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Cross-national differences in the prevalence and correlates of burden among older family caregivers in the World Health Organization World Mental Health (WMH) Surveys

Published online by Cambridge University Press:  09 August 2012

V. Shahly ,
S. Chatterji ,
M. J. Gruber ,
A. Al-Hamzawi ,
J. Alonso ,
L. H. Andrade ,
M. C. Angermeyer ,
R. Bruffaerts ,
B. Bunting  and
J. M. Caldas-de-Almeida
...Show all authors
V. Shahly
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
S. Chatterji
Affiliation:
World Health Organization, Geneva, Switzerland
M. J. Gruber
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
A. Al-Hamzawi
Affiliation:
Al-Qadisia University College of Medicine, Diwania Teaching Hospital, Diwania, Iraq
J. Alonso
Affiliation:
Health Services Research Unit, IMIM (Hospital del Mar Research Institute), and CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
L. H. Andrade
Affiliation:
Section of Psychiatric Epidemiology, São Paulo, Brazil
M. C. Angermeyer
Affiliation:
Center for Public Mental Health, Gösing am Wagram, Austria
R. Bruffaerts
Affiliation:
Universitair Psychiatrisch Centrum – Katholieke Universiteit Leuven (UPC-KUL), Leuven, Belgium
B. Bunting
Affiliation:
University of Ulster, Londonderry, UK
J. M. Caldas-de-Almeida
Affiliation:
Chronic Diseases Research Center (CEDOC) and Department of Mental Health, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo dos Mártires da Pátria, Lisbon, Portugal
G. de Girolamo
Affiliation:
IRCCS Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
P. de Jonge
Affiliation:
University Medical Center Groningen, Groningen, The Netherlands
S. Florescu
Affiliation:
National School of Public Health Management and Professional Development, Bucharest, Romania
O. Gureje
Affiliation:
Department of Psychiatry, University of Ibadan, College of Medicine, Ibadan, Nigeria
J. M. Haro
Affiliation:
Parc Sanitari Sant Joan de Déu, CIBERSAM, Sant Boi de Llobregat, Barcelona, Spain
H. R. Hinkov
Affiliation:
National Center for Public Health Protection, Sofia, Bulgaria
C. Hu
Affiliation:
Shenzhen Institute of Mental Health & Shenzhen Kangning Hospital, Shenzhen, People's Republic of China
E. G. Karam
Affiliation:
Institute for Development, Research, Advocacy and Applied Care (IDRAAC), St. George Hospital University Medical Center, Beirut, Lebanon
J.-P. Lépine
Affiliation:
Hôpital Lariboisiére Fernand Widal, Assistance Publique Hôpitaux de Paris INSERM U 705, CNRS UMR 7157 University Paris Diderot and Paris Descartes Paris, France
D. Levinson
Affiliation:
Research and Planning, Mental Health Services, Ministry of Health, Jerusalem, Israel
M. E. Medina-Mora
Affiliation:
Instituto Nacional de Psiquiatria Ramon de La Fuente Muñiz, Mexico City, Mexico
J. Posada-Villa
Affiliation:
Instituto Colombiano del Sistema Nervioso, Bogota, Colombia
N. A. Sampson
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
J. K. Trivedi
Affiliation:
Department of Psychiatry, C.S.M. Medical University, Lucknow, India
M. C. Viana
Affiliation:
Department of Social Medicine, Federal University of Espírito Santo, Vitória, Brazil
R. C. Kessler*
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
*
*Address for correspondence: R. C. Kessler, Ph.D., Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA, 02115, USA. (Email: ncs@hcp.med.harvard.edu)
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Abstract

Background

Current trends in population aging affect both recipients and providers of informal family caregiving, as the pool of family caregivers is shrinking while demand is increasing. Epidemiological research has not yet examined the implications of these trends for burdens experienced by aging family caregivers.

Method

Cross-sectional community surveys in 20 countries asked 13 892 respondents aged 50+ years about the objective (time, financial) and subjective (distress, embarrassment) burdens they experience in providing care to first-degree relatives with 12 broadly defined serious physical and mental conditions. Differential burden was examined by country income category, kinship status and type of condition.

Results

Among the 26.9–42.5% respondents in high-, upper-middle-, and low-/lower-middle-income countries reporting serious relative health conditions, 35.7–42.5% reported burden. Of those, 25.2–29.0% spent time and 13.5–19.4% money, while 24.4–30.6% felt distress and 6.4–21.7% embarrassment. Mean caregiving hours per week in those giving any time were 16.6–23.6 (169.9–205.8 h/week per 100 people aged 50+ years). Burden in low-/lower-middle-income countries was 2- to 3-fold higher than in higher-income countries, with any financial burden averaging 14.3% of median family income in high-, 17.7% in upper-middle-, and 39.8% in low-/lower-middle-income countries. Higher burden was reported by women than men and for conditions of spouses and children than parents or siblings.

Conclusions

Uncompensated family caregiving is an important societal asset that offsets rising formal healthcare costs. However, the substantial burdens experienced by aging caregivers across multiple family health conditions and geographic regions threaten the continued integrity of their caregiving capacity. Initiatives supporting older family caregivers are consequently needed, especially in low-/lower-middle-income countries.

Keywords

Caregiverscross-national studiesepidemiologyfamily burdenmental health
Type
Original Articles
Information
Psychological Medicine , Volume 43 , Issue 4 , April 2013 , pp. 865 - 879
Copyright
Copyright © Cambridge University Press 2012

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References

Awad, AG, Voruganti, LN (2008). The burden of schizophrenia on caregivers: a review. Pharmacoeconomics 26, 149–162.CrossRefGoogle ScholarPubMed
Beaglehole, R, Epping-Jordan, J, Patel, V, Chopra, M, Ebrahim, S, Kidd, M, Haines, A (2008). Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care. Lancet 372, 940–949.CrossRefGoogle ScholarPubMed
Bedard, M, Pedlar, D, Martin, NJ, Malott, O, Stones, MJ (2000). Burden in caregivers of cognitively impaired older adults living in the community: methodological issues and determinants. International Psychogeriatrics 12, 307–332.CrossRefGoogle ScholarPubMed
Bloom, DE (2011). 7 Billion and counting. Science 333, 562–569.CrossRefGoogle ScholarPubMed
Bolin, K, Lindgren, B, Lundborg, P (2008). Your next of kin or your own career? Caring and working among the 50+ of Europe. Journal of Health Economics 27, 718–738.CrossRefGoogle ScholarPubMed
Brummett, BH, Boyle, SH, Siegler, IC, Kuhn, CM, Surwit, RS, Garrett, ME, Collins, A, Ashley-Koch, A, Williams, RB (2008). HPA axis function in male caregivers: effect of the monoamine oxidase-A gene promoter (MAOA-uVNTR). Biological Psychology 79, 250–255.CrossRefGoogle ScholarPubMed
Buntin, MB, Zaslavsky, AM (2004). Too much ado about two-part models and transformation? Comparing methods of modeling Medicare expenditures. Journal of Health Economics 23, 525–542.CrossRefGoogle ScholarPubMed
Carmichael, F, Charles, S (2003). The opportunity costs of informal care: does gender matter? Journal of Health Economics 22, 781–803.CrossRefGoogle ScholarPubMed
Carter, R (2008). Addressing the caregiving crisis. Preventing Chronic Disease 5, A02.Google ScholarPubMed
Christakis, NA, Allison, PD (2006). Mortality after the hospitalization of a spouse. New England Journal of Medicine 354, 719–730.CrossRefGoogle ScholarPubMed
Christensen, K, Doblhammer, G, Rau, R, Vaupel, JW (2009). Ageing populations: the challenges ahead. Lancet 374, 1196–1208.CrossRefGoogle ScholarPubMed
Chumbler, NR, Grimm, JW, Cody, M, Beck, C (2003). Gender, kinship and caregiver burden: the case of community-dwelling memory impaired seniors. International Journal of Geriatric Psychiatry 18, 722–732.CrossRefGoogle ScholarPubMed
Ekwall, AK, Sivberg, B, Hallberg, IR (2007). Older caregivers' coping strategies and sense of coherence in relation to quality of life. Journal of Advanced Nursing 57, 584–596.CrossRefGoogle ScholarPubMed
Fredman, L, Cauley, JA, Satterfield, S, Simonsick, E, Spencer, SM, Ayonayon, HN, Harris, TB (2008). Caregiving, mortality, and mobility decline: the Health, Aging, and Body Composition (Health ABC) Study. Archives of Internal Medicine 168, 2154–2162.CrossRefGoogle ScholarPubMed
Fredman, L, Doros, G, Ensrud, KE, Hochberg, MC, Cauley, JA (2009). Caregiving intensity and change in physical functioning over a 2-year period: results of the caregiver-study of osteoporotic fractures. American Journal of Epidemiology 170, 203–210.CrossRefGoogle Scholar
Gallo, LC, Jimenez, JA, Shivpuri, S, Espinosa de los, Monteros K, Mills, PJ (2011). Domains of chronic stress, lifestyle factors, and allostatic load in middle-aged Mexican-American women. Annals of Behavioral Medicine 41, 21–31.CrossRefGoogle ScholarPubMed
Gysels, M, Evans, N, Menaca, A, Andrew, E, Toscani, F, Finetti, S, Pasman, HR, Higginson, I, Harding, R, Pool, R (2012). Culture and end of life care: a scoping exercise in seven European countries. PLoS One 7, e34188.CrossRefGoogle ScholarPubMed
Haley, WE, Allen, JY, Grant, JS, Clay, OJ, Perkins, M, Roth, DL (2009). Problems and benefits reported by stroke family caregivers: results from a prospective epidemiological study. Stroke 40, 2129–2133.CrossRefGoogle ScholarPubMed
Haley, WE, Roth, DL, Howard, G, Safford, MM (2010). Caregiving strain and estimated risk for stroke and coronary heart disease among spouse caregivers: differential effects by race and sex. Stroke 41, 331–336.CrossRefGoogle ScholarPubMed
Happe, S, Berger, K (2002). The association between caregiver burden and sleep disturbances in partners of patients with Parkinson's disease. Age and Ageing 31, 349–354.CrossRefGoogle ScholarPubMed
Harkness, J, Pennell, BE, Villar, A, Gebler, N, Aguilar-Gaxiola, S, Bilgen, I (2008). Translation procedures and translation assessment in the World Mental Health Survey Initiative. In The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders (ed. Kessler, R. C. and Üstün, T. B.), pp. 91–113. Cambridge University Press: New York.Google Scholar
Harwood, DG, Barker, WW, Ownby, RL, Bravo, M, Aguero, H, Duara, R (2000). Predictors of positive and negative appraisal among Cuban American caregivers of Alzheimer's disease patients. International Journal of Geriatric Psychiatry 15, 481–487.3.0.CO;2-J>CrossRefGoogle ScholarPubMed
Hastrup, LH, Van Den Berg, B, Gyrd-Hansen, D (2011). Do informal caregivers in mental illness feel more burdened? A comparative study of mental versus somatic illnesses. Scandinavian Journal of Public Health 39, 598–607.CrossRefGoogle ScholarPubMed
Heeringa, SG, Wells, EJ, Hubbard, F, Mneimneh, ZN, Chiu, WT, Sampson, NA, Berglund, PA (2008). Sample designs and sampling procedures. In The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders (ed. Kessler, R. C. and Üstün, T. B.), pp. 14–32. Cambridge University Press: New York.Google Scholar
Heitmueller, A (2007). The chicken or the egg? Endogeneity in labour market participation of informal carers in England. Journal of Health Economics 26, 536–559.CrossRefGoogle ScholarPubMed
Heitmueller, A, Inglis, K (2007). The earnings of informal carers: wage differentials and opportunity costs. Journal of Health Economics 26, 821–841.CrossRefGoogle ScholarPubMed
Hickenbottom, SL, Fendrick, AM, Kutcher, JS, Kabeto, MU, Katz, SJ, Langa, KM (2002). A national study of the quantity and cost of informal caregiving for the elderly with stroke. Neurology 58, 1754–1759.CrossRefGoogle ScholarPubMed
Hosmer, DW, Lemeshow, S (2000). Applied Logistic Regression, 2nd edn. Wiley and Sons: New York.CrossRefGoogle Scholar
Idstad, M, Roysamb, E, Tambs, K (2011). The effect of change in mental disorder status on change in spousal mental health: the HUNT study. Social Science and Medicine 73, 1408–1415.CrossRefGoogle ScholarPubMed
Izuhara, M (2004). Negotiating family support? The generational contract between long term care and inheritance. Journal of Social Policy 33, 649–665.CrossRefGoogle Scholar
Jacobzone, S (2000). Coping with aging: international challenges. Health Affairs (Millwood) 19, 213–225.CrossRefGoogle ScholarPubMed
Kakuma, R, Minas, H, van Ginneken, N, Dal Poz, MR, Desiraju, K, Morris, JE, Saxena, S, Scheffler, RM (2011). Human resources for mental health care: current situation and strategies for action. Lancet 378, 1654–1663.CrossRefGoogle ScholarPubMed
Kessler, RC, Üstün, TB (editors) (2008). The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders. Cambridge University Press: New York.Google Scholar
Kiecolt-Glaser, JK, Dura, JR, Speicher, CE, Trask, OJ, Glaser, R (1991). Spousal caregivers of dementia victims: longitudinal changes in immunity and health. Psychosomatic Medicine 53, 345–362.CrossRefGoogle ScholarPubMed
King, AC, Brassington, G (1997). Enhancing physical and psychological functioning in older family caregivers: the role of regular physical activity. Annals of Behavioral Medicine 19, 91–100.CrossRefGoogle ScholarPubMed
Kring, SI, Brummett, BH, Barefoot, J, Garrett, ME, Ashley-Koch, AE, Boyle, SH, Siegler, IC, Sørensen, TI, Williams, RB (2010). Impact of psychological stress on the associations between apolipoprotein E variants and metabolic traits: findings in an American sample of caregivers and controls. Psychosomatic Medicine 72, 427–433.CrossRefGoogle Scholar
Kusano, CT, Bouldin, ED, Anderson, LA, McGuire, LC, Salvail, FR, Simmons, KW, Andresen, EM (2011). Adult informal caregivers reporting financial burden in Hawaii, Kansas, and Washington: results from the 2007 Behavioral Risk Factor Surveillance System. Disability and Health Journal 4, 229–237.CrossRefGoogle ScholarPubMed
Lamura, G, Mnich, E, Nolan, M, Wojszel, B, Krevers, B, Mestheneos, L, Dohner, H (2008). Family carers' experiences using support services in Europe: empirical evidence from the EUROFAMCARE study. Gerontologist 48, 752–771.CrossRefGoogle ScholarPubMed
Lee, R (2011). The outlook for population growth. Science 333, 569–573.CrossRefGoogle ScholarPubMed
Levine, C, Halper, D, Peist, A, Gould, DA (2010). Bridging troubled waters: family caregivers, transitions, and long-term care. Health Affairs (Millwood) 29, 116–124.CrossRefGoogle ScholarPubMed
Levinson, D, Lakoma, MD, Petukhova, M, Schoenbaum, M, Zaslavsky, AM, Angermeyer, M, Borges, G, Bruffaerts, R, de Girolamo, G, de Graaf, R, Gureje, O, Haro, JM, Hu, C, Karam, AN, Kawakami, N, Lee, S, Lepine, JP, Browne, MO, Okoliyski, M, Posada-Villa, J, Sagar, R, Viana, MC, Williams, DR, Kessler, RC (2010). Associations of serious mental illness with earnings: results from the WHO World Mental Health surveys. British Journal of Psychiatry 197, 114–121.CrossRefGoogle ScholarPubMed
Lin, JP, Yi, CC (2011). Filial norms and intergenerational support to aging parents in China and Taiwan. International Journal of Social Welfare 20, S109–S120.CrossRefGoogle Scholar
Lockenhoff, CE, Duberstein, PR, Friedman, B, Costa, PT (2011). Five-factor personality traits and subjective health among caregivers: the role of caregiver strain and self-efficacy. Psychology and Aging 26, 592–604.CrossRefGoogle ScholarPubMed
Losada, A, Robinson Shurgot, G, Knight, BG, Marquez, M, Montorio, I, Izal, M, Ruiz, MA (2006). Cross-cultural study comparing the association of familism with burden and depressive symptoms in two samples of Hispanic dementia caregivers. Aging and Mental Health 10, 69–76.CrossRefGoogle ScholarPubMed
Mathers, CD, Lopez, AD, Murray, CJL (2006). The burden of disease and mortality by condition: data, methods, and results for 2001. In Global Burden of Disease and Risk Factors (ed. Lopez, A. D., Mathers, C. D., Ezzati, M., Jamison, D. T. and Murray, C. J. L.). World Bank: Washington, DC.Google Scholar
Maulik, PK, Darmstadt, GL (2007). Childhood disability in low- and middle-income countries: overview of screening, prevention, services, legislation, and epidemiology. Pediatrics 120 (Suppl. 1), S1–S55.CrossRefGoogle ScholarPubMed
McCullagh, P, Nelder, JA (1989). Generalized Linear Models, 2nd edn. Chapman and Hall: London.CrossRefGoogle Scholar
Morse, JQ, Shaffer, DR, Williamson, GM, Dooley, WK, Schulz, R (2012). Models of self and others and their relation to positive and negative caregiving responses. Psychology and Aging 27, 211–218.CrossRefGoogle ScholarPubMed
National Alliance for Caregiving in collaboration with AARP (2009). Caregiving in the U.S.: Executive Summary (http://assets.aarp.org/rgcenter/il/caregiving_09_es.pdf). Accessed 15 November 2011.Google Scholar
Navaie-Waliser, M, Spriggs, A, Feldman, PH (2002). Informal caregiving: differential experiences by gender. Medical Care 40, 1249–1259.CrossRefGoogle ScholarPubMed
Nomura, H, Inoue, S, Kamimura, N, Shimodera, S, Mino, Y, Gregg, L, Tarrier, N (2005). A cross-cultural study on expressed emotion in carers of people with dementia and schizophrenia: Japan and England. Social Psychiatry and Psychiatric Epidemiology 40, 564–570.CrossRefGoogle ScholarPubMed
Northridge, ME (1995). Public health methods – attributable risk as a link between causality and public health action. American Journal of Public Health 85, 1202–1204.CrossRefGoogle ScholarPubMed
Opree, SJ, Kalmijn, M (2012). Exploring causal effects of combining work and care responsibilities on depressive symptoms among middle-aged women. Ageing and Society 32, 130–146.CrossRefGoogle Scholar
Papastavrou, E, Charalambous, A, Tsangari, H, Karayiannis, G (2012). The burdensome and depressive experience of caring: what cancer, schizophrenia, and Alzheimer's disease caregivers have in common. Cancer Nursing 35, 187–194.CrossRefGoogle ScholarPubMed
Pennell, B-E, Mneimneh, Z, Bowers, A, Chardoul, S, Wells, JE, Viana, MC, Dinkelmann, K, Gebler, N, Florescu, S, He, Y, Huang, Y, Tomov, T, Vilagut, G (2008). Implementation of the World Mental Health Surveys. In The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders (ed. Kessler, R. C. and Üstün, T. B.), pp. 33–57. Cambridge University Press: New York.Google Scholar
Pinquart, M, Sörensen, S (2003 a). Associations of stressors and uplifts of caregiving with caregiver burden and depressive mood: a meta-analysis. Journal of Gerontology: Series B, Psychological Sciences and Social Sciences 58, P112–P128.CrossRefGoogle ScholarPubMed
Pinquart, M, Sörensen, S (2003 b). Differences between caregivers and noncaregivers in psychological health and physical health: a meta-analysis. Psychology and Aging 18, 250–267.CrossRefGoogle ScholarPubMed
Pinquart, M, Sörensen, S (2005). Ethnic differences in stressors, resources, and psychological outcomes of family caregiving: a meta-analysis. Gerontologist 45, 90–106.CrossRefGoogle ScholarPubMed
Pinquart, M, Sörensen, S (2006). Gender differences in caregiver stressors, social resources, and health: an updated meta-analysis. Journal of Gerontology: Series B, Psychological Sciences and Social Sciences 61, P33–P45.CrossRefGoogle ScholarPubMed
Pinquart, M, Sörensen, S (2007). Correlates of physical health of informal caregivers: a meta-analysis. Journal of Gerontology: Series B, Psychological Sciences and Social Sciences 62, P126–P137.CrossRefGoogle ScholarPubMed
Pinquart, M, Sörensen, S (2011). Spouses, adult children, and children-in-law as caregivers of older adults: a meta-analytic comparison. Psychology and Aging 26, 1–14.CrossRefGoogle ScholarPubMed
Poulin, MJ, Brown, SL, Ubel, PA, Smith, DM, Jankovic, A, Langa, KM (2010). Does a helping hand mean a heavy heart? Helping behavior and well-being among spouse caregivers. Psychology and Aging 25, 108–117.CrossRefGoogle Scholar
Prince, M (2004). Care arrangements for people with dementia in developing countries. International Journal of Geriatric Psychiatry 19, 170–177.Google ScholarPubMed
Prince, M, Livingston, G, Katona, C (2007). Mental health care for the elderly in low-income countries: a health systems approach. World Psychiatry 6, 5–13.Google ScholarPubMed
Schneider, J, Murray, J, Banerjee, S, Mann, A (1999). EUROCARE: a cross-national study of co-resident spouse carers for people with Alzheimer's disease: I – Factors associated with carer burden. International Journal of Geriatric Psychiatry 14, 651–661.3.0.CO;2-B>CrossRefGoogle ScholarPubMed
Schulz, R, Beach, SR (1999). Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. Journal of the American Medical Association 282, 2215–2219.CrossRefGoogle ScholarPubMed
Siegler, IC, Brummett, BH, Williams, RB, Haney, TL, Dilworth-Anderson, P (2010). Caregiving, residence, race, and depressive symptoms. Aging and Mental Health 14, 771–778.CrossRefGoogle ScholarPubMed
Sörensen, S, Pinquart, M, Duberstein, P (2002). How effective are interventions with caregivers? An updated meta-analysis. Gerontologist 42, 356–372.CrossRefGoogle ScholarPubMed
Stoltz, P, Uden, G, Willman, A (2004). Support for family carers who care for an elderly person at home – a systematic literature review. Scandinavian Journal of Caring Sciences 18, 111–119.CrossRefGoogle ScholarPubMed
Torti, FM Jr., Gwyther, LP, Reed, SD, Friedman, JY, Schulman, KA (2004). A multinational review of recent trends and reports in dementia caregiver burden. Alzheimer Disease and Associated Disorders 18, 99–109.CrossRefGoogle ScholarPubMed
Vitaliano, PP, Zhang, J, Scanlan, JM (2003). Is caregiving hazardous to one's physical health? A meta-analysis. Psychological Bulletin 129, 946–972.CrossRefGoogle ScholarPubMed
Vogeli, C, Shields, AE, Lee, TA, Gibson, TB, Marder, WD, Weiss, KB, Blumenthal, D (2007). Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. Journal of General Internal Medicine 22 (Suppl. 3), 391–395.CrossRefGoogle ScholarPubMed
Wiener, J (2003). The role of informal support in long-term care. In Key Policy Issues in Long-term Care (ed. Brodsky, J., Habib, J. and Hirschfeld, M.), pp. 3–24. World Health Organization: Geneva (http://whqlibdoc.who.int/publications/2003/9241562250.pdf). Accessed 9 November 2011.Google Scholar
Wimo, A, Winblad, B, Jonsson, L (2007). An estimate of the total worldwide societal costs of dementia in 2005. Alzheimer's and Dementia 3, 81–91.CrossRefGoogle ScholarPubMed
Winter, KH, Bouldin, ED, Andresen, EM (2010). Lack of choice in caregiving decision and caregiver risk of stress, North Carolina, 2005. Preventing Chronic Disease 7, A41.Google ScholarPubMed
Wolter, KM (1985). Introduction to Variance Estimation. Springer-Verlag: New York.Google Scholar
World Bank (2009). Data: Countries and Economies (http://data.worldbank.org/country). Accessed 9 November 2011.Google Scholar
Yee, JL, Schulz, R (2000). Gender differences in psychiatric morbidity among family caregivers: a review and analysis. Gerontologist 40, 147–164.CrossRefGoogle ScholarPubMed
Youn, G, Knight, BG, Jeong, HS, Benton, D (1999). Differences in familism values and caregiving outcomes among Korean, Korean American, and White American dementia caregivers. Psychology and Aging 14, 355–364.CrossRefGoogle ScholarPubMed