International Psychogeriatrics (2014), 26:9, 1455–1463 

C International Psychogeriatric Association 2014

doi:10.1017/S104161021400101X

Dimensionality of burden in Alzheimer caregivers:

confirmatory factor analysis and correlates of the Zarit Burden
interview
...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Sheung-Tak Cheng,1 Timothy Kwok2 and Linda C. W. Lam3

1
Department of Health and Physical Education, Hong Kong Institute of Education, Hong Kong
2
Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong
3
Department of Psychiatry, Chinese University of Hong Kong, Hong Kong

ABSTRACT

Background: To investigate dimensions of caregiver burden through factor analysis of the Zarit Burden
Interview (ZBI), and to examine predictors of different dimensions of burden.
Methods: Confirmatory factor analyses were performed on 395 Hong Kong Chinese Alzheimer caregivers to
examine whether several proposed factor structures fit the data well. Subsequently, participants were split
into two roughly equal subsamples, for the purpose of identifying the most optimal factor structure through
exploratory factor analysis in Sample A (n = 183) and an independent verification through confirmatory
factor analysis in Sample B (n = 212). ZBI subscales representing the established factors were correlated with
caregiver and care-recipient variables known to be associated with burden.
Results: Confirmatory factor analyses showed that factor models reported elsewhere did not fit the data well.
Subsequently, exploratory factor analysis in Sample A suggested a 4-factor structure. After dropping three
items due to poor factor loadings, the 4-factor structure was found to fit the data moderately well in Sample
B. The four factors tapped personal strain, captivity, self-criticism, and loss of control. However, self-criticism
was basically unrelated to the other three factors and showed a rather different pattern of correlations with
caregiver and care-recipient variables. Self-criticism was more common among child caregivers and those who
did not live with the care-recipient and was less involved in day-to-day care, yet feeling obligated and close to
the care-recipient.
Conclusions: The dimensions of caregiver burden may be culturally specific. More research is needed to
examine cultural considerations in measuring caregiver burden.

Key words: Alzheimer’s disease, caregiver burden, confirmatory factor analysis, Hong Kong Chinese

Introduction Gaugler et al., 2013; Rodriguez-Sanchez et al.,

2013). While it is most often used as a global
Caregiver burden will become a public health measure, researchers have attempted to discover
issue given the anticipated rise in the dementia distinguishable dimensions within the scale in
population, with Alzheimer’s disease being the order to provide more differentiated information
most prevalent condition (Alzheimer’s Disease about the impact of caregiving. Differentiating the
International, 2013; Cheng et al., 2013). The dimensions may also be useful for intervention
Zarit Burden Inventory (ZBI; Zarit et al., 1980) research as interventions may not have the same
is probably the most widely adopted instrument effects across the different dimensions of burden.
for measuring caregiver burden, whether in surveys To do so, researchers have used either exploratory
(e.g. Lin et al., 2012; Werner et al., 2012; or confirmatory factor analysis to examine the
Hayashi et al., 2013) or as an outcome measure factor structure (a.k.a. measurement model) of the
in intervention studies (e.g. Cheng et al., in press; items. However, substantial variations in the factor
structure have been found. To date, solutions of 2–
Correspondence should be addressed to: Sheung-Tak Cheng, PhD, Department 5 factors have been reported and not all solutions
of Health and Physical Education, Hong Kong Institute of Education, 10 Lo included the whole scale.
Ping Road, Tai Po, N.T., Hong Kong. Email: takcheng@ied.edu.hk. Received
4 Dec 2013; revision requested 3 Mar 2014; revised version received 27 Apr Whitlatch et al., (1991) were probably the first
2014; accepted 1 May 2014. First published online 3 June 2014. to examine the dimensions of the ZBI as outcomes
1456 S.-T. Cheng et al.
in caregiver interventions. Using exploratory factor
analysis (EFA), they found two factors, namely
Personal Strain (items 1, 4, 5, 8, 9, 14, 16–21)
and Role Strain (items 2, 3, 6, 11–13; see Table 3
for item content), which were equally responsive to
individual and family counseling as compared with
waitlist control, in a sample of 113 US dementia
caregivers. Four items were dropped by Whitlatch
and colleagues; the last item, itself a measure
of global burden, was probably dropped due to
simultaneous loading on the two factors (Knight
et al., 2000).
Subsequent efforts, however, have failed to
replicate this 2-factor structure. Using confirmatory
factor analysis (CFA), Knight et al. (2000) found
that the Whitlatch model did not fit their data well
in another US caregiver sample (n = 220). Instead,
they discovered, using EFA, a 3-factor structure
consisting of 14 items, namely Patient Dependency
(items 2, 8, 14), Embarrassment and Anger (items
4–6, 9–13, 18), and Self-criticism (items 20, 21).
CFA showed that this 3-factor structure fit the data
moderately well (comparative fit index [CFI] =
0.90, root-mean-square error of approximation
[RMSEA] = 0.06) in independent samples of
Black (n = 175) and White (n = 225) caregivers
in the United States, with factor loadings and
factor covariances being invariant (i.e. equivalent)
between the two ethnic groups (Longmire and
Knight, 2011).
In a recent study of 206 US caregivers using EFA,
Springate and Tremont (2014) found five factors
with eigenvalues > 1. However, the authors retained
only the first three factors because the fourth factor
contained just one item and the fifth factor consisted
of items conceptually unrelated. The three factors
retained were: Impact on Caregiver’s Life (items
2, 3, 6, 9–12, 17, 18, 22), Guilt (items 5, 19–21),
and Frustration and Embarrassment (items 1, 4,
13, 14). Altogether, 18 items were retained in this
final solution, including the last item (number 22)
measuring global burden. EFA in a French sample
(n = 152) by Ankri et al. (2005), again including
the last global item, also found five factors but the
last two factors were dropped for similar reasons. In
this study, factor 1 measured Social Impact (items
6, 10–13, 17), factor 2 Psychological Burden (items
4, 5, 9, 18, 19, 22), and factor 3 Guilt (items 15,
16, 20, 21), retaining altogether 16 of the 22 items.
Similar factor analytic analyses have also been
conducted in Asian populations. Cheah et al. (2012)
performed EFA on the full ZBI in a multiethnic
Singaporean caregiver sample (n = 130). They
found four factors, namely Demands of Care and
Social Impact (items 1–4, 7, 8, 11, 12, 14),
Loss of Confidence/Control (items 13, 15–18),
Psychological Impact (items 5, 6, 9, 10, 19, 22),
and Worry about Performance (items 20, 21; same
as Knight’s Self-criticism factor). Finally, a study
of 523 Mainland Chinese caregivers by Lu et al.
(2009) found a 5-factor structure, while item 22 was
omitted. The largest factor was labeled as Sacrifice
(items 3, 7, 8, 10–14) to refer to the cultural value
emphasizing one’s obligations for family members,
but was similar to Whitlatch’s role strain factor
and the factors framed in terms of daily/social
impact in other studies reviewed above. The other
factors were Loss of Control (items 15–17, 19),
Embarrassment and Anger (items 4–6, 9), Self-
criticism (items 20, 21), and Patient Dependency
(items 1, 2, 18).
Such variations in factor structure from sample
to sample are worrying. The differences in the
cultural backgrounds of the samples might have
contributed somewhat to this situation, but similar
samples from within United States appeared to
have caused similar confusions. Another reason
was that some of the samples were relatively
small, including the one used by Whitlatch et al.
(1991), thus yielding unreliable results. Moreover,
an important point to note is that researchers should
test whether an existing factor model fit the data
before embarking to do another factor analysis.
EFA is known as a “garbage in, garbage out”
procedure, capturing easily on chance correlations.
Thus, finding different results based on another
EFA alone is not sufficient justification to establish
a new factor model. To date, only Knight and
colleagues had performed this check using CFA,
before proposing a new factor model. In the present
study, we examined whether the factor models
reviewed above fit the data in a sample of Hong
Kong Alzheimer caregivers, and if not, what an
alternative model might be.
Methods
Participants and procedure
Data were merged from one survey study (Cheng
et al., 2013a) and an ongoing trial (baseline
measures only; Cheng et al., 2012) of Alzheimer
caregivers in Hong Kong. All were caring for
someone who had a physician diagnosis of
Alzheimer’s disease or who met the National
Institute of Neurological and Communicative
Disorders and Stroke–Alzheimer’s Disease and
Related Disorders Association criteria for possible
Alzheimer’s disease (McKhann et al., 1984).
Participants were recruited from outpatient and
memory clinics, day hospitals, and various non-
governmental organizations. Caregivers provided
informed consent to participate. Interviews took
place at home or in a private area in clinics/centers.

Table 1. Sample characteristics (N = 395)
Age, M/SD 56.6/11.71
Gender (women), % 81
Married, % 72
Education, %
Primary or below 28
Secondary 49
Tertiary 23
Relationship to care-recipient, %
Spouse 27
Child 65
Child-in-law 6 condition of the care-recipient: (a) the Clinical
Sibling, niece or grandchild 2 Dementia Rating (CDR) sum-of-box (Morris,
Living with care-recipient, % 70
Care hours per week, M/SD 73.86/53.60
Care duration (years), M/SD 3.73/3.10
More details about the sample are displayed in
Table 1. The survey study and the clinical trial,
from which data for this study were obtained, were
both approved by the Joint Chinese University of
Hong Kong-New Territories East Cluster Clinical
Research Ethics Committee and the Central
Research Committee of the Hong Kong Institute
of Education.
Measures
Besides the Zarit Burden Interview (rated on a 5-
point scale from 0 = not at all to 4 = extremely;
α = 0.88), caregivers responded to (a) Pearlin
and colleagues’ 4-item measure of role overload,
rated on a 4-point scale from 1 = not at all to
4 = completely (α = 0.80; Pearlin et al., 1990);
(b) the Hamilton Depression Rating Scale (α =
0.80; Hamilton, 1960); (c) self-rated health, being
the sum of two items (rating one’s health directly
and against age- and sex-peers from 1 = very
poor to 5 = excellent; α = 0.75); (d) a 4-item
measure of satisfaction with social support (Cheng
et al., 2013b) in terms of comforting and affection,
companionship, practical assistance, and advice on
caregiving (rated from 1 = very dissatisfied to
6 = very satisfied; α = 0.88); and (e) the Revised
Scale for Caregiving Self-Efficacy (Steffen et al.,
2002), with three items each measuring confidence
in obtaining respite (α = 0.95), managing disruptive
behaviors (α = 0.87), and controlling upsetting
thoughts (α = 0.77) on a scale of 0 = cannot do
at all to 100 = certain can do. In addition, we
constructed measures (five items each) of affection
(rated on a 6-point scale from 1 = not at all to
6 = extremely; α = 0.82) and obligation (rated
from 1 = strongly disagree to 5 = strongly agree;
α = 0.70), by referring to similar measures in the
literature (Cicirelli, 1993; Cicirelli, 2006). Sample
Dimensions of caregiver burden 1457
items are “How much do you understand (your
relative)?” and “Taking into account all factors, how
close you are to (your relative)?” for affection, and
“I should try my best to help (my relative)” and “If
I did not help (my relative), I would feel guilty” for
obligation. Lastly, caregivers reported on caregiving
hours per week, caregiving duration, relationship to,
and whether living together (0 = no, 1 = yes) with
the care-recipient.
A few other measures, based partly or fully on
the caregiver as an informant, pertained to the
1993; Tractenberg et al., 2005), yielding two scores,
that is, cognition (summed ratings of memory,
orientation, and judgment and problem-solving;
α = 0.89) and functioning (community affairs,
home and hobbies, and personal care; α = 0.84); (b)
activities of daily living as measured by a modified
version of the OARS Multidimensional Functional
Assessment Questionnaire, with 14 items rated
as 1 = dependent, 2 = needs assistance, 3 =
independent (α = 0.86; Fillenbaum and Smyer,
1981); and (c) the Neuropsychiatric Inventory
(NPI; Cummings, 1997) assessing 12 behavioral
and psychological symptoms (BPSD) in terms of
frequency (from 1 = occasionally or less than once
a week to 4 = very frequently, once or more per
day or continuously) and severity (1 = mild, 2 =
moderate, 3 = severe), with the total score being
the sum of the product of frequency and severity
across 12 items (α = 0.78). Chinese versions of the
instruments are all available and have been reported
elsewhere (Cheng et al., 2012; Cheng et al., 2013a;
2013b; 2013c).
Statistical analysis
The covariance matrix of the items was subject
to maximum likelihood estimation using LISREL
version 8.52. Following some prior studies, item
22 was not included. Because the ZBI data were
positively skewed, we report the Satorra–Bentler
scaled version of the Chi-square (Satorra and
Bentler, 1994), which corrects the statistic (and
all fit indices based on it), along with the standard
errors of estimates, for nonnormality. As the Chi-
square statistic (the lower, the better) is sensitive to
sample size leading to an inflated chance of falsely
rejecting the null hypothesis of model and observed
data being equivalent, we report additionally CFI,
non-normed fit index (NNFI), RMSEA, and
standardized root-mean-square residual (SRMR).
A well-fitting model should yield CFI/NNFI
ࣙ 0.95 and RMSEA/SRMR ࣘ 0.05, whereas
corresponding values of ࣙ0.90 and ࣘ0.08 would
suggest moderate fit (Marsh et al., 2005). Because
1458 S.-T. Cheng et al.

Table 2. Fit indices of various proposed models

χ2 df p CFI NNFI RMSEA SRMR
............................................................................................................................................................................................................................................................................................................................

Whitlatch’s 2-factor model 1064.31 134 < 0.001 0.75 0.72 0.13 0.11
Knight’s 3-factor model 573.83 75 < 0.001 0.84 0.81 0.13 0.09
Springate’s 3-factor model 942.40 132 < 0.001 0.85 0.83 0.12 0.12
Ankri’s 3-factor model 651.25 101 < 0.001 0.83 0.80 0.12 0.13
Cheah’s 4-factor model 880.94 184 < 0.001 0.88 0.86 0.10 0.09
Lu’s 5-factor model 753.84 180 < 0.001 0.90 0.89 0.09 0.08

the models did not always include the same were loaded simultaneously on the other factors.
number of items, they were not necessarily nested Instead of dropping these items, as was done in
with each other and the Chi-square difference previous studies, we asked for a 4-factor solution.
test could not be used to evaluate relative fit. Interestingly, items 1–10 were loaded on factor 1,
When necessary, we would refer to the Akaike’s items 11–14 on factor 2, items 20 and 21 on factor
information criterion (AIC), which adjusts Chi- 3, and items 15–19 on factor 4.
square for model complexity, with a difference of This 4-factor structure was then subject to CFA
ࣙ10 suggesting an inferior model (Burnham and in Sample B, yielding χ2 (184) = 349.75, p <
Anderson, 2002). However, EFA using principal 0.001, CFI = 0.92, NNFI = 0.91, RMSEA = 0.07,
component analysis with oblique rotation would be SRMR = 0.08. However, on examining the factor
conducted to explore new factor structure if none of loadings, three items were loaded poorly on their
the existing models fit the data at least moderately respective factors, namely item 5 = 0.38, item 15 =
well. Items with loadings ࣙ0.40 were considered to 0.27, and item 18 = 0.12. Modification indices
belong to a specific factor. Finally, product-moment also suggest two large correlated errors associated
correlations were computed between ZBI subscales with item 5. Part of the reason might be the low
(composite scores) as indicated by factor pattern endorsement rates of these items, especially item 5
and caregiver and care-recipient variables to tap into to which a rating of “never” was given by 79% of the
the constructs measured by the respective subscales. participants in Sample B. As a result, we removed
Because symptom measures were skewed, we took these items and fit the model again, yielding even
the square roots of NPI and Hamilton depression. better fit indices: χ2 (130) = 217.80, p < 0.001,
Alpha was set at 0.05, two-tailed. CFI = 0.95, NNFI = 0.94, RMSEA = 0.06,
SRMR = 0.06. Although the χ2 was still statistically
significant, the χ2 /df ratio was a respectable 1.68.
Results Moreover, AIC was found to be 299.80, much
lower than the AIC value of 344.04 before the three
Factor structure items were removed, suggesting that it was a clearly
Confirmatory factor analyses on the whole sample superior model.
(N = 395) showed that none of the models Standardized factor loadings of the final model
fit the data reasonably well (Table 2). Although are presented in Table 3. In light of item contents
Lu and colleagues’ model, discovered in another and previous literature, we named the factors
Chinese sample, produced the most impressive Personal Strain, Captivity, Self-criticism, and
fit indices, the NNFI and RMSEA were still Loss of Control, respectively. Nevertheless, on
marginally outside the acceptable range. Given examination of item contents, item 8 appears to be
these results, we attempted to identify the most more closely related conceptually to Captivity, and
fitting model for Chinese Alzheimer caregivers using item 7 to Loss of Control. To ascertain that the
both exploratory and confirmatory procedures. model presented in Table 3 was indeed optimal,
We randomly split the sample into two using we ran the analysis again with these two items
the random sample function in SPSS version 20, hypothesized to load on Captivity (Alternate A)
performing EFA on Sample A (n = 183) while and Loss of Control (Alternate B), respectively,
using Sample B (n = 212) for an independent resulting in (a) Alternate A: χ2 (130) = 278.33, p
verification of the EFA results. Based on Sample A, < 0.001, CFI = 0.93, NNFI = 0.91, RMSEA =
EFA suggested a 5-factor structure. The last factor 0.07, SRMR = 0.08, AIC = 360.33; and
had three items with both positive (items 8 and 14) (b) Alternate B: χ2 (130) = 235.62, p < 0.001,
and negative (item 19) factor loading coefficients, CFI = 0.94, NNFI = 0.94, RMSEA = 0.06,
hence uninterpretable. Moreover, these three items SRMR = 0.07, AIC = 317.62. Although the fit
 Dimensions of caregiver burden 1459

Table 3. Item descriptive statistics and standardized factor loadings, Sample B (n = 212)
ITEMS M (SD) F1 F2 F3 F4
............................................................................................................................................................................................................................................................................................................................

1. Feel that your relative asks for more help than he/she 0.69 (1.14) 0.50
needs
2. Feel that because of the time you spend with your relative 1.30 (1.47) 0.84
that you do not have enough time for yourself
3. Feel stressed between caring for your relative and trying to 1.51 (1.48) 0.84
meet other responsibilities for your family or work
4. Feel embarrassed over your relative’s behavior 0.76 (1.06) 0.56
5. Feel angry when you are around your relative 0.37 (0.86) —
6. Feel that your relative currently affects your relationships 0.56 (1.01) 0.52
with other family members or friends in a negative way
7. Afraid what the future holds for your relative 1.20 (1.44) 0.45
8. Feel your relative is dependent on you 1.97 (1.72) 0.64
9. Feel strained when you are around your relative 0.53 (1.02) 0.40
10. Feel your health has suffered because of your involvement 0.67 (1.11) 0.71
with your relative
11. Feel that you would not have as much privacy as you 1.77 (1.44) 0.80
would like because of your relative
12. Feel that your social life has suffered because you are 1.43 (1.46) 0.85
caring for your relative
13. Feel uncomfortable about having friends over because of 1.05 (1.42) 0.53
your relative
14. Feel that your relative seems to expect you to take care of 2.17 (1.61) 0.49
him/her as if you were the only one he/she could depend
on
15. Feel that you do not have enough money to take care of 0.74 (1.12) —
your relative in addition to the rest of your expenses
16. Feel that you will be unable to take care of your relative 0.93 (1.36) 0.66
much longer
17. Feel you have lost control of your life since your relative’s 1.04 (1.39) 0.68
illness
18. Wish you could leave the care of your relative to someone 0.77 (1.06) —
else
19. Feel uncertain about what to do about your relative 1.10 (1.28) 0.42
20. Feel you should be doing more for your relative 1.59 (1.36) 0.89
21. Feel you could do a better job in caring for your relative 1.66 (1.30) 0.92
22. Overall, how burdened do you feel about caring for your 2.14 (1.16)
relativea

Note: — = item removed due to poor loading. F1 = personal strain; F2 = captivity; F3 = self-criticism; F4 = loss of control.
a Not included in factor analysis.

Table 4. Factor intercorrelations, Sample B (n = 212) Personal Strain, Captivity, and Loss of Control were
moderately to strongly correlated with each other,
F1 F2 F3 F4 whereas Self-criticism was relatively independent of
........................................................................................................................................................
the other three.
F1: Personal strain —
F2: Captivity 0.65 —
F3: Self-criticism 0.08 0.05 — Correlations with caregiver and
F4: Loss of control 0.38 0.61 0.21 — care-recipient variables
Subscale composites corresponding to the four
factors were created and were correlated with
indices of both of these models were within the selected caregiver and care-recipient variables
acceptable range, their AICs were increased by known to be associated with burden. As a larger
60.5 and 17.8 points, respectively, clearly higher sample can yield more precise estimates due to
than the 10-point threshold. Thus, the model smaller standard errors and is more representative,
presented in Table 3 remains the model of choice. Samples A and B were merged (N = 395) in
Factor intercorrelations (Table 4) suggest that this analysis. A noted finding from Table 5 was
1460 S.-T. Cheng et al.

Table 5. Correlations with caregiver and care-recipient variables, whole sample (N = 395)
F1 F2 F3 F4
............................................................................................................................................................................................................................................................................................................................

Caregiver variables
Age − 0.09 0.06 − 0.30∗∗∗ − 0.11∗
Relationshipa − 0.03 − 0.11∗ 0.26∗∗∗ 0.07
Gender (women) 0.16∗∗∗ 0.07 0.10∗ 0.14∗∗
Care hours per week 0.13∗∗ 0.34∗∗∗ − 0.14∗∗ 0.01
Living together with care-recipient 0.04 0.16∗∗∗ − 0.14∗∗ − 0.04
Self-rated health − 0.37∗∗∗ − 0.09 − 0.21∗∗∗ − 0.21∗∗∗
Felt obligation − 0.02 − 0.00 0.16∗∗ 0.11∗
Affection toward care-recipient 0.05 − 0.09 0.21∗∗∗ 0.00
Social support satisfaction − 0.27∗∗∗ − 0.14∗∗ − 0.11∗ − 0.12∗
Self-efficacy: obtaining respite − 0.28∗∗∗ − 0.28∗∗∗ 0.01 − 0.14∗∗
Self-efficacy: behavior management − 0.35∗∗∗ − 0.21∗∗∗ − 0.09 − 0.12∗
Self-efficacy: controlling upsetting thoughts − 0.47∗∗∗ − 0.38∗∗∗ − 0.11∗ − 0.32∗∗∗
Role overload 0.63∗∗∗ 0.58∗∗∗ 0.19∗∗∗ 0.39∗∗∗
Depressionb 0.55∗∗∗ 0.44∗∗∗ 0.07 0.35∗∗∗
Care-recipient variables
CDR cognition 0.07 0.18∗∗∗ − 0.02 0.05
CDR functioning 0.17∗∗∗ 0.26∗∗∗ − 0.04 0.10∗
BPSDb 0.48∗∗∗ 0.32∗∗∗ 0.12∗ 0.22∗∗∗
Activities of daily living − 0.22∗∗∗ − 0.28∗∗∗ − 0.03 − 0.19∗∗∗

Note: ∗ p < 0.05, ∗∗ p < 0.01, ∗∗∗ p < 0.001. CDR = Clinical Dementia Rating; BPSD = behavioral and psychological symptoms of
dementia; F1 = personal strain; F2 = captivity; F3 = self-criticism; F4 = loss of control. Composite scores, not factor scores, were used in
computation.
a Coded as 0 = spouse and sibling, 1 = adult child, child-in-law, and grandchild.
b Transformed by taking the square root.

that, mirroring the factor intercorrelations, Self- After the removal, the alpha coefficient was found
criticism showed a correlational pattern that was to be 0.88 for this 17-item version of the ZBI (item
rather different from those of the other three 22 included). Had the five items been retained, the
subscales. Not only was Self-criticism unrelated to alpha coefficient was nonetheless identical. Thus,
many variables but the directions of association no internal reliability was lost by removing the five
were even reversed in some cases, such as when items concerned.
correlated with caregiver age, relationship, care
hours, and whether living together. The pattern
suggested that caregivers who did not live with the
Discussion
care-recipient, spent less time in providing care,
and were children, tended to feel that they should This study investigated the dimensions of burden
have done more. Self-criticism was also correlated, in a sample of Hong Kong Chinese Alzheimer
positively, with affection and obligation, suggesting caregivers. As interventions may not address all
that this subscale tapped a sense of guilt by family aspects of caregiver burden, dimensions that can
members who felt a strong sense of responsibility be differentiated from one another may allow
for and were close to the care-recipient, but could researchers to assess the effects of interventions
not provide care as much as one wanted to. more precisely.
Other than the above, the correlational However, none of the factor models reported
patterns were consistent with what one might in the literature were found to fit our data well.
expect from the literature. Of the care-recipient The most plausible model appeared to be a 5-
variables, daily functioning was generally more factor model found in another Chinese sample using
distressing to caregivers than cognitive decline, EFA by Lu et al. (2009). Nevertheless, given the
but the most important predictor of burden was limitations of EFA, it was not even certain whether
BPSD. that particular model fit their data well. In any
Given the findings concerning the Self-criticism case, their model generated from EFA was very
subscale, which consists of only two items, we different from our final model. To some extent, it is
removed them from the scale, together with the difficult to compare the results across studies due to
three items already removed in the factor analysis. differences in the sample and the method employed.

At the same time, the variations in findings suggest
that more research is necessary to replicate a certain
factor structure in any particular cultural group as
well as across cultures.
Using a rigorous, multistep procedure, we found
that a 4-factor model was optimal for Hong
Kong Chinese Alzheimer caregivers. This model
bears some resemblance to others reported in the
literature but is also unique in important ways.
The Self-criticism factor, sometimes labeled as guilt
or worry about performance, was found in several
other studies (Knight et al., 2000; Lu et al., 2009;
Longmire and Knight, 2011; Cheah et al., 2012)
and appears to be the most stable or generalizable
factor across samples and cultures. With further
analysis, we showed that this dimension was related
to the quality of the dyadic relationship and the
feeling that one was obligated to help but was not
doing enough for the loved relative. Future research
may demonstrate whether such observations hold
in other cultural groups. Furthermore, it should be
noted that existing interventions tend to focus on
tackling psychological strain and distress, activity
restriction, physical dependencies, and BPSD
(Cheng et al., in press; Gallagher-Thompson et al.,
2012; Mittelman, 2013), while neglecting Self-
criticism as a contributory factor to caregiver
mental health. Researchers should examine whether
addressing performance concerns would further
enhance the effectiveness of caregiver interventions,
especially in child caregivers.
Personal Strain was the largest dimension of
all, being composed of nine items. This dimension
incorporates several factors referred to by other
researchers as the impacts on one’s life and
psychological well-being (Cheah et al., 2012;
Springate and Tremont, 2014). It is no wonder
that this dimension was, in general, more strongly
correlated with various predictors than the other
dimensions of burden. The second dimension
was often referred to as social impact by other
researchers, although it was not necessarily a
separate factor in other studies (Ankri et al., 2005;
Cheah et al., 2012). On examination of the items,
we feel that this factor taps the extent to which one is
tied to the caregiving role, while the effect on social
life may be one aspect of this experience. If this
factor was measuring social impact, item 6 would
have been loaded on it also. However, not only was
item 6 loaded on a different factor but it had a low
mean score, whereas items in the Captivity factor
had relatively high mean values (Table 3). The
mean values of the Captivity items and correlations
between the total and various variables of interest
suggest that this subscale captures some of the most
common and significant concerns of caregivers.
Finally, the last factor resembles the Loss of Control
Dimensions of caregiver burden 1461
factors found in two other Asian/Chinese samples,
suggesting that the fear of not being able to manage
the situation may be rather common among Asian
caregivers. Correlational analysis suggested that it
was related somewhat to a sense of obligation
for family members, a value system rooted in
Chinese/Asian cultures (Table 5).
It is noteworthy that item 5 on anger had
the lowest endorsement rate. In another study of
Taiwan dementia caregivers, Li and Lewis (2013)
found, within the Level of Expressed Emotion Scale
(Cole and Kazarian, 1988), that the Attitude toward
Illness subscale measuring mostly hostility had low
internal reliability (α = 0.55), probably due to
very low endorsement rates and low variability of
most of the items. The authors attributed this to
the cultural belief in fatalism, helping caregivers to
accept the role. Similarly, the low endorsement rate
of another removed ZBI item, number 18, might
be related to the cultural norm that is strongly
against abandoning an ill family member, especially
the parent. Together with what has been discussed
above, clearly more research into cultural factors in
caregiver burden is needed.
To conclude, a 4-factor structure of the ZBI
discovered through EFA was independently verified
through CFA in another sample of Hong Kong
Chinese caregivers. Not all items appeared to cohere
well; it was found that the internal reliability of the
scale remained the same after removing five suspect
items. Beyond the factor structure of the ZBI,
cultural issues were identified that may be relevant
for optimizing the measurement of caregiver burden
in the Chinese. As the ZBI can be shortened for
the Chinese, more items may be added to subscales
with few items to improve measurement of different
aspects of burden, without substantially lengthening
the administration of the measure. Additionally,
Self-criticism may be studied in its own right,
and may constitute an independent outcome
to be tackled specifically in future intervention
studies.
Finally, more studies using larger and more
representative samples are needed to demonstrate
that this factor structure can be replicated and
generalized. In addition, it will be useful to show
that the factor structure is also valid for those caring
for other types of dementia. This will allow direct
comparison of different aspects of caregiver burden
across dementia types and at different stages of the
different conditions.
Conflict of interest
None.
1462 S.-T. Cheng et al.
Description of authors’ roles
S.-T. Cheng is the principal investigator and led
study design, data analysis, and writing the paper,
while T. Kwok and L.C.W. Lam contributed
to study conceptualization, data collection, and
writing.
Acknowledgments
This study was supported by Strategic Public Policy
Research Grant No. HKIEd1001-SPPR-08 and
General Research Fund No. HKIEd140609, both
from the Research Grants Council of Hong Kong.
The funding source had no involvement in any part
of the project.
References
Alzheimer’s Disease International. (2013). The Global
Impact of Dementia 2013–2050. London: Alzheimer’s
Disease International.
Ankri, J., Andrieu, S., Beaufils, B., Grand, A. and
Henrard, J. C. (2005). Beyond the global score of the
Zarit Burden Interview: useful dimensions for clinicians.
International Journal of Geriatric Psychiatry, 20, 254–260.
Burnham, K. P. and Anderson, D. R. (2002). Model
Selection and Multimodel Inference: A Practical
Information-Theoretic Approach. New York: Springer.
Cheah, W. K., Han, H. C., Chong, M. S., Anthony, P. V.
and Lim, W. S. (2012). Multidimensionality of the Zarit
Burden Interview across the severity spectrum of cognitive
impairment: an Asian perspective. International
Psychogeriatrics, 24, 1846–1854. doi: 10.1017/
S104161021200110X.
Cheng, S.-T., Chou, K.-L. and Zarit, S. H. (2013).
Dementia in Asia: introduction to a special section. Aging
& Mental Health, 17, 911–914. doi:
10.1080/13607863.2013.837151.
Cheng, S.-T., Kwok, T. and Lam, L. C. W. (2012).
Neuropsychiatric symptom clusters of Alzheimer’s disease
in Hong Kong Chinese: prevalence and confirmatory factor
analysis of the Neuropsychiatric Inventory. International
Psychogeriatrics, 24, 1465–1473. doi:
10.1017/S1041610212000609.
Cheng, S.-T., Lam, L. C. W. and Kwok, T. (2013a).
Neuropsychiatric symptom clusters of Alzheimer’s disease
in Hong Kong Chinese: correlates with caregiver burden
and depression. The American Journal of Geriatric Psychiatry,
21, 1029–1037. doi: 10.1016/j.jagp.2013.01.041.
Cheng, S.-T., Lam, L. C. W., Kwok, T., Ng, N. S. S. and
Fung, A. W. T. (2013b). The social networks of Hong
Kong Chinese family caregivers of Alzheimer’s disease:
correlates with positive gains and burden. The Gerontologist,
53, 998–1008. doi: 10.1093/geront/gns195.
Cheng, S.-T., Lam, L. C. W., Kwok, T., Ng, N. S. S. and
Fung, A. W. T. (2013c). Self-efficacy is associated with
less burden and more gains from behavioral problems of
Alzheimer’s disease in Hong Kong Chinese caregivers. The
Gerontologist, 53, 71–80. doi: 10.1093/geront/gns062.
Cheng, S.-T. et al. (in press). Benefit-finding intervention for
Alzheimer caregivers: conceptual framework,
implementation issues, and preliminary efficacy. The
Gerontologist. doi: 10.1093/geront/gnu018.
Cheng, S.-T. et al. (2012). A benefit-finding intervention for
family caregivers of persons with Alzheimer disease: study
protocol of a randomized controlled trial. Trials, 13, 98.
doi: 10.1186/1745-6215-13-98.
Cicirelli, V. G. (2006). Caregiving decision making by older
mothers and adult children: process and expected outcome.
Psychology and Aging, 21, 209–221. doi:
10.1037/0882-7974.21.2.209.
Cicirelli, V. G. (1993). Attachment and obligation as
daughters’ motives for caregiving behavior and subsequent
effect on subjective burden. Psychology and Aging, 8,
144–155. doi: 10.1037/0882-7974.8.2.144.
Cole, J. D. and Kazarian, S. S. (1988). The level of
expressed emotion scale: a new measure of expressed
emotion. Journal of Clinical Psychology, 44, 392–397. doi:
10.1002/1097-4679(198805)44:3< 392::AID-
JCLP2270440313> 3.0.CO;2-3.
Cummings, J. L. (1997). The neuropsychiatric inventory:
assessing psychopathology in dementia patients. Neurology,
48, S10–S16. doi: 10.1016/S0140-6736(05)67889-0.
Fillenbaum, G. G. and Smyer, M. A. (1981). The
development, validity, and reliability of the OARS
Multidimensional Functional Assessment Questionnaire.
Journals of Gerontology, 36, 428–434.
Gallagher-Thompson, D. et al. (2012). International
perspectives on nonpharmacological best practices for
dementia family caregivers: a review. Clinical Gerontologist,
35, 316–355. doi: 10.1080/07317115.2012.678190
Gaugler, J. E., Reese, M. and Mittelman, M. S. (2013).
Effects of the NYU caregiver intervention-adult child on
residential care placement. The Gerontologist, 53, 985–997.
doi: 10.1093/geront/gns193.
Hamilton, M. (1960). A rating scale for depression. Journal of
Neurology, Neurosurgery & Psychiatry, 23, 56–61. doi:
10.1136/jnnp.23.1.56.
Hayashi, S. et al. (2013). Burden of caregivers for patients
with mild cognitive impairment in Japan. International
Psychogeriatrics, 25, 1357–1363. doi: 10.1017/
S1041610213000537.
Knight, B. G., Fox, L. S. and Chou, C. (2000). Factor
structure of the burden interview. Journal of Clinical
Geropsychology, 6, 249–258. doi: 10.1023/
A:1009530711710.
Li, C. Y. and Lewis, F. M. (2013). Expressed emotion and
depression in caregivers of older adults with dementia:
results from Taiwan. Aging & Mental Health, 17,
924–929.
Lin, W., Tsai, C., Wang, S., Hwang, J. and Fuh, J.
(2012). Comparison of the burdens of family caregivers
and foreign paid caregivers of the individuals with
dementia. International Psychogeriatrics, 24, 1953–1961. doi:
10.1017/S1041610212001354.
Longmire, C. V. F. and Knight, B. G. (2011).
Confirmatory factor analysis of a brief version of the Zarit
Burden Interview in Black and White dementia caregivers.
The Gerontologist, 51, 453–462. doi: 10.1093/geront/gnr011.

Lu, L., Wang, L., Yang, X. and Feng, Q. (2009). Zarit
Caregiver Burden Interview: development, reliability and
validity of the Chinese version. Psychiatry and Clinical
Neurosciences, 63, 730–734. doi: 10.1111/j.1440-
1819.2009.02019.x.
Marsh, H. W., Hau, K. and Grayson, D. (2005). Goodness
of fit in structural equation models. In J. J. McArdle (ed.),
Contemporary Psychometrics: A Festschrift for Roderick P.
McDonald (pp. 275–340). Mahwah, NJ: Lawrence
Erlbaum.
McKhann, G., Drachman, D., Folstein, M., Katzman,
R., Price, D. and Stadlan, E. M. (1984). Clinical
diagnosis of Alzheimer’s disease: report of the
NINCDS-ADRDA Work Group under the auspices of
Department of Health and Human Services Task Force on
Alzheimer’s Disease. Neurology, 34, 939–944.
Mittelman, M. (2013). Psychosocial interventions to address
the emotional needs of caregivers of individuals with
Alzheimer’s disease. In S. H. Zarit and R. C. Talley (eds.),
Caregiving for Alzheimer’s Disease and Related Disorders:
Research, Practice, Policy (pp. 17–34). New York: Springer.
Morris, J. C. (1993). The Clinical Dementia Rating (CDR):
current version and scoring rules. Neurology, 43,
2412–2414.
Pearlin, L. I., Mullan, J. T., Semple, S. J. and Skaff,
M. M. (1990). Caregiving and the stress process: an
overview of concepts and their measures. The Gerontologist,
30, 583–594.
Rodriguez-Sanchez, E. et al. (2013). Effects of a
psychological intervention in a primary health care center
for caregivers of dependent relatives: a randomized trial.
The Gerontologist, 53, 397–406. doi: 10.1093/
geront/gns086.
Dimensions of caregiver burden 1463
Satorra, A. and Bentler, P. M. (1994). Corrections to test
statistics and standard errors in covariance structure
analysis. In A. von Eye, C. C. Clogg, A. von Eye and
C. C. Clogg (eds.), Latent Variables Analysis: Applications
for Developmental Research (pp. 399–419). Thousand Oaks,
CA: Sage.
Springate, B. A. and Tremont, G. (2014). Dimensions of
caregiver burden in dementia: impact of demographic,
mood, and care recipient variables. The American Journal of
Geriatric Psychiatry, 22, 294–300.
Steffen, A. M., McKibbin, C., Zeiss, A. M.,
Gallagher-Thompson, D. and Bandura, A. (2002).
The Revised Scale for caregiving self-efficacy: reliability
and validity studies. Journal of Gerontology: Psychological
Sciences, 57B, P74–P86.
Tractenberg, R. E., Weiner, M. F., Cummings, J. L.,
Patterson, M. B. and Thal, L. J. (2005). Independence
of changes in behavior from cognition and function in
community-dwelling persons with Alzheimer’s disease: a
factor analytic approach. The Journal of Neuropsychiatry and
Clinical Neurosciences, 17, 51–60. doi: 10.1176/
appi.neuropsych.17.1.51.
Werner, P., Mittelman, M. S., Goldstein, D. and Heinik,
J. (2012). Family stigma and caregiver burden in
Alzheimer’s disease. The Gerontologist, 52, 89–97. doi:
10.1093/geront/gnr117.
Whitlatch, C. J., Zarit, S. H. and von Eye, A. (1991).
Efficacy of interventions with caregivers: a reanalysis. The
Gerontologist, 31, 9–14. doi: 10.1093/geront/31.1.9.
Zarit, S. H., Reever, K. E. and Bach-Peterson, J. (1980).
Relatives of the impaired elderly: correlates
of feelings of burden. The Gerontologist, 20,
649–655.