Ways of coping of Chinese caregivers for family members with schizophrenia in two metropolitan cities: Guangzhou and Hong Kong,China

Abstract

Background:

In Chinese societies, family caregivers play an important role in the recovery of persons with serious mental illness, such as schizophrenia. While family caregivers are often invaluable sources of caregiving in the community, a majority of them lack adequate knowledge and support skills to cope with the tasks involved.

Aims:

This study compares the coping strategies and psychological health of caregivers for family members with schizophrenia in two Chinese cities, Hong Kong and Guangzhou.

Method:

A total of 109 caregivers, including 39 from Hong Kong and 70 from Guangzhou, were recruited from non-governmental mental health organizations in the two cities. They were assessed by the Chinese version of the Ways of Coping Questionnaire and the General Health Questionnaire.

Results:

While there was no significant difference in the psychological distress of the family caregivers in the two locations, the Guangzhou caregivers adopt significantly more of the eight coping strategies, namely, confronting coping, distancing, self-control, seeking social support, accepting responsibility, escape–avoidance, planful problem solving and positive reappraisal, than their counterparts in Hong Kong. Significant correlations were also found between psychological distress and coping strategies of caregivers in the two cities.

Conclusion:

There were significant differences in the coping strategies of family caregivers for people with schizophrenia in the two Chinese cities. Further studies are warranted to investigate factors affecting their coping strategies and their effects on psychological health.

Keywords

Coping with caregiving severe mental illness Chinese caregivers

Background

Caregivers play an important role in the recovery of people with serious mental illness in Chinese families. While caregiving stress has been well documented in the literature (Greenberg, Kim, & Greenley, 1997; Martens & Addington, 2001), many do not investigate its adverse effects on caregivers’ physical and mental health (Lam, Ng, & Tori, 2013). It is well established that the diagnosis of schizophrenia in a family member can result in shock, anger, confusion and even denial by the family. Research in Hong Kong and China has also indicated that family caregivers have encountered social burdens and coping stress in providing care to family members with schizophrenia (Huang, Hung, Sun, Lin, & Chen, 2009; Liu, Lambert, & Lambert, 2007).

Caregiving of family members with schizophrenia in the Chinese context

As a severe mental illness, schizophrenia is prevalent in China; however, there is a paucity of studies on the effect of caregiving for schizophrenia in China (Huang et al., 2009; Liu et al., 2007). In Chinese societies, caregivers are often bound by kinship obligations beyond those normally associated with a family role (Y. N. Ng & Ho, 2006). In Hong Kong and in most parts of China, it is still a cultural norm for married adult sons or daughters to live with or near the parents after they get married and to provide financial support. In return, the aged parents would continue to shoulder a caregiving role through taking care of the grandchildren and of a family member with mental illness, if necessary. In Hong Kong, family caregivers are affected not only by illness of their family members but also by contextual problems and by the current inadequacies in the mental health care system (Y. N. Ng & Ho, 2006). Many were under stress and were at risk of developing mental health problems (Wong, 2000; Yip, 2004). In China, studies also identified the detrimental impact of the burden of care on the mental health of caregivers themselves (Miao et al., 2003; Yao, 2009). Many family caregivers were found to have poor mental health and to be bearing a heavy burden of care (Yao, 2009).

Coping of caregivers of family members with mental illness

Mental health professionals have examined the role of coping strategies as a means of understanding and assisting families (Hatfield, 1987; Kanter, 1994). Caregivers of family members with mental illness may use a variety of different strategies, which could be categorized as problem-oriented, emotional, cognitive and physical strategies (Matheny, Aycock, Pugh, Curlette, & Cannella, 1986; Spaniol & Jung, 1987).

Problem-oriented strategies include getting and using practical advice, developing tangible support and resources, learning coping skills and becoming involved in advocacy. Emotional strategies include sharing problems and feelings with others, joining a support group, making time for oneself and enhancing spirituality. Cognitive strategies involve recognizing the long-term and serious nature of the illness as well as the limits of mental health interventions. Physical strategies refer to exercising, maintaining proper diet and nutrition, getting sufficient sleep and relaxation, and meditating. Studies in the West indicate that there are variations among family caregivers in the use of these strategies, including

to accept the mental illness and its consequences; to focus on individual and family capabilities rather than limitations; to more actively seek information about the mental illness, services and resources; to be able to develop coping skills related to mental illness; to assume an active and constructive role within the family and the social system; to understand the cognitive, behavioral, emotional and social components of the process of family adaptation; to develop realistic expectations for the family members and for the family; to achieve a balance that meets the needs of all family members; to maintain cognitive and behavioral flexibility; to strive to maintain a normal family lifestyle; to understand and strengthen the family system; to improve communication, conflict resolution, problem-solving, assertiveness, behavior management, and stress management skills; to seek informal and formal sources of social support; to share feelings and coping strategies with other families; to seek outlets outside of the family; to develop collaborative relationships with professionals; to seek professional counselling when appropriate; and to move into an advocacy role. (Marsh, 1992, p. 148)

Cultural concerns of caregiving in Chinese contexts

Caregiving is not only a matter of concern for the well-being of a loved one but also linked to societal and cultural views on personal and collective responsibility and particularly to notions of what is right and appropriate with respect to obligations toward one’s kin (Lefley, 1996). For Chinese caregivers, it is impossible to obtain a comprehensive understanding of their coping without exploring the influence of Chinese cultural characteristics. Chinese caregivers may adopt a different approach from that of their Western counterparts in understanding and coping with caregiving stress. For many Chinese people, caregiving stress is often subsumed under the rubric of ‘suffering’ (Lam & Palsane, 1997), which is determined by fate (P. Ng, Tsun, Su, & Young, 2013). Thus, the patient forbearance or ‘ren’ of such suffering is highly valued. ‘Ren’ has become an important characteristic of the personality of many Chinese people and is a culturally constructed way of coping with ‘suffering’. In order to have greater achievement, Chinese people often believe that they have to endure enormous hardship or ‘ren’ (W. O. Lee, 1996). The ability to tolerate pain, suffering and hardship has been considered to be a process toward perfection of personality in Chinese culture (Chan, Leung, & Ho, 1999). Chinese people believe that ‘ren’ repays the debts of previous lives and cultivates their character. It has positive functions, such as maintaining harmony and peace, decreasing interpersonal conflicts, accomplishing one’s goals, gaining property or benefit, bringing in blessing and preventing future mishaps (M. L. Lee & Yang, 1998).

Furthermore, Chinese cultural values emphasize the importance of maintaining harmonious social relationships, even at the cost of increased personal stress (Y. N. Ng & Ho, 2006). Chinese people tend to consider the reaction of others before determining what coping strategies to adopt. Placing primary concern on familial interests can also be found throughout Chinese society. Although it has been argued that industrialization and modernization have undermined the values and norms of the traditional Chinese family (R. P. L. Lee, 1991), these traditional values still seem to have an ongoing, albeit attenuated, influence.

Objectives

This study aimed at testing and comparing psychological health and ways of coping of family caregivers with relatives with schizophrenia in two Chinese cities, namely, Hong Kong and Guangzhou.

Methods

Sample and procedure

The participants of this study were family caregivers of people with schizophrenia in Hong Kong and Guangzhou. Ethical approvals were obtained from a family resource center in Guangzhou and non-governmental organization providing mental health care service in Hong Kong. Upon consent, 160 caregivers with family members experiencing schizophrenia were invited to attend the interview for the study. In all, 109, including 70 from Guangzhou and 39 from Hong Kong, completed the questionnaire.

Hypothesis

China has a fundamentally different mental health system in comparison with Hong Kong (Xiang, Weng, Leung, Tang, & Ungvari, 2008). It was expected that there would be significant differences in strategies of coping with caregiving stress between caregivers in Hong Kong and Guangzhou. Demographic differences, such as gender and age, on coping strategies between caregivers in Hong Kong and Guangzhou were hypothesized as well.

Instruments

The Ways of Coping Questionnaire

The Ways of Coping Questionnaire (WOC) was developed to assess different coping strategies with specific stressful encounters (Folkman & Lazarus, 1988). A revised version of 50-item WOC, which includes eight subscales, including: (a) Confronting coping, (b) Distancing strategies, (c) Self-control strategies, (d) Seeking social support, (e) Accepting responsibility, (f) Escape–avoidance, (g) Planful problem solving and (h) Positive reappraisal strategies, was used in this study (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986). The Cronbach’s alphas of the eight subscales were .70, .61, .70, .76, .66, .72, .68 and .79, respectively (Folkman et al., 1986). As the participants of this study are Chinese, a Chinese version of the WOC has been developed and verified through stringent back-translation procedures. Two bilingual professionals, one of whom is a primary care physician, independently translated the WOC into Chinese. The Chinese version of the WOC was then back-translated to an English version by a third professional. The participants responded to each item on a 4-point Likert-type scale from ‘0’ (does not apply or is not used’) to ‘3’ (is used a great deal).

General Health Questionnaires-12

The General Health Questionnaires-12 (GHQ-12) is a widely used screening instrument for general psychological distress in both clinical and non-clinical settings (Goldberg & Williams, 1988). In this study, the 12-item Chinese version GHQ was adopted (Boey & Chiu, 1998). The GHQ has two scoring methods, including (a) the total raw score which is the sum of the ratings for each item and (b) a standard score scale that was derived from a two-point scoring procedure whereby each item was rated as becoming worse (1) or better (0). Persons will be identified as psychologically at risk if the sum of their standard scores is ≥3. The internal consistency of Cronbach’s alpha was reported to be .92 and .93 in studies of Chinese samples (Chou, 2007).

Data analysis

Chi-square tests were used to detect differences between participants with regard to demographic variables. Data were inspected for outliers (i.e. scores more than 3 standard deviations (SDs) from the mean), and none were found. With respect to normality, skew and kurtosis values were within reasonable limits ranging from −.04 to 1.59. The highest and lowest kurtosis statistics were −.15 and 1.91. Independent sample t-test was conducted to compare the group difference of the WOC subscale score and GHQ score between the Hong Kong and Guangzhou sample, as well as between the male and female caregivers. Correlational analysis was performed to explore the relationship between WOC and GHQ scores, as well as between demographic variables and WOC scores.

Results

Demographic characteristics of participants

There were 109 participants in the combined samples in this study. The demographic characteristics of the caregivers by the two locations are presented in Table 1. In all, 35 (32.1%) were men and 74 (67.9%) were women. The two samples showed significant differences with regard to the (a) occupation(s) of the caregiver(s), (b) relationship(s) with the patient(s), (c) age(s) of the caregivers, (d) living with the patient(s) and (e) contact with the patient(s). Specifically, the mean age of the Guangzhou caregivers (M = 66.53, SD = 8.34) was significantly higher than that of the Hong Kong caregivers (M = 59.83, SD = 15.17) (p < .05). More caregivers (97.1%) in the Guangzhou sample were retired than those (25.6%) in the Hong Kong sample (p < .001). More caregivers (91.4%) in the Guangzhou sample were parents than those (64.1%) in the Hong Kong sample (p < .01). More caregivers (90.0%) in the Guangzhou sample lived with patients than those (41.0%) in the Hong Kong sample (p < .001).

Table 1.

Demographic characteristics of caregivers and patients by location.

Characteristics	Total sample (N = 109)		Guangzhou sample (n = 70)		Hong Kong Sample (n = 39)		p^a
Gender of caregivers							.055
Men	35 (32.1%)		18 (25.75)		17 (43.6%)
Women	74 (67.9%)		52 (74.3%)		22 (56.4%)
Education level							.115
Primary or lower	36 (32.7%)		23 (32.9%)		13 (32.5%)
Forms 1 to 3	27 (24.5%)		14 (20%)		13 (32.5%)
Forms 4 to 7	26 (23.7%)		15 (21.4%)		11 (27.5%)
University or above	21 (19.1%)		18 (25.7%)		3 (7.5%)
Marital status							.389
Single	3 (2.8%)		1 (1.4%)		2 (5.1%)
Married	80 (73.4%)		52 (74.3%)		28 (72.7%)
Divorced	5 (4.6%)		2 (2.9%)		3 (7.7%)
Widowed	21 (19.3%)		15 (21.4%)		6 (15.4%)
Occupation							.000
Other	31 (28.4%)		2 (2.9%)		29 (74.4%)
Retired	78 (71.6%)		68 (97.1%)		10 (25.6%)
Relationship with patient							.005
Parents	89 (81.7%)		64 (91.4%)		25 (64.1%)
Others	20 (18.3%)		6 (8.6%)		14 (35.9%)
Gender of patients
Male	59 (54.1%)		40 (57.1%)		19 (48.7%)		.397
Female	50 (45.9%)		30 (42.9%)		20 (51.3%)
Living situation of caregivers							.142
Living alone	3 (2.8%)		1 (1.4%)		2 (5.1%)
Living with spouse and children	99 (90.8%)		67 (95.7%)		32 (82.1%)
Living with parents and siblings	3 (2.8%)		1 (1.4%)		2 (5.1%)
Living with others	4 (3.7%)		1 (1.4%)		3 (7.7%)
Living with patients							.000
Yes	79 (72.5%)		63 (90%)		16 (41.0%)
No	30 (27.5%)		7 (10%)		23 (59%)
Weekly contact hour with patients							.035
Less than 4 hours	29 (26.6%)		13 (18.5%)		16 (41.0%)
5–16 hours	26 (23.9%)		16 (22.9%)		10 (25.6%)
More than 17 hours	54 (49.5%)		41 (58.5%)		13 (33.4%)
	M	SD	M	SD	M	SD	p ^b
Period of living with patients in last 4 weeks (days)	20.14	12.15	24.77	8.07	11.82	13.8	.000
Age of patients	38.91	8.48	37.71	7.85	40.82	9.31	.069
Age of caregivers	64.09	11.69	66.53	8.34	59.83	15.17	.011
Duration of onset of illness (year)	16.87	8.75	16.53	8.3	17.49	9.59	.586

M: mean; SD: standard deviation.

Chi-square test.

Independent sample t test.

Differences in coping with caregiving stress in Hong Kong and Guangzhou

Independent sample t-tests showed that the Guangzhou caregivers had a significantly higher mean on all eight WOC subscales than the Hong Kong caregivers (see Table 2). Specifically, the Guangzhou caregivers used significantly more coping strategies of positive reappraisal (M = 11.62, SD = 5.38), seeking social support (M = 11.45, SD = 4.16), self-control (M = 10.45, SD = 4.36), planful problem solving (M = 9.92, SD = 4.30), escape–avoidance (M = 8.94, SD = 3.60), distancing (M = 8.82, SD = 3.64), confronting coping (M = 7.61, SD = 3.82) and accepting responsibility (M = 5.37, SD = 2.64).

Table 2.

Differences in coping strategies and mental health of caregivers by location.

Coping strategies	Overall sample (N = 109)		Guangzhou sample (n = 70)		Hong Kong sample (n = 39)		t	p
	M	SD	M	SD	M	SD
Confronting coping	6.90	3.83	7.61	3.82	5.61	3.55	−2.65	.009
Distancing	7.90	3.77	8.82	3.64	6.25	3.44	−3.59	.000
Self-control	9.39	4.50	10.45	4.36	7.48	4.60	−3.46	.001
Seeking social support	10.39	4.60	11.45	4.16	8.48	4.77	−3.38	.001
Accepting responsibility	4.78	2.79	5.37	2.64	3.71	2.75	−3.08	.003
Escape–avoidance	7.77	4.00	8.94	3.60	5.66	3.85	−4.44	.000
Planful problem solving	8.81	4.46	9.92	4.30	6.79	4.06	−3.72	.000
Positive reappraisal	10.31	5.54	11.62	5.38	7.94	5.06	−3.49	.001
GHQ	13.74	6.85	14.49	7.26	12.41	5.92	−1.53	.130

M: mean; SD: standard deviation; GHQ: General Health Questionnaire.

Regarding the resources for coping, the Guangzhou caregivers were more likely to consult general practitioners (n = 35, 50%) (χ²(1, 109) = 10.8, p < .001) and more likely to seek help from social workers, psychologists or psychiatrists (n = 34, 48.6%) (χ²(1, 109) = 13.9, p < .001; see Table 3). Significantly more caregivers in Guangzhou (n = 55, 78.6%) than those in Hong Kong (n = 5, 13.5%) reported to pay for professional help (χ²(1, 109) = 43.76, p < .001). Similarly, significantly more caregivers in Guangzhou (n = 46, 65.7%) reported to pay for medication for the patients than those in Hong Kong (n = 5, 13.5) (χ²(1, 109) = 28.15, p < .001).

Table 3.

Differences in coping resources by caregivers in Hong Kong and Guangzhou.

Coping resources	Overall sample (N = 109)	Guangzhou sample (n = 70)	Hong Kong sample (n = 39)	x²	p^a
Receiving help from physicians	42 (38.5%)	35 (50%)	7 (17.9%)	10.8	.001
Receiving help from social workers, psychologists, psychiatrists	39 (35.8%)	34 (48.6%)	5 (12.8%)	13.9	.001
Taking medicine	25 (22.9%)	20 (28.6%)	5 (12.8%)		.061

To compare the coping efforts of caregivers, a relative score on the proportion of effort put into each type of coping strategy on a percentage ranging from 1 to 100 was calculated, with a higher percentage representing a greater effort with regard to the application and a lower percentage a lesser effort. The results of the percentage of the relative scores in coping strategies by location are presented in Table 4. The most highly developed coping effort in the total sample was that of seeking social support (16.3%), followed by planful problem solving (13.8%) and positive reappraisal (13.8%), while escape–avoidance (9.1%) and confronting coping (10.8%) represented less effort. Caregivers in the two cities showed similar patterns in the application of the coping strategies. Seeking social support and escape–avoidance were, respectively, ranked as the most and least frequently applied efforts of coping in both Hong Kong and Guangzhou.

Table 4.

Relative scores in coping of caregivers by location and gender.

Coping strategies	Overall sample (%)	Hong Kong sample (%)	Guangzhou sample (%)	Male caregivers (%)	Female caregivers (%)
Seeking social support	16.3	16.9	16.0	16.7	16.1
Planful problem solving	13.8	13.5	13.9	14.0	13.7
Positive reappraisal	13.8	13.6	13.9	12.3	14.4
Self-control	12.6	12.8	12.5	11.8	12.9
Distancing	12.4	12.5	12.3	12.7	12.3
Accepting responsibility	11.2	11.1	11.3	12.9	10.6
Confronting coping	10.8	11.2	10.6	10.3	11.0
Escape–avoidance	9.1	8.5	9.4	9.2	9.1

Differences in psychological health of caregivers in Hong Kong and Guangzhou

No statistically significant difference in the GHQ scores was found between the caregivers in the two locations (t = −1.53, p = .13). A total of 44 (40.4%) mental health cases were identified in the total sample, with 15 (38.5%) in the Hong Kong sample and 29 (41.4%) in the Guangzhou sample. Chi-square test also showed no significant difference in the number of cases and non-cases between the caregivers in Hong Kong and Guangzhou (χ² = .09, p = .76).

Gender differences in psychological health and coping with caregiving stress

Although no significant gender difference in the GHQ score was found (t = −.78, p = .439), significant gender differences were found on all the coping strategies except accepting responsibility (t = −.76, p = .45; see Table 5). Female caregivers utilized significantly more coping strategies than male caregivers (see Table 5).

Table 5.

Gender differences in coping strategies of caregivers.

Coping strategies	Overall sample (N = 109)		Male caregiver (n = 35)		Female caregiver (n = 74)		t	p
	M	SD	M	SD	M	SD
Confronting coping	6.90	3.83	5.37	3.69	7.64	3.71	−2.98	.004
Distancing	7.90	3.77	6.63	3.54	8.51	3.76	−2.49	.014
Self-control	9.39	4.50	7.20	4.14	10.4	4.32	−3.70	.000
Seeking social support	10.39	4.60	8.71	5.02	11.19	4.19	−2.70	.008
Accepting responsibility	4.78	2.79	4.49	3.00	4.92	2.69	−0.76	.451
Escape–avoidance	7.77	4.00	6.37	4.17	8.43	3.77	−2.57	.011
Planful problem solving	8.81	4.46	7.31	4.29	9.51	4.40	−2.46	.016
Positive reappraisal	10.31	5.54	7.49	5.07	11.65	5.27	−3.90	.000

M: mean; SD: standard deviation.

As for the coping effort, seeking social support and escape–avoidance were also ranked, respectively, as the most and least frequently applied efforts of coping for both male and female caregivers. Planful problem solving ranked second among the male caregivers and third among the female caregivers. Furthermore, male caregivers tended to expend less effort on confronting coping. Female caregivers, however, paid less attention to accepting responsibility (see Table 4).

Correlation analysis

Table 6 shows the statistically significant correlations between the GHQ and WOC subscales, as well as between demographic variables and WOC subscales. In the Hong Kong sample, the GHQ score had a significant positive correlation with confronting coping (r = .335, p < .05), indicating that more use of confronting coping strategy was associated with higher level of psychological distress for Hong Kong caregivers. In the Guangzhou sample, the GHQ score was significantly and negatively correlated with positive reappraisal (r = −.256, p < .05), indicating that more use of positively reappraisal was related to less psychological distress for Guangzhou caregivers.

Table 6.

Correlations (r) between WOC subscales and demographic variables and the GHQ of caregivers.

Variables	Confronting coping	Planful problem solving	Positive reappraisal
Hong Kong caregivers
Age of patient		−.359*	−.378*
GHQ	.335*
Guangzhou caregivers
Age of caregiver	−.307**
Educational level of caregiver			−.251*
GHQ			−.256*
Total sample
Age of patient		−.217*

GHQ: General Health Questionnaire; WOC: Ways of Coping Questionnaire.

p < .05; **p < .01; (a) Confronting coping, (b) Distancing, (c) Self-control, (d) Seeking social support, (e) Accepting responsibility, (f) Escape–avoidance, (g) Planful problem solving and (h) Positive reappraisal; only statistically significant correlations are reported.

As for the demographic variables, the age of a patient was found to have a significant negative correlation with planful problem solving in the total sample (r = −.217, p < .05). Different correlational patterns of demographic variables and the WOC subscales were also found between the Hong Kong and Guangzhou sample. In the Hong Kong sample, the age of a patient had a significant negative correlation with planful problem solving (r = −.359, p < .05) and positive reappraisal (r = −.378, p < .005). For Guangzhou caregivers, the age of a patient was found to be negatively correlated with confronting coping (r = −.307, p < .01), while the educational level of caregivers was found to have a significant negative correlation with their positive reappraisal coping (r = −.251, p < .05).

Discussion

Demographic differences in caregivers in Hong Kong and Guangzhou

It was found that more Guangzhou caregivers lived with the patients and consequently had a higher total of weekly contact hours with them. This was probably related to the difference in the availability of psychiatric rehabilitation services and community mental health services between the two cities. In China, psychiatric rehabilitation and community mental health services are limited. There are no residential services such as half-way houses or hostels in Guangzhou. This explains why 90% (63) of the Guangzhou caregivers were living with the patients, while in Hong Kong only 16 (41%) caregivers were doing so. In Hong Kong, more patients were living in half-way houses or hostels, and some of the caregivers were siblings or children who lived farther away from the patients. In addition, vast majority (91.4%) of the Guangzhou caregivers were parents taking care of their children with schizophrenia at home. This percentage was significantly higher than that in the Hong Kong caregivers (64.1%). Also, more caregivers in the Guangzhou sample (97.1%) were retired than those in the Hong Kong sample (25.6%). This indicated that the Guangzhou caregivers may have less financial recourses and more responsibility of caregiving than their counterparts in Hong Kong.

Differences in coping strategies and psychological health of caregivers in Hong Kong and Guangzhou

Guangzhou caregivers were found to have utilized the eight coping strategies more than their counterparts in Hong Kong. The differences in ways of coping with caregiving may also be explained by the differences in the availability of medical and rehabilitation services between the two locations. In Hong Kong, with its relatively comprehensive health care system, every citizen is entitled to public medical services. Moreover, the social security system provides allowances to psychiatric patients or to their families if they have financial need. Various community psychosocial rehabilitation services and facilities have been developed by non-governmental organizations for people with mental illness and their caregivers in Hong Kong. Family caregivers have benefited from these services, as they have thereby been accorded some relief from the tasks involved in providing care and have been equipped with appropriate knowledge and skills in caregiving.

Caregivers in Guangzhou do not enjoy such benefits as the fees for psychiatric inpatient treatment are beyond their means. The monthly rate for inpatient treatment in a psychiatric hospital run by the Civil Affairs Bureau is around RMB 2,000, which is roughly equal to the average monthly income of a family. The monthly fees for inpatient treatment at the psychiatric hospital run by the Health Bureau are even higher (Lam et al., 2013). Unlike Hong Kong, there is no fee exemption policy in Guangzhou and families have to bear a heavy financial burden if their patients require inpatient treatment. In order to reduce such medical expenses, caregivers in Guangzhou must try their best to prevent their afflicted family members from relapse. The socio-economic environment and limited availability of rehabilitation services in Guangzhou place the responsibility for caregiving of afflicted family members on the shoulders of the family itself. This may be consistent with the Chinese cultural value of ‘ren’, self-reliance and face-saving practices. In Chinese communities, families are often unwilling to disclose the mental health problems of family members due to stigmatization. Coupled with limited professional mental health services, they have to rely on themselves to take care of their sick family members. These culturally relevant coping strategies may have positive functions on caregivers’ own psychological health and could explain why no significant difference was found on the GHQ score between Hong Kong and Guangzhou caregivers, although the latter have less available resources for caregiving.

Association of coping strategies and psychological distress for caregivers in Hong Kong and Guangzhou

This study found that psychological distress correlated with coping strategies in different ways in the two Chinese cities. In Hong Kong, caregivers using more confronting coping were found to experience a higher level of psychological distress, while in Guangzhou caregivers who had developed positive meaning for personal growth from caregiving had a lower GHQ. Hong Kong caregivers were more aggressive in taking advantage of opportunities and community resources to facilitate their caregiving tasks. However, they may also be subject to more psychological distress as a result of their efforts. For Guangzhou caregivers, the lack of resources and facilities for psychiatric rehabilitation means that they have to adopt coping strategies more intensively in order to change the situation that they face or to regulate their own emotions. It is also possible that many Guangzhou caregivers may conclude that personal misfortunes are determined by forces beyond their control. They may look at caregiving as preordained and have therefore come to believe that the ‘sufferings’ were also their fate (P. Ng et al., 2013).

There are also significant correlation between the age of patients and caregivers engaging in planful problem solving in Hong Kong and the age of patients and caregivers engaging in confronting coping in Guangzhou. Hong Kong caregivers with young patients tend to use planful problem solving, while younger caregivers in Guangzhou tend to use more confronting coping. Perhaps the Hong Kong caregivers, who are afforded more access to community resources, are more ready to devote efforts to trying to alter the situation. On the other hand, younger caregivers in Guangzhou have undertaken more aggressive efforts in order to alter the situation. The negative correlation found between the level of education of Guangzhou caregivers and their positive reappraisal coping was not surprising. The educational level of people has increased throughout China after the Cultural Revolution, when the government introduced a system of 9 years of free education (Liu et al., 2007). Thus, the increase in the overall educational level may be helping to extend the repertoire of coping strategies upon which Guangzhou caregivers can rely, rather than focusing on the development of personal meaning from the arduous caregiving tasks. However, these are only speculations. More comprehensive research is warranted with regard to the beliefs of the caregivers and to their roles in shaping caregiving coping experiences in China.

Gender differences in coping for caregiving stress

Significant gender differences were found in this study on the use of coping strategies for taking care of relatives with schizophrenia. With the exception of accepting responsibility, female caregivers have made significantly more frequent use of the other seven coping strategies than their male counterparts. Their coping strategies may be affected by both personality variables and the given situations (Lazarus & Folkman, 1984). In general, if a situation is perceived as unchangeable, distancing or positive reappraisal is more likely to be used. In a situation that is regarded as amenable, problem-focused coping should be more likely to be adopted. Although caregivers made use of seeking social support, planful problem solving and positive reappraisal more often than they did of escape–avoidance, the findings are consistent with overseas studies suggesting that caregivers tend to draw on a combination of coping strategies (Magliano et al., 1998; Ohaeri, 2001). Seeking social support is the most frequently adopted coping strategy of both genders. For the male caregivers, accepting responsibility ranked second. However, the second most frequently used coping strategy for female caregivers was positive reappraisal. This is consistent with other studies wherein women tended to use relatively more positive reappraisals than did men (Folkman, Lazarus, Pimley, & Novacek, 1987).

Limitations and future research

This study has several limitations. First, cross-sectional design was used, so it is difficult to determine the causal relationship between coping strategies and psychological distress of caregivers. Second, the relative small sample size of the study may limit the generalization of the findings to a larger group of caregivers. Third, because of the differences in the respective socio-political and health care systems between the two locations, we are mindful of the equivalence and comparability between the Hong Kong Guangzhou caregivers in terms of their efforts and expectations. Future research with more variables, especially some variables related to Chinese cultural values such as ‘ren’, and a longitudinal approach to investigate factors affecting the coping strategies of the caregivers over time and the effects thereof on their psychological health are recommended.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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