little or no
burden”; 21 to 40: “mild to moderate burden”; 41 to 60: “moderate to severe burden” and a score
> 61: “severe burden” [ CITATION Héb00 \l 1033 ]. The internal consistencies of these instruments
were measured in this study with Cronbach’s Alpha for ZBI were 0.84.

Perceived social support will be measured through Social Support Rating Interview Scale
[SSRI]. The SSRI scale is a 10-item scale that comprises three subscales (subjective support,
objective support, and utilization of social support). If SSRI Scale totals score of: ≤22 – indicate
low social support; 23- 44 – indicate Moderate social support and ≥45 higher scores indicate
better social support. The SSRS has adequate reliability and validity. The test–retest reliability
coefficient was 0.92, and internal consistency of the scale was 0.89 .The Cronbach’s alpha
coefficient was 0.90 in this study (???). The questionnaires will be translated to Amharic and
back translated to English. Completeness of the questionnaires will be checked by the
investigators daily.

4.7.2. Data collection plan

The data collection will be carried out by all research group members who are graduated batch of
BSc Nurse. This data collection process will take one month duration and the data will be
collected from selected health facility using a sampling frame sequence. First the data collectors
will greet the respondents, introduce them self and ask the respondents to answer questions from
the questionnaire. These questionnaires are face to face interviewers administered questionnaires
filled by the data collector by circling the best alternatives out of the given alternatives based on
the participant response and the questionnaires will take maximum time of 30 minutes to
complete it.

17
4.7.3. Data quality control
The questionnaire will be adapted from previous literatures & modified in to the study context. It
was prepared first in English and translated to Amharic and then retranslated back to English by
expert who is fluent in both languages to maintain its consistency. Pre-test will be made in 10%
of sample size in other health facility that have similar service and the finding from pretest will
be used to modify questionnaire and for formatting. Induction Training/ seminar will be
organized to the research assistance group member and supervisors in order to develop common
understnding about the tool. From the group member, one person will be seleted for actin as
principal investigator and supervisors to check completeness and clarity of each questionnaire on
daily basis. He will also check the activities of each data collectors by random spot-checking of
the individual data collection process of a given sample to ensure reliability of the data. Any
error, ambiguity, incompleteness, or any other problems were addressed on the following day
before starting next day activities.

4.7.3. Data processes and analysis

The data will be edited, coded and entered in to EPI data version 3.1 and exported to SPSS
version 22.0 statistical software for analysis. Further, data cleaning (editing, recoding, checking
for missing values, and outliers) will be made after exported to SPSS. The data analysis ranges
from the basic description to the identification of potential predictors of care burdens of families
of cancer patients. Bi-variate analysis and multivariable logistic models will be used to show the
relation between care burdens of families of cancer patients and various associated factors.
Descriptive statistics will be computed and presented using frequencies, proportions, summary
statistics, graphs and tables. Variables that have P-value < 0.25 on bi-variate analyses will be
entered in the multivariate logistic regression model to identify independent predictors of care
burdens of families of cancer patients. All tests were two-sided and P < 0.05 will be considered
as statistically significant. The strength of association and precision will be examined using
adjusted odds ratio at 95%confidence interval.

For the qualitative data manual analysis will be used based on the recording and notes taken
during the study time. Transcription, translation, coding of important phrases of the respondent
own words; summary of data using summary sheet and categorizing of similar themes will be
done.

18
ZBI and SRSI will be used to determine the magnitude and severity of burden among family
caregivers of cancer patients who have treatment.

4.8. Ethical Consideration

The study will be conducted after obtaining ethical clearance from ethical school of Nursing of
Hawassa University. Letter of permission will be secured from Hawassa University
comprehensive Specialized Hospital administrators. Informed consent will be obtained from
each study subject prior to the interview after the purpose of the study is explained to respondent.
Confidentiality of the information will be assured and privacy of the respondent will be
maintained by removing personal identities.

4.9. Operational definition

Family caregivers are an individuals (for example, a parent, spouse, family member, friend, or
neighbor) who provide care that is typically unpaid for, usually takes place at home, and
involves considerable amounts of time and energy.

Caregiver burden is a stress perceived by caregivers due to physical, psychological, social,

financial reaction that might emerge while providing care

ZBI Interpretation of Score analyzed as follows:

Total scores range from 0 (low burden) to 88 (high burden). If ZBI total score of:
 0 to 21: “little or no burden”;
 21 to 40: “mild to moderate burden”;
 41 to 60: “moderate to severe burden” and
 >61: “severe burden”

Perceived Social Support:

Social Support Rating Scale [SSRI] Interpretation of score:
 low social support ≤22
 Moderate 23-44
 High ≥45

xxxxxxx

4.10. Dissemination of the result

19
The results of this study will be submitted to school of Nursing and CBE office, Hawassa
University College of medicine and health science. They can use the results for planning and
implementation of intervention programs. Oral presentation of the proposal will be made.

20
 CHAPTER FIVE

5. WORK PLAN

Table 1: Tentative work plan of a study on to assess caregiver burden and its associated
factors among family members of patients diagnosed with cancer and who had
treatment / care follow-up in oncology unit of Hawassa University
comprehensive and specialized hospitals in Hawassa, Southern Ethiopia

No. Activities Responsible 2020

body

Jan

Mary

May
Dec

Jun
Nov

Apr
Feb
1 Topic selection and submission PI
2 Proposal development and submission PI and RA
3 Ethical clearance School of
Nursing
4 Prepare for field work PI
6 Recruit and train data collectors and PI
supervisor
7 Pre-test the questionnaire and PI, supervisor
adjustment and ,DC
8 Data collection DC, PI &
supervisor
9 Data entry and processing PI and DC
10 Data analysis and thesis write up PI & RA
11 Final Defence PI
12 Submission the final research PI

13 Monitoring the overall activities PI

Key: PI=principal investigator, RA= research advisor,

21
 CHAPTER SIX
6. BUDGET PLAN
Table 2:Budget breakdown of the study done to assess caregiver burden and its associated
factors among family members of patients diagnosed with cancer and who had
treatment / care follow-up in oncology unit of Hawassa University comprehensive
and specialized hospitals in Hawassa, Southern Ethiopia
No I. Budget for Stationary and service charges
Unit price Total Total price
Items Unit Birr Cent Unit Birr Cent
110 00 2 220 00
1 Paper Pack
2 Pen Pieces 5 00 10 50 00
3 Pencil Pieces 3 00 5 15 00
4 Pencil eraser Pieces 3 00 3 9 00
5 Ruler Pieces 5 00 3 15 00
6 Staples Pieces 5 00 4 20 00
7 Stapler Pieces 120 00 1 120 00
8 Compact disk Pieces 5 00 5 25 00
9 Graph paper Pieces 10 00 5 50 00
10 Marker Pieces 15 00 5 75 00
11 Scotch tape Roll 5 00 1 5 00
12 Telephone Prepaid card 25 00 5 125 00
charges
13 Internet Minutes 0 40 900 360 00
14 Photo copy Per Page 1 00 220 220 00
15 Typing and Per 5 00 100 500 00
printing Page
Sub Total
II. Budget for personnel
1 Data collector
cost
2 Supervisor cost
3 Data clerk cost
4 Transport cost Per trip 18 00 8 144 00
Sub Total
Grand Total

22
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Annexes:
Annex I: Consent Form
Annex II: Questionnaire (English Version)

Annex III: Questionnaire (Amharic Version)

Questionnaire
Annex : I Socio- demographic character for patients
No Question Response
1 Sex 1 Male
2 Female
2 Age __________
3 Marital status A, Married
B, Single
C, Divorced
D, Widowed
4 Religion A, Muslim
B, Orthodox
C, Protestant
D, Catholic
E, Other
5 Ethnicity A, Oromo
B, Amara

27
 C, Sidama
D, Gurage
E, Tigray
F, Other
6 Educational status A, Illiterate
B, Junior (1-8)
C, Secondary (9-10)
D, Higher (<12)
E, Diploma
F, Degree

7 Duration of illness A.1 month

B.1-3 month
C.3-6 month
D.6month -1year
E. 1year or more
8 Number of hosipitalization A.0
B.1
C.2
D.3 or more
9 Stage of cancer A. stage I
B. stage II
C. stage III
D. stage IV
10 Number of comorbidity A.0
B.1
C.2
D.3 or more

28
Annex :IISocio demographic character for familycaregivers
No Question Response
1 Sex 1 Male
29
 2 Female
2 Age __________
3 Marital status A, Married
B, Single
C, Divorced
D, Widowed
4 Religion A, Muslim
B, Orthodox
C, Protestant
D, Catholic
E, Other
5 Ethnicity A, Oromo
B, Amara
C, Sidama
D, Gurage
E, Tigray
F, Other
6 Educational status A, Illiterate
B, Junior (1-8)
C, Secondary (9-10)
D, Higher (<12)
E, Diploma
F, Degree

7 Employment status A.Housewife

B. Farmer
C.Government employee
D. Student
E. Daily laborer
F. merchant
G. Other…..
8 Monthly family income Specify
9 Relation to patient A. husband or wife
B. children
C. other relatives
10 Duration of caregiving A.1 month
B.1-3 month
C.3-6 month
D.6month -1year
E. 1year or more
11 Caregiving hour per day A. 1hour and less
B. 1-3 hour
C. 3-5 hour

30
 D. 5-8 hour
E. 8 or more
12 Co-residence with patient A. yes
B. no

Annex III: zarit burden interview

Please circle the response the best describes how you feel.

Question Score

1 Do you feel that your relative asks for more help than he/she needs?
0 1 2 3 4
2 Do you feel that because of the time you spend with your relative
0 1 2 3 4
that you don’t have enough time for yourself?
3 Do you feel stressed between caring for your relative and trying to
0 1 2 3 4
meet other responsibilities for your family or work?

31
 4 Do you feel embarrassed over your relative’s behaviour? 0 1 2 3 4
5 Do you feel angry when you are around your relative? 0 1 2 3 4
6 Do you feel that your relative currently affects our relationships with
0 1 2 3 4
other family members or friends in a negative way?
7 Are you afraid what the future holds for your relative? 0 1 2 3 4
8 Do you feel your relative is dependent on you? 0 1 2 3 4
9 Do you feel strained when you are around your relative? 0 1 2 3 4
10 Do you feel your health has suffered because of your involvement
0 1 2 3 4
with your relative?
11 Do you feel that you don’t have as much privacy as you would like
0 1 2 3 4
because of your relative?
12Do you feel that your social life has suffered because you are caring
0 1 2 3 4
for your relative?

Question Score

13Do you feel uncomfortable about having friends over because of your
0 1 2 3 4
relative?

14Do you feel that your relative seems to expect you to take care of
0 1 2 3 4
him/her as if you were the only one he/she could depend on?

15Do you feel that you don’t have enough money to take care of your
0 1 2 3 4
relative in addition to the rest of your expenses?

16Do you feel that you will be unable to take care of your relative much
0 1 2 3 4
longer?

17Do you feel you have lost control of your life since your relative’s
0 1 2 3 4
illness?

18Do you wish you could leave the care of your relative to someone
0 1 2 3 4
else?

19Do you feel uncertain about what to do about your relative? 0 1 2 3 4

20Do you feel you should be doing more for your relative? 0 1 2 3 4

21Do you feel you could do a better job in caring for your relative? 0 1 2 3 4

22Overall, how burdened do you feel in caring for your relative? 0 1 2 3 4

32
 Zbiscore : 0 never
1 rarely
2 sometimes
3 quite frequently
4 nearly always

Interpretation of Score:
0 - 21 little or no burden
21 - 40 mild to moderate burden
41 - 60 moderate to severe burden
61 - 88 severe burden

Annex IV: Social support rating scale

Address or Organization: Date:
Instructions: The following questions are designed to measure your support received in society.
Depending on the fact, please finish the rating scale in accordance with the specific requirements
of each issue. Thank you for your cooperation.

1. How many intimate friends do you have, from whom you can receive support and help?
(Exclusive Choice)
(1) None
(2) 1~2
(3) 3~5
(4) no less than 6
2. Over the past year, you (Exclusive Choice)
(1) stay away from family, and live alone
(2) often move the residence, and most of time live together with strangers
(3) live together with students, colleagues or friends
(4) live together with family
3. With your neighbors, you (Exclusive Choice)
(1) have a speaking acquaintance and never care about each other

33
 (2) maybe have a little concern when meeting trouble
(3) are deeply concerned by some of them
(4) are deeply concerned by most of them
4. With your colleagues, you (Exclusive Choice)
(1) have a speaking acquaintance and never care about each other
(2) maybe have a little concern when meeting trouble
(3) are deeply concerned by some of them
(4) are deeply concerned by most of them

5. Obtain support and help from family members (Draw “√” in the suitable box)
non rarely normall full
e y support

A. couple

B. parents

C. children

D. siblings

E. others (for example, sister-

in-law)
6. In the past, when you encounter difficulties, what is the source that you ever received either
economic support or practical problem-solving help?
(1) no source
(2) the following source (more than one answer is permitted)
A. spouse
B. other family members
C. friends
D. relatives
E. colleagues
F. companies
G. official or semi-official organizations, such as, parties, leagues and trade union
H. unofficial organizations, such as, religion, social group and etc.

34
 I. others (please list)
7. In the past, when you encounter difficulties, what is the source that you ever received
comfort and caring?
(1) no source
(2) the following source (more than one answer is permitted)
A. spouse
B. other family members
C. friends
D. relatives
E. colleagues
F. companies
G. official or semi-official organizations, such as, parties, leagues and trade union
H. unofficial organizations, such as, religion, social group and etc.
I. others (please list)
8. What is the way of talking when you are in trouble? (Exclusive Choice)
(1) never complain to anyone
(2) only complain to 1 or 2 persons who have a close relationship with
(3) will talk to the friend who takes the initiative to inquiry
(4) take the initiative to talk their own troubles in order to get support and understanding
9. What is the way of seeking help when you are in trouble? (Exclusive Choice)
(1) just rely on myself, and do not accept the help of others
(2) rarely ask someone for help
(3) sometimes ask someone for help
(4) ask family, friends or organizations for help when facing troubles
10. Organized activities for groups (such as, party and youth league organizations, religious
organization, trade union, student union and etc.), you . (Exclusive Choice)
(1) never attend
(2) occasionally attend
(3) often attend
(4) take the initiative to attend and are active with

35
ANNEX V: consent form
Interviewer Administered Questionnaire To Study Caregiver Burden And Related
Factors Among Family Caregivers Of Patient With Cancer In Oncology Unit At Hawassa
University Comprehensive And

Dear Madam/ sir

Dear interviewee, we are a final year nursing students from Hawassa University, College of
Medicine and Health sciences working formally to detect problems of our society. The purpose
of this study is to assess familycaregivers burden for patients attending treatment on oncology
unit at HUCSH. I will ask you about your burden while giving care for your family and other
factors contributing to it. Therefore you are kindly requested to play your decisive role being the
most important part of this interview in assessing the magnitude of this community issue. The
whole interviewee will take about 20 minutes. We assure you that your name and other personal
information will not be documented in the questionnaires and the information you provide to us
will be kept confidential and will not be used for anything other than the research purpose. You
have the right to withdraw anytime you feel uncomfortable.

Are you willing to participate? A. yes B. No

If Yes, continue if No thank him /her and go to the next Respondent.

Thank you!

Data collectors name -------------------------------------------------------- sign-------------

Supervisors name-------------------------------------------------- sign----------------

36
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