920100

research-article2020
JAGXXX10.1177/0733464820920100Journal of Applied GerontologyKhalaila

Original Manuscript
Journal of Applied Gerontology

Caregiver Burden and Compassion 1­–9

© The Author(s) 2020
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https://doi.org/10.1177/0733464820920100
DOI: 10.1177/0733464820920100

Caregivers of Older Relatives journals.sagepub.com/home/jag

Rabia Khalaila1 

Abstract
Objectives: To examine the associations and the mechanisms between caregiver burden and compassion fatigue among
family caregivers.
Method: A cross-sectional study comprising 300 family caregivers of older relatives in Arab communities in Israel was
conducted. Data were collected via face-to-face interviews in Arabic using structured questionnaires to identify factors
associated with compassion fatigue (using a secondary traumatization stress scale). Bootstrapping with resampling strategies
tested the multiple mediator model.
Main findings: The results show a significant total effect of caregiver burden on compassion fatigue (b = 3.79,
t(300) = 3.47, p < .001; R2 =.50). This association was found to be partially mediated by family support (B = .81, 95%
confidence interval [CI] = 0.23, 1.85) and disengagement coping (B = .97, 95% CI = 0.19, 2.14), but was not mediated
by engagement coping strategies.
Conclusion: Compassion fatigue is prevalent among family caregivers and requires more attention from professionals and
policymakers.

Keywords
compassion fatigue, family caregiver, older relatives, secondary traumatization stress, coping strategies

Introduction
Compassion fatigue is “a state of exhaustion and dysfunction
(biological, psychological, and social) which results from pro-
longed exposure to compassion stress” (Figley, 1995, p. 253)
or from exposure to a single intensive event, or from caregiver
exposure to, or over-involvement in, their patients’ emotions
and suffering following traumatic events (Figley, 2002; Radey
& Figley, 2007; Stamm, 2005). Compassion fatigue is also
known as secondary traumatic stress (Figley, 1995; Nimmo &
Huggard, 2013; Stamm, 2005). Compassion fatigue and sec-
ondary traumatic stress (STS) are terms used to describe the
potential emotional impact (such as obsessive thoughts, deep
feelings of pain, anxiety, tension, insomnia, confusion, con-
centration difficulties, or lack of peace of mind) on profes-
sional caregivers who come into close contact with the victim
of a traumatic event (Figley, 1995, 2002). The two terms are
often used interchangeably (Nimmo & Huggard, 2013).
Compassion fatigue has been studied extensively in the
context of professional caregivers, that is, nurses, physi-
cians, social workers, and psychologists (Day & Anderson,
2011; El-bar et al., 2013; Figley, 2002; Sabo, 2006; Yoder,
2010). However, information about compassion fatigue
among family caregivers is scarce (Blair & Perry, 2017;
Day & Anderson, 2011; Lynch & Lobo, 2012; Perry et al.,
2010; Ward-Griffin et al., 2011). Existing studies are mostly
qualitative and examine family members who cared for a
parent in an institution, or professional nurses who cared
for their chronically ill parents living in an institution (Perry
et al., 2010; Ward-Griffin et al., 2011). The extent of com-
passion fatigue among family caregivers and the factors
associated with it have been the subject of only one quanti-
tative study, which used the professional Quality of Life
Scale for measuring compassion fatigue among profes-
sional caregivers (Lynch et al., 2018).
In conservative societies, such as Arab-Israeli or Asian
societies, caregiving by family caregivers is rooted in the
cultural beliefs that encourage family members to ensure
their older relatives’ wellbeing (Khalaila & Litwin, 2012;
Manuscript received: November 22, 2019; final revision received:
March 24, 2020; accepted: March 25, 2020.
1
Zefat Academic College, Israel
Corresponding Author:
Rabia Khalaila, Associate Professor, Vice President for Academic Affairs,
Zefat Academic College, 11 Jerusalem St., P.O.B 169, Zefat 13206, Israel.
Email: rabeikh@zefat.ac.il
2 Journal of Applied Gerontology 00(0)
Lee & Mjelde-Mossey, 2004). Arab society in Israel repre-
sents a minority ethnic group (about 21% of the Israeli popu-
lation) with a conservative orientation in which family
caregiving norms prevail (Khalaila & Litwin, 2012). At the
same time, this society is also undergoing rapid social change
(Litwin & Zoabi, 2003). Family caregivers in Arab-Israeli
society are a unique group who are physically and emotion-
ally involved in the process of caring for an elderly family
member (Khalaila & Litwin, 2012). Almost 99% of the
elderly reside with their families and relatives, and the rest
live in long-term care institutions (Myers-JDC-Brookdale
Institute, 2012).
The burden of supporting and caring for this Arab popula-
tion usually falls on family members due to social, religious,
and cultural obligations (Khalaila & Litwin, 2012). On aver-
age, five family members are involved in caregiving tasks
and provide complex, diverse, and long-term care, but report
high levels of burden and depression (Khalaila & Litwin,
2011, 2012). With the expected increase in the numbers of
senior citizens in general, and in Arab society in Israel in
particular, the caregiver’s burden will increase, and mental
distress will intensify.
The current research attempts to clarify the factors associ-
ated with compassion fatigue among Arab family caregivers
of older relatives in Israel. As such, this inquiry fills a gap in
the literature on how the caregiving process impacts on an
under-investigated conservative population, namely Arab-
Israeli citizens. Because of shared norms, a study of this
population could have implications for conservative Arab
societies and communities worldwide.
Theoretical Framework
Family caregivers exposed to the suffering or illness of
older family members face a variety of pressures and
cumulative burdens, which can lead to negative outcomes
such as compassion fatigue (Day & Anderson, 2011; Lynch
& Lobo, 2012; Lynch et al., 2018). Lazarus and Folkman’s
(1984) theory—The Transactional Model of Stress and
Coping—is the most comprehensive theory to date of cop-
ing with stressful situations such as caring for an older
relative. The theory’s main assumption is that caregivers
are differentiated by three factors: their responses (com-
passion fatigue), the extent to which they are influenced by
the caregiver burden, and background variables (such as
the caregiver’s characteristics). These factors will differ
from individual to individual in terms of the inner resources
(such as coping strategies) and external resources (family
support) accessible to the caregiver during stressful events.
In the present study, this model serves as the basis for
examining the ramifications of compassion fatigue among
family caregivers. Caregiver burden has been defined as
the type of stress or strain that caregivers experience result-
ing from the problems and challenges they face in their
interactions with the care recipients (Zarit et al., 1980). A
number of studies investigating the process of caring for
an older relative have found that family caregivers consis-
tently report high levels of burden (Bainbridge et al., 2009;
James et al., 2020; Khalaila & Litwin, 2011; Kim et al.,
2012; Lynch et al., 2018).
Caregiver burden and compassion fatigue are two differ-
ent states, although it possible that the relationship between
burden and compassion fatigue is reciprocal (Day &
Anderson, 2011). Among family caregivers, the level of per-
ceived burden may correlate with a higher risk of compas-
sion fatigue (Day & Anderson, 2011; Lynch et al., 2018), as
well as with other psychological and emotional states
(Khalaila & Litwin, 2011).
There is also an association between the caregiver’s cop-
ing strategies and mental and emotional distress. One
approach is that of Carver & Connor-Smith (2010) and
Connor-Smith & Flachsbart (2007), who discuss engage-
ment and disengagement coping strategies. In their view,
engagement coping strategies, consisting of active and
engaged strategies, also include emotional coping strategies,
such as active processing and expression of emotion (e.g.,
positive reframing, acceptance, seeking support, problem-
solving, and expressing emotions), and these are assumed to
have an adaptive value under certain stressful circumstances.
Disengagement coping strategies, in contrast, are likely to
distance the individual from the person, environment, or
transaction (e.g., wishful thinking, avoidance, self-criticism,
or social withdrawal) (Carver & Connor-Smith, 2010;
Connor-Smith & Flachsbart, 2007).
Some studies have shown that family caregivers who use
engagement coping more frequently are better able to cope
with stressful situations and respond with lower distress lev-
els (Brodaty & Donkin, 2009). In contrast, disengagement
coping increases the caregiver’s psychological distress
(Brodaty & Donkin, 2009; Zakowski et al., 2001) and is
associated with compassion fatigue (Lynch et al., 2018).
External resources can play a major role in lessening fam-
ily caregivers’ compassion fatigue (Day & Anderson, 2011).
Extensive family support in various forms is an important
resource for reducing caregiver compassion fatigue (Day &
Anderson, 2011; Lynch et al., 2018) and other common care-
giver states such as burden (Lopez-Hartmann et al., 2012).
Conversely, limited family support for the caregiver increases
the burden (Salama & Abou El-Soud, 2012). Furthermore,
the larger the size of the caregiving network, the lesser the
perceived burden (Khalaila & Litwin, 2011).
Several background characteristics associated with the
caregiver, the older relative and caregiving, can be related
to compassion fatigue, due to their relationships with
other common caregiver states such as burden. The care-
giver’s younger age (Pinquart & Sorensen, 2011), female
gender (Kim et al., 2012), unemployed status (Bass et al.,
1996), lower education level (Khalaila & Litwin, 2011),
and co-residency with the care-recipient (Brodaty &
Donkin, 2009; Kim et al., 2012) are all associated with
Khalaila 3
Caregiving Compassion
C
burden fatigue
Perceived
family support
b3
Engagement
a3
coping
Disengagement
coping b2
a2
b1
a1
Caregiver C'
Compassion
burden fatigue
Figure 1.  Multiple mediator model depicting direct effect
without mediators (weight C), and with mediators (weight C′);
and the indirect effects (sum of all a × b weights) of caregiver
burden on CF via three mediators (perceived family support,
coping engagement, and coping disengagement), controlling
covariates.
Note. CF = compassion fatigue.
higher levels of caregiver burden and psychological dis-
tress. Spouses serving as caregivers suffer from mental
distress more than other relatives caring for an older fam-
ily member, with grandchildren suffering less than daugh-
ters-in-law (Pinquart & Sorensen, 2011).
In addition, greater caregiving demands such as the num-
ber of caregiving hours and a large number of caregiving
tasks are associated with high levels of burden, compassion
fatigue, and burnout among family caregivers (Kim et al.,
2012; Lynch et al., 2018; Pinquart & Sorensen, 2011; Salama
& Abou El-Soud, 2012). Contributing factors to family care-
givers’ high levels of caregiver burden may be recipients’
lower cognitive functioning, physical dysfunction, and
behavioral problems (Bass et al., 1996; Pinquart & Sorensen,
2011; Schulz & Martire, 2004).
The purpose of the present study is to examine the asso-
ciation between, and the mechanisms of, caregiver burden
and compassion fatigue among Arab family caregivers of
older relatives; and to examine whether perceived family
support, engagement, and disengagement coping mediate the
associations between caregiver burden and compassion
fatigue (See Study Model: Figure 1).
Hypotheses
1. Hypothesis 1: Caregiver burden is positively associ-
ated with compassion fatigue (after covariates have
been controlled for).
2. Hypothesis 2: Caregiver burden is positively associ-
ated with disengagement coping, which in turn, links
with compassion fatigue.
3. Hypothesis 3: Caregiver burden is negatively associ-
ated with engagement coping, which in turn, links
with compassion fatigue.
4. Hypothesis 4: Caregiver burden is negatively associ-
ated with family support, which in turn links with
compassion fatigue.
Research Design and Method
Design
A cross-sectional study was used to test the hypotheses.
Population and Sample
A convenience sample of family caregivers was recruited
from 10 Arab localities in three regions in Israel: the
north, where 50% of Arab-Israeli citizens reside (five
localities), the center (the Wadi ’Ara area) where 30%
reside (three localities), and the south (the Negev) where
20% reside (two localities). The 10 localities were ran-
domly selected from a list of localities in each area accord-
ing to the distribution of the Arab population in that area.
Social workers specializing in geriatrics in each setting
located all older people in their caseloads defined as need-
ing help for activities of daily living (ADLs), and also
located their family caregivers.
In line with sample size recommendations by Harrell
et al. (1996), that is, 10 participants per parameter for multi-
variate analysis, 320 family caregivers were recruited for the
present study as a convenience sample: 150 from the north,
90 from the center, and 60 from the south of the country.
Inclusion criteria were as follows: adult children (>18 years
old) from the Arab community in Israel who provide care for
older home-based relatives (aged 60 years or more) who
experienced difficulty in at least one ADL. Twenty families
(representing all three areas, including six participants from
the north, five from the center, and nine from the south)
declined to take part in the study, yielding an effective sam-
ple of 300 (response rate = 94%). Unfortunately, we could
not get any more information from those who declined.
Data Collection
Data were collected using a structured questionnaire. We
used a face-to-face survey administration design. All study
instruments were administered in Arabic after they were
translated, adapted for the Arab-Israeli community and vali-
dated in a pilot study of 30 family caregivers from the three
areas representing the research population; back translation
was used to confirm clarity. The data were collected from
December 2014 to November 2015. Face-to-face inter-
views of about 1 hr each were conducted in Arabic at the
4 Journal of Applied Gerontology 00(0)
respondent’s home. No data were missing on variables of
interest to the present analysis; all 300 caregiver-respon-
dents were included in the current analysis.
Measures
Dependent variables.  Compassion fatigue was assessed using
the Secondary Traumatic Stress (STS) Scale (Bride et al.,
2004). This scale was designed specifically for formal care-
givers to evaluate their emotional and behavioral responses
arising from the stories, trauma and pain of people who were
significant in their lives, or from the stress of caring for suf-
fering or traumatized patients (Figley, 1995). The question-
naire consisted of 17 items in the form of statements, for
example, “I was irritable.” Each participant was asked to
rank the frequency of the times that a statement was appro-
priate to a situation in the previous week, on a scale of 0 to 4,
in which 0 = never and 4 = frequently. The total score
results ranged from 0 to 68, in which a high score indicated a
high level of compassion fatigue. Cronbach’s α was .86,
reflecting high internal consistency.
Independent Variable
Perceived caregiver burden.  The full version of this instrument
for measuring the caregiver burden consisted of 22 items
designed for family caregivers to measure the caregiver’s
subjective caregiver burden (Zarit et al., 1980). In the present
study, a short Hebrew version of 12 items (Bachner & Aya-
lon, 2010), was translated into Arabic by Khalaila et al.
(2014). A sample question was “Do you feel stressed between
caring for your relative and trying to meet other responsibili-
ties for your family or work?” In this questionnaire, each
caregiver was asked to note the degree of emotion felt in the
relationship with the family member who was the care-recip-
ient, on a scale of 0 = never to 4 = almost always. Higher
scores correspond to greater caregiver burden. Cronbach’s α
was .89.
Mediators
Coping strategies were measured with the 30-item short ver-
sion of the Coping Orientation to Problems Experienced
(COPE) Scale (Carver et al., 1989) translated into Arabic and
used in previous research (Khalaila et al., 2014). Caregivers
were asked to report the use of coping strategies in dealing
with the care-recipient’s functioning limitations. Coping
strategies include self-blame, active coping, substance use,
behavioral disengagement, denial, humor, planning, emo-
tional processing, emotional expression, self-distraction, and
religious observance. Respondents were asked to rate the
extent to which each strategy was used on a 4-point scale
(0 = not at all, 3 = to a great extent). Factor analysis using
oblique rotation yielded two higher order factors (with 37.5%
of the variance explained). The first was engagement coping
(19.85%), with 11 items such as “Turning to work,” and
“Concentrating my efforts on doing something about the sit-
uation I’m in,” and the second was disengagement coping
(17.62%), with 14 items such as “Doing something to think
about it less,” and “Refusing to believe that it has happened.”
However, five items were dropped (Items 4, 8, 18, 21, and
28) since these items had negative or lower loadings (less
than .40). The two higher order factors were consistent with
findings in other studies (Carver & Connor-Smith, 2010;
Khalaila et al., 2014) and with Carver and Connor-Smith’s
(2010) categorization into two dimensions of engagement/
disengagement coping. The two coping dimensions had
acceptable internal consistency: α = .84 for engagement
coping and α = .82 for disengagement coping.
Perceived family support was measured using the
Expressive Social Support eight-item Scale (Pearlin et al.,
1990). Respondents were asked to rank on a 4-point Likert-
type scale their degree of agreement or disagreement with
statements about the help and support they got from their
friends and relatives in their role as caregivers. A high aver-
age score indicated the perception of a high level of family
support. Cronbach’s α was .85.
Background Variables
Caregiver characteristics.  These were gender, age, education,
family status, employment status, and relationship to the
older care-recipient (son, daughter, grandson/granddaughter,
spouse). Relationship to the older care-recipient was clus-
tered into three categories: adult children = 1, daughters-in-
law = 2, and spouses = 3. In the multivariate analysis, the
variable was divided into two dummy variables: Dummy
Variable 1—daughter-in-law (daughters-in-law = 1, adult
children = 0). Dummy Variable 2—spouse (spouse = 1,
adult children = 0). Caregiving characteristics included the
number of days per week, the number of caregiving tasks,
and the number of secondary family caregivers. There were
13 assistance tasks (e.g., bathing the care-recipient, feeding,
or shopping), with a high score on this measure indicating a
greater number of assistance tasks.
The questionnaire also included items relating to the older
care-recipient, such as the proximity of residence to the care-
giver (different building or distant neighborhood = 0, co-
resident or in the same building = 1). Also tested was the
degree to which the care-recipient experienced difficulties in
ADLs as measured by the ADL Scale (ADLs) developed by
Katz et al. (1970). The overall score on this scale ranges
from 0 to 8, where a high score indicates very limited func-
tioning. The questionnaire included a measure for assessing
the cognitive status of the older relative developed by Galvin
and colleagues (2005), consisting of eight items. Caregivers
were asked to respond with a “yes” or “no” to each item (e.g.,
“The older relative has impaired judgment,” “. . . problems in
decision-making”). A high score indicated cognitive impair-
ment. Cronbach’s α was .83.
Khalaila 5

Data Analyses Table 1.  Bivariate Tests of Covariates and Compassion Fatigue
(N = 300).
Descriptive statistics were applied to the background and
study variables (p < .05). Next, associations between the Covariates Test
independent variable, dependent variable, mediators, and Caregiver’s gender t = 3.3**
control variables were examined using an independent  Male 13.0 (11.8)
t test, one-way analysis of variance (ANOVA) and the  Female 18.0 (12.7)
Pearson correlation test. Multiple mediator analyses were Caregiver’s employment status t = 2.1*
then computed in which the three selected mediators  Employed 14.6 (11.7)
(Meds.: engagement coping strategies, disengagement cop-  Unemployed 17.8 (13.3)
ing strategies, and perceived family support) were entered Caregiver’s relationship F = 13.3***
simultaneously to test the components of the mediation   Daughter, son, or grandchild 13.8 (11.6)
model using bootstrapping to assess the indirect effects of  Daughter-in-law 23.0 (12.6)
the mediation model (Model 4) (Hayes, 2012; Preacher &  Spouse 19.1 (14.4)
Hayes, 2008). Thus, the multiple meditation model was Caregiver’s marital status t = 1.3
examined by directly testing the significance of the indirect  Married 15.4 (12.2)
effect of the independent variable (caregiver burden) on the  Unmarried 17.6 (13.2)
dependent variable (compassion fatigue) through the three Caregiver’s age r = –.04
selected mediators described above, while controlling for Caregiver’s education r = –.20**
Number of secondary caregivers r = –.14*
background variables identified earlier as significant in the
Caregiving days/week r = –.02
bivariate analyses.
Number of caregiving tasks r = –.15*
This method is based on regression analysis, calculating
Residential proximity ρ = .07
the direct effect (weight C′, with mediators), total effect (1 = co-resident, 6 = distant)
(C, without mediators), and indirect effects (a × b weights) Care-recipient ADL r = .07
of an independent variable on a dependent variable. The Care-recipient’s cognitive status r = .17**
total and specific indirect effects were calculated through
bootstrapping set at 5,000 samples. Confidence intervals Note. ADL = activity of daily living.
*p < .05. **p < .01. ***p < .001.
were calculated using this method by sorting the lowest to
highest of these 5,000 samples of the original data set,
yielding a 95 percentile confidence interval. All analyses Table 2.  Descriptive Statistics and Pearson Correlations Among
were run using SPSS 20.0 with the PROCESS statistical Independent Variable, Mediators, and Compassion Fatigue
program (Hayes, 2012). (N = 300).
Variables 1. 2. 3. 4.

Results 1. Caregiver burden 1.00  

The results show that 61% of the caregivers were mostly
adult children (sons, 31.7%; daughters, 29.3%), followed by
daughters-in-law, grandchildren, and spouses. Most of the
caregivers were married (approx. 71%) and slightly less
than half were unemployed; average age was 40.7 years,
ranging from 18 to 75 years. The caregivers’ average years
of education was 11.5 years with a wide range of between 0
and 20 years.
The results also show that primary family caregivers pro-
vided care on an average of 5 days a week, helped by an
average of five secondary family caregivers. The caregivers
were found to provide assistance in about 10 of 13 ADLs
that the older care-recipient could not carry out indepen-
dently. About half of the caregivers were co-resident with
the care-recipient in the same house or building, while oth-
ers were close by in the same or adjacent neighborhood. The
population of the care recipients was characterized by a
medium-level of need of assistance in ADL (median = 3.5,
interquartile range = 2–6.5) and high-level cognitive func-
tioning (median = 6.0, interquartile range = 2.7–8.0).
2. Engagement coping −.18*  
3. Disengagement coping .21*** .04  
4. Perceived family support −.33*** .24*** −.20***  
6. Compassion fatigue .40*** −.10 .43*** .39***
*p < .05. **p < .01. ***p < .001.
Table 1 displays the results of the bivariate tests of covari-
ates between the background variables and compassion
fatigue. The table shows that greater levels of compassion
fatigue are related to female gender, relationship with the
care-recipient (daughters-in-law and spouses as compared
with children and grandchildren), unemployed status, low
level of education, a greater number of care tasks, and a
decrease in the care-recipient’s cognitive performance.
Table 2 displays the outcomes of the Pearson correlations
among the independent variable, mediators, and compassion
fatigue. The table shows that greater compassion fatigue
scores are related to higher levels of caregiver burden and
disengagement coping scores, and to lower levels of per-
ceived family support and engagement coping scores.
6 Journal of Applied Gerontology 00(0)

Table 3.  Summary of Multiple Mediator Model Depicting Direct and Indirect Effects of Caregiver Burden on Compassion Fatigue,
Controlling for Covariates (N = 300).
Effect Effect of IV Effect of Direct Indirect effect
Background variables Mediating variables background on mediator mediator on effect Total Variance
covariates IV (mediators) DV variables on DV (Paths a) DV (Paths b) (Path C′) (a × b) 95% CI effect (C) R2

Gender Caregiver Perceived social Compassion 0.33 −0.22** −3.72** 3.79*** 0.81 [0.2, 1.8] 5.66** .50***
burden support fatigue
Employment status Engagement coping 1.11 −0.15* −0.53 0.08 [−0.3, 0.5]  
Caregiver’s relationship Disengagement 7.32** 0.16* 6.24*** 0.97 [0.2, 2.1]  
(D1) coping
Caregiver’s relationship 6.32  
(D2)
Caregiver’s education −0.48*  
Number of secondary −0.49**  
caregivers
Number of caregiving 0.55  
tasks
Care-recipient’s 0.12  
cognitive state

Note. Value labels of categorical variables: employment status (1 = employed, 0 = unemployed), relationship D1 (1 = daughter-in-law, 0 = adult children), relationship
D2 (1 = spouse, 0 = adult children). IV = independent variable; DV = dependent variable; CI = confidence interval; R-squared = the proportion of the variance for a
dependent variable that’s explained by an independent variables.
*p < .05. **p < .01. ***p< .001.

Table 3 displays the multiple mediator analysis for exam-
ining the effect of caregiver burden on compassion fatigue
among Arab family caregivers, before and after the simulta-
neous introduction of three mediators (family support,
engagement coping, and disengagement coping), while con-
trolling for the significant background variables. The results
show a significant total effect of caregiver burden on com-
passion fatigue (C: b = 5.66, t[300] = 4.91, p < .001;
R2 =.35). The findings show an indirect significant associa-
tion between caregiver burden and compassion fatigue
through two mediators: perceived family support (B = .81,
95% confidence interval [CI] = 0.23, 1.85) and disengage-
ment coping (B = .97, 95% CI = 0.19, 2.14). However, the
mediating effect of engagement coping was not found to be
significant. Thus, a positive significant association was
found between perceived caregiver burden and disengage-
ment coping (Path a1), which, in turn, was associated posi-
tively with compassion fatigue (Path b1). A significant
negative association was also found between caregiver bur-
den and family support (Path a3), which, in turn, exhibited a
negative association with compassion fatigue (Path b3). The
findings also show that the association between caregiver
burden and compassion fatigue remains significant after con-
trolling for mediating variables and for background variables
(C′: b = 3.79, t(300) = 3.47, p < .001; R2 =.50). This means
that family support and disengagement coping partially
mediate between caregiver burden and compassion fatigue.
However, engagement coping does not mediate in the asso-
ciation between caregiver burden and compassion fatigue,
neither does it correlate with compassion fatigue.
In addition, we found that the daughter-in-law relation-
ship, education, number of family caregivers, and number of
caregiving tasks are all associated with compassion fatigue.
Daughters-in-law reported higher compassion fatigue scores
than adult children. In contrast, higher educational levels and
a greater number of secondary caregivers reduce the compas-
sion fatigue scores. Caregiver involvement in a greater num-
ber of caregiving tasks was also associated with higher
compassion fatigue scores.
Discussion
The aim of the present study was to investigate the factors
and the mediators of compassion fatigue among Arab family
caregivers. As posited in the first hypothesis, the major factor
correlating with compassion fatigue was the caregiver bur-
den. We found that the caregiver burden is positively associ-
ated with compassion fatigue. However, it is difficult to
determine whether a greater burden of care produces greater
compassion fatigue, or vice versa. The direction of the cor-
relation between the two states of the caregiver may even be
reciprocal (Day & Anderson, 2011). This reinforces findings
from previous studies that found similar associations (Day &
Anderson, 2011; Lynch & Lobo, 2012; Lynch et al., 2018).
The present findings show that the physical and emotional
involvement of Arab family caregivers in the caregiving pro-
cess of older relatives is reflected in a perceived high-care-
giver burden as well as in the development of symptoms of
compassion fatigue.
Our results also reinforce the distinction between care-
giver burden and compassion fatigue (Day & Anderson,
2011; Lynch & Lobo, 2012). In fact, our bivariate analysis
(see Table 2) showed that these two measures were not
strongly related (r = .40, p < .001). In addition, the results
also show that each measure correlated differently with the
other measures of the caregivers, such as engagement and
disengagement coping, and family support. These indicate
that there are no grounds for possible multicollinearity
between the caregivers’ measures in the current study, and
each measure tested a different state.
Khalaila 7
This result can be partially understood by identifying
which coping strategies the caregiver used—disengagement
coping or engagement coping. We found that perceived care-
giver burden increases the use of disengagement coping,
which in turn increases the caregiver’s compassion fatigue.
However, engagement coping did not mediate the correlation
between caregiver burden and compassion fatigue. These
findings confirm the second hypothesis, while failing to con-
firm the third hypothesis. The results reinforce those of a pre-
vious study, which noted the negative ramifications of caring
for an older family member for the family caregiver’s mental
and physical health, leading to emotion-focused coping strat-
egies or disengagement coping that could indicate early
compassion fatigue (Lynch et al., 2018).
Using disengagement coping for compassion fatigue rein-
forces the assumptions at the heart of Lazarus and Folkman’s
theory, which refer to the function of coping strategies as
mediators in the association between the caregiver burden
during the caregiving process for an older relative and the
caregiver’s distress (Lazarus & Folkman, 1984). The bivari-
ate associations between engagement coping and compas-
sion fatigue appear to be correlated with other variables
entered in the present study analyses. Consequently, it is
likely that the impact of the engagement coping strategy on
compassion fatigue is blocked by disengagement coping,
which was the stronger factor.
The findings also reveal that perceived family support has
a significant mediating effect between the caregiver burden
and compassion fatigue. A perceived high burden is associ-
ated with perceived low family support, which in turn
increases symptoms of compassion fatigue. This result con-
firms the fourth hypothesis and supports the model devel-
oped by Pearlin and colleagues (1990) who pointed
specifically to family support of the caregiver’s role as a
mediating factor between the caregiver burden and its mental
and emotional ramifications. However, we cannot determine
whether a high burden reduces family support or whether
high family support mediates the impact of burden on com-
passion fatigue. Nevertheless, it is possible that a lower care-
giver burden reinforces family cohesion and support for the
role of the primary caregiver.
This finding reinforces those of other studies conducted in
various world locations that point to the vital importance of
family support for the role of the caregiver in lessening the
damage done by the caregiver burden leading to mental and
physical distress (Khalaila & Litwin, 2011; Lynch et al.,
2018; Salama & Abou El-Soud, 2012). Such support medi-
ates between the caregiver burden and mental health
(Khalaila & Litwin, 2011; Lopez-Hartmann et al., 2012).
Limitations
The current study has several potential limitations that should
be addressed in future research. First, since it is a cross-sec-
tional study, its ability to identify a causal effect between the
variables is limited. For example, we cannot determine
whether a high caregiver burden increases compassion
fatigue or whether high compassion fatigue causes the care-
giver burden. The second limitation is the lack of a control
group of adult respondents with no caregiving experience.
An additional limitation is associated with the generalizabil-
ity of the research data to the overall family caregivers of
older people, because the sample represents a small minority
group in Israel.
Conclusion and Implications
The present study focused on the issues related to family
caregiving of relatives. Compassion fatigue is a phenomenon
that probably exists among family caregivers, as revealed in
this study of family caregivers in Arab communities in Israel.
The study highlighted several major contributors of compas-
sion fatigue. The major factor was the caregiver’s burden. In
addition, a perceived high level of family support and the
avoidance of disengagement coping strategies are important
mediators between caregiver burden and compassion fatigue.
Practitioners working with family caregivers of older rela-
tives that belong to conservative communities could benefit
from more carefully considering culturally tailored interven-
tions to support caregivers’ well-being and to help minimize
their sense of burden and compassion fatigue symptoms.
From an empirical viewpoint, the potential contribution
of this study to scholars in the fields of social gerontology
and family research is embodied in the originality of this
study as a pioneering examination of compassion fatigue
among family caregivers in the minority Arab group in Israel
and as an investigation of the mechanisms of this phenome-
non. The study has the potential to stimulate further research
and can lead to programming implications for practice and
theory. The data obtained in this study contribute to the theo-
retical basis for future studies seeking to examine this phe-
nomenon among family caregivers in different societies.
Future research should continue to expand our knowledge of
the factors and mechanisms that are related to compassion
fatigue among family caregivers in various societies else-
where, because of the different cultural and religious
approaches to the moral obligation of caring for older
relatives.
Acknowledgments
We acknowledge the Israel National Institute for Health Services
and Health Policy for its assistance in support of this research.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Ethical Approval
The Institutional Review Board (IRB) of the Zefat Academic
College, Israel, approved the current research prior to the study (the
IRB is written in Hebrew. It says that the study meets the ethical
8 Journal of Applied Gerontology 00(0)
requirements and is approved). The IRB application number: 2014-
27. Participants gave written informed consent and received a guar-
antee of confidentiality.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: The
current study is funded by the “The Israel National Institute for
Health Policy and Services Research.” Study number 198-14.
ORCID iD
Rabia Khalaila https://orcid.org/0000-0003-0488-1303
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