Psychiatry and Clinical Neurosciences 2010; 64: 377386

doi:10.1111/j.1440-1819.2010.02104.x

Regular Article

Caregiver burden and coping strategies for patients with

schizophrenia: Comparison between Japan and Korea
pcn_2104

377..386

Setsuko Hanzawa, PhD,1* Jeong-Kyu Bae, PhD,2 Hideki Tanaka, PhD,3 Yong Jun Bae,4
Goro Tanaka, PhD,5 Hiroyuki Inadomi, PhD,6 Yoshibumi Nakane, MD, PhD7 and
Yasuyuki Ohta, MD, PhD8
1

School of Nursing, Jichi Medical University, Tochigi, 3Graduate School of Human Sciences, Waseda University, Saitama,
Faculty of Social Welfare, Nagasaki Wesleyan University, 5Graduate School of Biomedical Sciences, Nagasaki University,
7
Dejima Shinryosho (Mental Clinic), Nagasaki, 6Faculty of Rehabilitation, Hyogo Medical University, Hyogo, 8Graduate
School of Health and Social Welfare, Nishikyushu University, Saga, Japan and 2Department of Psychology, Daegu
University, Daegu, Korea
4

Aim: With the current shift to community-centered

mental health services, considerable research on the
family burden of caring for patients with schizophrenia has been conducted in developed countries.
However, there has been no investigation of families
with Japanese or Korean sociocultural backgrounds.
Therefore, the present study compared the caregiver
burden and coping strategies of families of patients
with schizophrenia in Japan and Korea in order to
elucidate similarities and differences in the sociocultural factors that affect the care experience of families
in Northeast Asia.
Methods: A total of 99 Japanese (Nagasaki) and 92
Korean (Seoul, Daegu) family members of patients
with schizophrenia were surveyed in regards to caregiver burden, coping strategies, and nursing awareness of the caregiver role regarding the patient with
schizophrenia.
Results: Analysis revealed the following: (i) although
no difference in caregiver burden and coping strategy

HE LAST SEVERAL decades have produced two

important lines of research involving families of

*Correspondence: Setsuko Hanzawa, PhD, School of Nursing, Jichi

Medical University, Yakushiji 3311-159, Shimotsuke-shi, Tochigi
329-0498, Japan. Email: hanzawa@jichi.ac.jp
Field: (6) social psychiatry and epidemiology
Received 10 April 2009; revised 10 March 2010; accepted 25 April
2010.

was observed between the countries, the nursing

awareness of families caregiver role was significantly
higher in Japan than in Korea; (ii) caregiver burden
was significantly associated with the patients social
functioning and care needs in both countries; and
(iii) caregiver burden was significantly associated
with reduction of social interests, coercion, avoidance, resignation, and nursing awareness of caregiver
role in both countries.

Conclusion: Although the nursing awareness of families roles in caring for patients with schizophrenia
differed between Japan and Korea, similar trends
were observed for the causes of caregiver burden.
These findings suggest that in order to provide effective support for reducing caregiver burden, the necessity of such support must be emphasized in both
countries.
Key words: caregivers, cross-cultural comparison,
Japan, Korea, schizophrenia.

persons with severe mental illness: one has focused

on family burden and the experience of caring for an
ill relative and the other on family communication
patterns and interactions (e.g. expressed emotion).
These lines of research have led to the development
and testing of clinical models of family psychoeducation.1 Previous research suggests that the level
of caregiver burden is reduced when family members
have a more positive attitude toward the patient and

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377

378

S. Hanzawa et al.

when there is an increase in social support, fewer

hospitalizations, and improved social functioning of
the patient.1
Recently, the factors influencing the extent of caregiver burden have attracted attention, and various
caregiver characteristics, patient variables and
regional differences have been identified as predictors
of caregiver burden.2 Caregiver burden can also reflect
regional differences regarding patients socioeconomic situation and family support,3 as well as the
provision of rehabilitative interventions for patients.4
Roick et al. reported that the burden placed on family
members of people with schizophrenia may be influenced not only by patient and caregiver characteristics but also by national differences in the provision
of mental health-care services.5 This assumption was
evaluated by comparing Germany and Britain, two
Northern European countries that differ appreciably
in the provision of mental health services. Even after
controlling for patient and caregiver characteristics,
British caregivers reported a significantly higher level
of burden than German caregivers.5 In another comparison study, higher burden was observed in Italy
and Britain compared with the Netherlands, Spain
and Denmark as a result of differences in the provision of mental healthcare services.6 Differences in
caregiver burden could be caused by cultural characteristics, as cultures may differ in their appraisal of
mental illness, ranging in attitude from acceptance
and integration into society to stigmatization; religious beliefs, beliefs about the origin of mental
illness, and societys appraisal of the caregivers role
also play a part.6
In addition, as the vast majority of previous studies
were conducted in Western cultures, it has been difficult to apply their findings to family caregivers in
Asian countries. In a sample of caregivers of family
members with schizophrenia in Japan and England,
Nomura et al. reported that expressed emotion did
not correlate significantly with caregiver burden,
and a decreasing tendency in caregivers positive
and negative emotional reactions towards family
members, particularly critical comments in the
Japanese sample, was observed.7 In our research in a
Japanese population, we identified resignation and
losing social interests as coping strategies that
correlated significantly with caregiver burden in
schizophrenia.8
East Asian cultures (Japan, Korea and China),
based primarily on Confucian ideas, have traditionally emphasized the importance of providing care for

Psychiatry and Clinical Neurosciences 2010; 64: 377386

dependents. Studies of Chinese families in Malaysia

have demonstrated that the stigma of relatives
mental illness has a strong and pervasive impact on
family caregivers, and as a result family caregivers
often avoid talking about their relatives mental
illness with extended family or friends in order to
protect their families from losing face.9 In a recent
study on caregiver burden in China, families who
perceived a higher level of caregiver burden had
poorer functioning, worse health status and lower
satisfaction with social support, and social support
was identified as the best predictor of caregiver burden.10 These results were similar to those obtained
from our survey of Japanese families.11
A cross-cultural and cross-national comparison of
caregiver burden between Japan and Taiwan showed
that Japanese respondents perceived a significantly
stronger stigma for the parents and neighbors of a
person with a mental illness presented in a vignette
than Taiwanese respondents.12,13 Haraguchi et al.
reported that social distance, knowledge of mental
illness, and treatment (medication) for mental illness
were all higher in Japan than in China; the reasons
for this include the fact that there are many advanced
mental health-care inpatient facilities as well as
regional rehabilitation services in Japan, and Japan
formerly had a long-term hospitalization system and
hospital detention policy (people with mental illnesses could be admitted involuntarily to a psychiatric hospital).14 In contrast, a recent study of Korea,
Japans closest neighbor, indicated that among relatives of patients with schizophrenia, those with less
knowledge exhibited more inappropriate coping
strategies and a higher burden.15
In Japan, where the institutionalization rate for
schizophrenia patients is the highest in the world, the
number of psychiatric beds has not decreased, while
in Korea, a steady increase in the number of psychiatric beds has been observed over the past 10 years.16
However, little is known about the correlation
between caregiver burden for families of patients
with schizophrenia in Northeast Asian countries and
sociocultural factors, which may differ from country
to country in the appraisal of the caregivers role and
coping strategies. Therefore, it is important to
compare Japan and Korea to identify differences
in sociocultural background that could contribute
to differences in caregiver burden in these two
countries.
The following research points regarding intercultural aspects formed the focus of the present study.

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Psychiatry and Clinical Neurosciences 2010; 64: 377386

Care burden comparison Japan and Korea

First, the tendency for Japanese families to exhibit

decreased emotional expression towards family
members as compared to Korean families was
explored. Second, differences in religious beliefs and
beliefs about the origin of mental illness and in
appraisal of the caregivers role were identified
through cross-cultural comparison of Japan and
Korea, emphasizing the history of hospitalization
and cultural differences.

relationship to the patient and whether the respondent lived with the patient. Section 3 consisted of
self-rated questions relating to caregiver burden,
coping strategies and nursing awareness of the caregivers role.
In the present study, caregiver burden was assessed
using the eight-item short version of the Zarit
Caregiver Burden Interview (ZBI-8).8,1824 The ZBI-8
consists of eight questions graded using a fivepoint Likert scale (04 points), with higher scores
representing increased caregiver burden.
The 23-item Family Coping Questionnaire (FCQ23)25 was used to rate coping strategies on seven
subscales: information acquisition, positive communication, social interest, coercion, avoidance, resignation, and patients social involvement. The FCQ-23
consists of 23 questions graded using a four-point
Likert scale (14 points), with higher scores indicating better coping strategies.
The seven-item Nursing Awareness Among Caregivers Scale (NA-7)26 was used to rate family
members awareness of the caregivers role. For this
scale, seven items were evaluated using a four-point
Likert scale (14 points), with lower scores indicating
higher awareness of the caregivers role.
Korean translations of the J-ZBI-8, FCQ-23 and
NA-7 were administered to the Korean participants.
Each item was first translated by Korean members of
our research project, one of whom has 10 years of
experience working in a Japanese university. Another
Korean member, a research assistant at Daegu
University, checked the accuracy of the translated
questionnaires.

METHODS
Subjects
The purpose and methods of the study were
explained in advance at the general meeting of the
Federation of Families of People with Mental Illness
in Nagasaki, Japan and in Seoul and Daegu, Korea.
During the meeting, 13 local family groups for
mutual support in Nagasaki and 12 local family
groups for mutual support in Seoul and Daegu agreed
to participate in the study. Before conducting the
survey, all participants received a written explanation
about the purpose of the study and provided
informed consent to participate. A total of 162 family
members in Nagasaki and 125 family members in
Seoul and Daegu gave consent to participate and were
included in the study. The study was conducted from
October 2004 to March 2005 in Nagasaki and from
October 2007 to March 2008 in Seoul and Daegu.
The study protocol was approved by the Ethics Committee of Nagasaki University Graduate School of
Biomedical Sciences (Approval no. 15111258).
Subjects were from 99 families in Nagasaki and 92
families in Seoul and Daegu. All subjects were family
members of a patient who was diagnosed with
schizophrenia according to the ICD-10 diagnostic criteria.17 If a family was caring for two or more patients,
they were asked to fill out the questionnaire with
respect to the patient who required the greatest level
of care.

Questionnaire
The questionnaire consisted of three sections. Section
1 collected patient-related information on the demographic features of the participants: age, gender,
total number of hospitalizations, and occupation
(employment/workshop/day-care center) and the
patients social functioning and care needs. Section 2
collected family-related information: age, family

379

Statistical analyses
Caregiver burden was compared among families with
different sociodemographic backgrounds using a
t-test (for comparisons between two groups) and
analysis of variance (for comparisons among three or
more groups). In addition, caregiver burden, coping
strategies, and nursing awareness were compared
between Japan (Nagasaki) and Korea (Seoul and
Daegu) using a t-test. Relationships between caregiver
burden and other factors were then investigated using
multiple regression analysis with burden of care as
the dependent variable after deriving Spearmans
rank-order correlation coefficients. SPSS 12.0 for
Windows (SPSS, Chicago, IL, USA) was used for all
statistical analyses. The level of statistical significance
was set at less than 5%.

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S. Hanzawa et al.

RESULTS
Sociodemographic characteristics and
caregiver burden
Table 1 shows the sociodemographic characteristics
of patients and families for the Japanese and Korean
surveys.
In both Japan and Korea, approximately 70% of
patients were men. The mean age of patients was
39 years in Japan and 36 years in Korea. In Korea,
patient age was found to be associated with burden of
care (P < 0.05). A total of 21% and 4% of Japanese
and Korean patients, respectively, reported no
previous hospitalization. Approximately half of
the patients regularly visited workshops or day-care
centers for disabled individuals. The proportion of
patients who occasionally required support due to
limitations in their daily or social lives was 35% in
Japan and 48% in Korea. In both countries, patients
social functioning and care needs were found to be
associated with caregiver burden.
The mean age of family members was 65 years in
Japan and 60 years in Korea. A total of 72% and 59%
of Japanese and Korean family members, respectively, were mothers. Approximately 90% of families
lived with patients in both countries. A total of 48%
and 28% of Japanese and Korean families, respectively, had alternative caregivers.

Evaluation of burden of care, coping

strategies and nursing awareness
Table 2 shows the results from the burden of care,
coping strategies, and nursing awareness for the
Japanese and Korean surveys.
For the ZBI-8, Cronbachs alphas were high, at 0.91
in Japan and 0.88 in Korea. ZBI-8 scores ranged from
1 to 32; the mean total score was 11.0 (SD = 8.0) in
Japan and 10.3 (SD = 7.0) in Korea. There was no
significant difference between Japan and Korea in
mean ZBI-8 score. Table 2 shows the distribution of
response scores for each item. Responses with mean
scores that were higher in Japan than in Korea
included Do you feel embarrassed by your relatives
behavior? (P < 0.05).
For the FCQ-23, Cronbachs alphas were moderately high, at 0.74 in Japan and 0.77 in Korea. The
mean total scores were 65.6 (SD = 8.1) in Japan and
67.8 (SD = 8.4) in Korea. The mean FCQ-23 score
was not significantly different between Japan and

Psychiatry and Clinical Neurosciences 2010; 64: 377386

Korea. Table 2 shows the distribution of response

scores for each item. Responses with mean scores
higher in Korea than in Japan included social
involvement (P < 0.001).
For the NA-7, Cronbachs alphas were high, at 0.89
in Japan and 0.66 in Korea. The mean total scores
were 16.7 (SD = 6.3) in Japan and 20.9 (SD = 4.5) in
Korea. The mean NA-7 score was significantly lower
in Japan than in Korea (P < 0.001). In the distribution of response scores for each item, responses with
mean lower scores in Japan than in Korea included I
want care to be provided only by family members as
much as possible without using home help services
(P < 0.05), I do not feel comfortable having
someone outside the family take care of the individual (P < 0.001), The individual seems to feel
uncomfortable with others entering his/her house
(P < 0.001), The individual seems to feel uncomfortable being cared by someone outside the family
(P < 0.001), My other family members do not feel
comfortable with having others take care of the individual (P < 0.01), and I am concerned about what
my relatives and neighbors might think (P < 0.001).

Factors related to caregiver burden

Correlations between ZBI-8 score and other factors,
such as coping strategies and nursing awareness, are
summarized in Table 3. Significant correlations with
ZBI-8 score were observed for the total coping strategy score in both countries (P < 0.01 in Japan,
P < 0.001 in Korea). Regarding individual scores for
the subscales of coping strategies, in both countries,
correlations with ZBI-8 score were observed for
social interests (P < 0.01 in Japan, P < 0.001 in
Korea), coercion (P < 0.001 in Japan, P < 0.001
in Korea), avoidance (P < 0.001 in Japan, P < 0.001
in Korea), and resignation (P < 0.001 in Japan,
P < 0.001 in Korea).

Multiple regression analysis using ZBI-8

scores as dependent variables
Results of the multiple regression analysis are
summarized in Table 4.
Multiple regression analysis of the data from
Japanese participants was performed using variables
that were significantly associated with caregiver
burden (patients social functioning and care needs,
social interests, coercion, avoidance and resignation
subscales of coping strategies, and the three

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Psychiatry and Clinical Neurosciences 2010; 64: 377386

Care burden comparison Japan and Korea

381

Table 1. Sociodemographic characteristics

Japan
(n = 99)
n
Patients
Age
Mean (SD)
Gender
Male
Female
Total number of hospitalizations
0
1
2
3
4
5+
Total years of hospitalization
0
<1
<3
<5
<10
<15
<20
<30
>30
Current treatment status
Inpatient
Outpatient
Social involvement
Employment
Part-time employment
Workshop & Day care
Able to help around the house
Unable to help around the house and
sometimes goes outside
Unable to help around the house and doesnt
go outside
Patients social function and care needs
Able to behave ordinarily in their daily or
social lives
Occasionally requires support due to certain
limitations
Occasionally requires support due to serious
limitations
Usually requires support due to serious
limitations
Always requires support because unable to
perform in daily or social lives

Korea
(n = 92)
P

r = -0.222 0.034

r = -0.176 0.093 35.8 (8.1)

38.5(9.5)

74
25

74.7 t = -1.561
25.3

0.122 65
27

70.7 t = 0.413
29.3

0.681

21
29
15
13
7
14

21.2 F = 0.932
29.3
15.2
13.1
7.1
14.1

0.465

4
9
24
16
13
26

4.3 F = 0.656
9.8
26.1
17.4
14.1
28.3

0.658

20
33
20
10
8
2
0
1
0

20.2 F = 0.986
33.3
20.2
10.1
8.1
2.0
0.0
2.0 .
0.0

0.440

6
44
22
8
8
1
3
0
0

6.5 F = 0.565
47.8
23.9
8.7
8.7
1.1
3.3
0.0
0.0

0.757

1
90

1.0 t = -0.875
90.9

0.384

7
85

7.6 t = -1.130
92.4

0.299

2
4
42
11
18

2.0 F = 1.949
4.0
42.4
11.1
18.2

0.094

2
2
53
8
16

2.2 F = 1.435
2.2
57.6
8.7
17.4

0.220

15

15.2

11

12.0

24

24.2 F = 7.890

34

34.3

44

47.8

18

18.2

12

13.0

13

13.1

6.5

3.0

3.3

0.000 27

29.3 F = 7.303

0.000

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S. Hanzawa et al.

Psychiatry and Clinical Neurosciences 2010; 64: 377386

Table 1. (Continued)
Japan
(n = 99)
n
Age
Mean (SD)
Relationship
Father
Mother
Husband
Wife
Daughter
Son
Other
Living with patient
Alternative carer

Spearman.

ANOVA.

65.0 (8.2)
18
71
1
2
0
1
1
84
47

Korea
(n = 92)
P

r = -0.113 0.277 59.7 (11.7)

18.2 F = 0.613 0.690 22
71.7
54
1.0
3
2.0
3
0.0
2
1.0
1
1.0
7
84.8 t = -0.171 0.865 83
47.5 t = -0.002 0.998 26

P
r = -0.022 0.834

23.9 F = 0.315 0.927

58.7
3.3
3.3
2.2
1.1
7.6
90.2 t = -1.173 0.272
28.3 t = -1.001 0.316

t-test.

individual scores of nursing awareness) as independent variables and caregiver burden as the dependent
variable. Caregiver burden was found to be significantly associated with the patients social functioning
(P < 0.05), the coercion and resignation subscale of
coping strategies (P < 0.05), and The individual
seems to feel uncomfortable being cared for by
someone outside of the family as a factor of nursing
awareness (P < 0.05).
Multiple regression analysis of the data from
Korean participants was performed using variables
that were significantly associated with caregiver
burden (patients age, social functioning and care
needs, social interests, coercion, avoidance and resignation subscales of coping strategies, and the four
individual scores of nursing awareness) as independent variables and caregiver burden as the dependent
variable. Caregiver burden was significantly associated with patients age (P < 0.05), social functioning
and care needs (P < 0.05), social interests (P < 0.05),
coercion (P < 0.01), avoidance (P < 0.01), and My
other family members do not feel comfortable with
having others take care of the individual as a factor of
nursing awareness (P < 0.05).

DISCUSSION
The results of the present study clarified similarities
and differences in the characteristics of patients with
schizophrenia and their families who belong to
family support groups in Japan and Korea.

Several differences between patients in Korea and

Japan were observed. For example, when compared
to Japanese patients, Korean patients were younger,
and in Korea, the younger the patient, the greater the
caregiver burden. In addition, the proportion of Japanese and Korean patients who were frequently hospitalized (at least three times) was 34.3% and 59.8%,
respectively; clearly, Korean patients with schizophrenia were hospitalized more frequently over short
periods of time. There were also differences between
the two countries in social activities over the past year
and the levels of living skills and care needs. In the
present study, Korean patients were younger, had
more opportunities to go out during the day and
exhibited less impairment in activities of daily living
as compared to Japanese patients. However, Korean
patients were hospitalized more frequently and their
families more strongly encouraged social participation. A multiple regression analysis in a previous
study identified the number of hospitalizations in the
previous 3 years and kinship (mother/father/other)
as significant predictors of caregiver burden.24 The
present results did not identify the total number of
hospitalizations in the previous year as a significant
predictor in either country; however, patients social
function and care needs were both identified as
significant predictors of caregiver burden in both
Japan and Korea.
The results of the present study also suggest that
when compared to Korean families, nursing awareness of the caregivers role in Japanese families (I

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Psychiatry and Clinical Neurosciences 2010; 64: 377386

Care burden comparison Japan and Korea

383

Table 2. ZBI-8, FCQ-23, and NA-7 scores for Japan and Korea
Japan
(n = 99)

ZBI-8
Do you feel embarrassed over your relatives behavior?
Do you feel angry when you are around your relative?
Do you feel that your relative currently affects your
relationship with other family members or friends?
Do you feel strained when you are around your relative?
Do you feel that your social life has suffered because you
are caring for your relative?
Do you feel uncomfortable about having friends over
because of your relative?
Do you wish you could just leave the care of your relative
to someone else?
Do you feel uncertain about what to do about your
relative?
FCQ-23
Information
Positive communication
Social interests
Coercion
Avoidance
Resignation
Patients social involvement
NA-7
I want care to be provided only by family members as
much as possible
I do not feel comfortable with having someone outside
the family take care of the individual
I am reluctant to have others take care of the individual
because it is my responsibility
The individual seems to feel uncomfortable with others
entering his/her house
The individual seems to feel uncomfortable with being
cared for by someone outside the family
My other family members do not feel comfortable with
having others take care of the individual
I am concerned about what my relatives and neighbors
might think

Korea
(n = 92)

Mean

SD

Mean

SD

11.0
1.9
1.5
1.3

8.0
1.2
1.2
1.3

10.3
1.5
1.5
1.3

7.0
1.3
1.0
1.2

-0.682
-2.559
0.135
-0.308

0.496
0.011*
0.893
0.758

1.5
1.0

1.3
1.3

1.2
1.2

1.2
1.2

-1.920
1.185

0.056
0.237

1.4

1.5

1.2

1.2

-1.044

0.298

1.1

1.3

0.8

1.2

-1.446

0.150

1.6

1.2

1.7

1.2

0.331

0.741

65.6
5.1
12.8
10.6
15.7
10.9
6.3
4.4
16.7
2.4

8.1
1.6
3.5
2.3
2.5
1.6
1.9
1.7
6.3
1.3

67.8
5.7
14.0
10.4
15.1
10.9
6.1
5.7
20.9
2.8

8.4
1.7
3.3
2.5
2.8
1.7
1.9
1.7
4.5
1.2

1.807
2.324
2.378
-0.505
-1.575
-0.124
-0.559
5.359
5.108
2.264

0.072
0.021*
0.018*
0.614
0.117
0.901
0.577
0.000***
0.000***
0.025*

2.6

1.2

3.4

1.0

5.099

0.000***

2.6

1.2

2.9

1.2

1.350

0.179

2.3

1.2

2.9

1.1

3.558

0.000***

2.1

1.1

2.8

1.1

4.245

0.000***

2.4

1.1

2.9

1.1

3.022

0.003**

2.5

1.1

3.3

1.0

5.246

0.000***

*P < 0.05; **P < 0.01; ***P < 0.001.

FCQ-23, Family Coping Questionnaire; NA-7, seven-item Nursing Awareness Among Caregivers Scale; ZBI-8, the 8-item short
version of the Zarit Caregiver Burden Interview.

want care to be provided only by family members as

much as possible) was significantly greater; however,
in both countries, family caregiver burden was significantly correlated with nursing awareness of the fact
that The individual seems to feel uncomfortable with
being cared by someone outside the family. In other

words, in both countries, patients with schizophrenia

are likely to avoid contact with non-family members
and isolate themselves from society, and these factors
are related to the degree of family caregiver burden.
In a study comparing five European countries,
regional differences were identified in caregiver

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S. Hanzawa et al.

Psychiatry and Clinical Neurosciences 2010; 64: 377386

Table 3. Correlations between ZBI-8 and other scales for Japan and Korea
Japan
(n = 99)

FCQ-23
Information
Positive communication
Social interests
Coercion
Avoidance
Resignation
Patients social involvement
NA-7
I want care to be provided only by family members as much as
possible
I do not feel comfortable with having someone outside the family
take care of the individual
I am reluctant to have others take care of the individual because it is
my responsibility
The individual seems to feel uncomfortable with others entering
his/her house
The individual seems to feel uncomfortable with being cared for by
someone outside the family
My other family members do not feel comfortable with having
others take care of the individual
I am concerned about what my relatives and neighbors might think

Korea
(n = 92)

-0.330
0.143
0.074
-0.271
-0.437
-0.582
-0.652
0.159
-0.042
0.275

0.001**
0.173
0.482
0.009**
0.000***
0.000***
0.000***
0.126
0.705
0.008**

-0.454
0.166
-0.124
-0.349
-0.400
-0.435
-0.393
-0.171
0.022
0.163

0.000***
0.113
0.240
0.001**
0.000***
0.000***
0.000***
0.104
0.838
0.121

0.051

0.631

-0.132

0.209

0.124

0.238

0.350

0.001**

-0.220

0.035*

-0.241

0.020*

-0.310

0.003**

-0.228

0.029*

-0.078

0.467

0.208

0.046*

-0.137

0.192

-0.133

0.206

*P < 0.05; **P < 0.01; ***P < 0.001 (Spearman).

FCQ-23, Family Coping Questionnaire; NA-7, seven-item Nursing Awareness Among Caregivers Scale; ZBI-8, the 8-item short
version of the Zarit Caregiver Burden Interview.

burden and support inside and outside the family.27

The present results demonstrated slight differences in
independent factors for caregiver burden between
Japan and Korea. In Japan, families who agreed with
the statement The individual seems to feel uncomfortable with being cared for by someone outside the
family were more likely to have greater caregiver
burden. In Korea, family members who agreed with
the statement My other family members do not feel
comfortable with having others take care of the individual were more likely to have low caregiver
burden. The results from Korea suggest that when
other family members also think that a patient with
schizophrenia should be cared for by family, family
members are more likely to collaborate in order to
reduce caregiver burden. However, 70% of Korean
families did not have someone who could provide
care, which was a higher proportion than that
observed in Japan. These findings suggest that, in
Korea, it is difficult for family members to find car-

egivers who can provide care on behalf of the family,

despite the fact that Confucian ideas and the tradition of providing care to family members contribute
to the reduction of caregiver burden.
The present results clarified that, while caregiver
burden is high in both Korea and Japan, patients
and family members have a strong desire to restrict
care to family members. This issue should be discussed further, especially in relation to the quality
of community mental health-care services, in order
to reduce family caregiver burden; e.g. general practitioners, home-visit nurses, home-help service providers, mutual support group members, other
outreach services, and integrated assertive community services should provide advice for families
having difficulties finding treatment and should
suggest coping strategies for patients, especially
during relapse of illness. Early intervention may be
an effective form of support for the first episode of
schizophrenia.

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Journal compilation 2010 Japanese Society of Psychiatry and Neurology

Psychiatry and Clinical Neurosciences 2010; 64: 377386

Care burden comparison Japan and Korea

385

Table 4. Multiple regression for ZBI-8 as a dependent variable for Japan and Korea
Japan
(n = 80)
b

Independent variable
Patients age
Patients social function and care needs
FCQ-23
Social interests
Coercion
Avoidance
Resignation
NA-7
I want care to be provided only by family members as much
as possible
I am reluctant to have others take care of the individual
because it is my responsibility
The individual seems to feel uncomfortable with others
entering his/her house
The individual seems to feel uncomfortable with being cared
for by someone outside the family
My other family members do not feel comfortable with
having others take care of the individual
R
R2

Korea
(n = 91)
P

0.216

2.596

0.011*

-0.197
0.199

-2.558
2.335

0.012*
0.022*

-0.061
-0.181
-0.169
-0.352

-0.751
-2.134
-1.936
-3.582

0.455
0.036*
0.057
0.001**

-0.193
-0.244
-0.269
-0.140

-2.268
-2.743
-2.918
-1.630

0.026*
0.007**
0.005**
0.107

0.103

1.183

0.022

0.222

0.825

0.241

0.189

1.460

0.149

-0.091

-1.030

0.306

-0.342

-2.656

0.010*

-0.114

-1.230

0.222

0.204

2.173

0.033*

0.796
0.633

0.767
0.588

*P < 0.05; **P < 0.01.

b, standardized regression coefficient; FCQ-23, Family Coping Questionnaire; NA-7, seven-item Nursing Awareness Among
Caregivers Scale; R, multiple correlation coefficient; ZBI-8, the 8-item short version of the Zarit Caregiver Burden Interview.

Limitations and future studies

First, although the reliability and validity of each
questionnaire used in the present study have been
confirmed in Japan,8 the reliability of the Korean
version has not been sufficiently investigated.
Second, as participants lived only in Nagasaki, Seoul
or Daegu, our target population is therefore not representative of the general populations of Japan and
Korea. A comparative study of national surveys across
different cultures requires more in-depth studies in
both countries. In particular, further investigation of
factors influencing the stigmatization of schizophrenia and its effect on the families of patients with
schizophrenia is therefore necessary. In order to
design more effective family and community support
programs, we plan to address these issues in future
studies.

ACKNOWLEDGMENTS
This study was conducted as part of a research project
entitled Sociocultural and natural-environmental

factors related to the burden for families of patients

with schizophrenia, which was supported by a
Grant-in-Aid for Scientific Research (KAKENHI) (C)
(19592603) (2007-09) from the Japanese Ministry of
Education, Culture, Sports, Science and Technology
(MEXT). The authors deeply appreciate the cooperation of the members of the Federation of Families of
People with Mental Illness in Nagasaki and Seoul and
Daegu, without which the study would never have
been completed.

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