**6. Materials and method**

## **6.1 Location of the study**

The study was conducted in Calabar Municipality, a local government in Cross River State (CRS) of Nigeria between June to December 2009. Cross River State is one of the 36 States of the Federal republic of Nigeria situated in the South South zone of Nigeria. Calabar Municipality has an area of 142 km2 and a population of 179,392 by the 2006 census. Calabar Municipality otherwise called '*Efik eburutu'* has a rich cultural heritage and very hospitable. Compared with other communities in Nigeria, they operate the patriarchal system with male preference and dominance. Moreover the families take responsibilities for their sick member. CRS operate the three tier health care system which includes primary, secondary and tertiary, however the health facility is skewed to the urban area. The University of Calabar

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

female primary caregivers ranging between 30 and 55 years [22].

financial, physical as well as emotional domain of burden scale.

The high prevalence of HIV in Africa and Nigeria, coupled with improvements in treatment modalities and life expectancy predict the inevitable loss of autonomy as disease trajectory progressed into AIDS. It has been noted that in spite of prophylaxis for opportunist infection and antiretroviral therapy in preventing AIDS associated illness, PLWHA will still be sick and have disability in functional ability, hence require care [50]. This terminal stage invariable signals the need for either formal or informal caregivers. Studies also revealed that HIV infected individuals return to their homes for physical and psychological support and adequate discharge preparation which incorporate health care team; and family care givers become imperative [50]. However, health care system especially in developing countries do not have the capacity to provide long-term services, they rarely involved family caregivers in the discharge planning, neither are they educated

**5.1 Caregiving and support**

**5. Gender and caregivers burden**

female role in caregiving and home centered care give a greater sense of family obligation with longer duration spent in caregiving than men [37–39]. Another report stated that duration of care increased among cultures and societies who designate caregiving as a woman's primary role [39]. Additionally, females' care giving role commenced at a younger age and persists as they grow older with an average age for

African traditional gender norms feminize caregiving and exclude men and boys from caregiving. The normative women roles extend from reproductive role to nurturing infant and sick family members and remain progressive all through their lifetime [40]. However, these roles remain unrecognized except by the beneficiaries. Therefore, personal sacrifice comes with fulfillment of this role, while some female may have to leave school to provide care [41]. The added responsibility may overshadow the individual coping ability and it manifest as stress or burden. Caregiver's burden is defined as an individual response to physical, emotional, psychological, financial as well as social stressors in Ref. to caregiving experience [42]. Burden maybe objective or subjective. Objective burden refers to disruption in household routines, social relations, leisure, time, finances, work as well as physical health which is often observable [43–45]. Subjective burden refers to how the caregiver appraises the caregiving task [44]. However it has been reported that objective burden depends on subjective appraisal of the caregiving task [44]. Report reveals that caregivers of PLWHA experienced high level of burden [34]. With common sessional symptoms and exacerbation in terminal phase of HIV, many are overwhelmed with caregiving demands resulting in burden [46]. Moreover burden may be compounded with lack of support and financial constraint. Studies revealed higher level of both subjective and objective burden among females compared to males [17, 38, 47, 48] and higher level of physical and social burden [49]. But women experienced more objective burden which is often associated with physical task of caregiving [40]. Similarly, another report stated that women are directly involved in providing personal care which is more demanding and significantly contributes to burden [11, 33]. Studies in Nigeria also affirmed a significant relationship between caregiver's burden and gender with 67.5% female accounting for those with high level of caregivers' burden [10, 28]. Similarly, another study in Lagos, Nigeria also affirmed higher level of burden among female and more stressor emanating from

**104**

Teaching Hospital (UCTH) is a tertiary institution and a referral center to other health care facilities. The facility offers both inpatient and outpatient services and collaborates with nongovernmental organizations (NGOs) in the treatment of PLWHA from rural/urban areas and neighboring country, Cameroun. The state is one the 12 + 1 states which contribute about 70% of HIV burden in Nigeria. UCTH is one of the centers for the management of PLWHA. The high HIV prevalence (10.4%) at the study site inform the choice of study setting [10, 60].
