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Reconsidering the Caregiving Stress Appraisal scale: Validation and examination of its association with items used for assessing long-term care insurance in Japan
Archives of Gerontology and Geriatrics 44 (2007) 287–297 www.elsevier.com/locate/archger
Reconsidering the Caregiving Stress Appraisal scale: Validation and examination of its association with items used for assessing long-term care insurance in Japan Koji Abe * Department of Gerontological Policy, National Institute for Longevity Sciences (NILS), 36-3 Gengo, Morioka-cho, Aichi 474-8522, Japan Received 7 October 2005; received in revised form 31 May 2006; accepted 6 June 2006 Available online 4 August 2006
Abstract The Caregiving Stress Appraisal (CSA) scale is a simple scale for measuring family caregiver stress. However, information on its validity and association with new social welfare systems in Japan is inadequate. The purpose of the present study is to examine the criterion validity of the CSA and to explore its association with the variables used for assessing long-term care insurance in Japan. In the present study, 219 family caregivers completed a self-administered questionnaire. Of these, 50 and 202 caregivers were used for the analysis of the criterion validity and construct validity, respectively. The CSA, the Japanese version of the Zarit Burden Interview (J-ZBI), the Center for Epidemiological Studies-Depression (CES-D), and the items used for assessing long-term care insurance in Japan were used for the analyses. The results revealed that the CSA had significant correlations with the JZBI and the CES-D. Despite the small sample size, the CSA had significant correlations with the items used for assessing long-term care insurance in Japan. These results suggest sufficient criterion and construct validity of the CSA for the future study. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Family caregivers; Caregiving burden; Stress-coping theory; Validation study
* Tel.: +81 562 46 2311x5716; fax: +81 562 46 8429. E-mail address: [email protected]. 0167-4943/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2006.06.001
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1. Introduction Recently, several countries have witnessed the growth of the problem concerning the stress experienced by the family members who care for older people (Torti et al., 2004). Therefore, several studies have been conducted in this area to enhance social services both for older people and family caregivers (Lieberman and Fisher, 1995; Newcomer et al., 1999). In the nascent stage of the studies, Zarit et al. (1980) formulated the concept of ‘‘burden’’ among family caregivers and developed the ‘‘Zarit Burden Interview’’ (ZBI) for psychological assessment. The ZBI is currently being widely used in many studies and has been translated into several languages (The 10/66 Dementia Research Group, 2004; Torti et al., 2004). However, there remain several unsolved problems in measuring the burden of family caregivers. First, Lawton et al. (1989) indicated an assortment of the ZBI items that described the symptoms of older people and the subjective feelings of family caregivers. The difficulty in distinguishing between the concepts of ‘‘objective’’ burden and ‘‘subjective’’ burden has also been discussed (Thommessen et al., 2002). Second, Vitaliano et al. (1991) presented the difficulties in capturing the complex feeling of burden in a single dimension. Therefore, some multidimensional caregiver burden or stress scales have been developed for this assessment (Green et al., 1982; Stull, 1996). Although these multidimensional scales have certain psychometric advantages, not many reports have used these scales (e.g., Thommessen et al., 2002). Third, it is necessary to reexamine the construct that accompanies the recent developments in social services provided to older people and their families. Few studies have examined the association among the variables based on social services, caregiving burden, and disabilities of older people (Zarit et al., 1998; Arai et al., 2003). In order to reexamine the concept of burden from a psychological perspective, attempts have been made to analyze the problems faced by family caregivers by using the stresscoping theory. Lawton et al. (1989) developed the Philadelphia Geriatric Center Caregiving Appraisal Scales (PGCCAS) based on the stress-coping theory put forth by Lazarus and Folkman (1984). The PGCCAS considers burden as a cognitive appraisal and has negative and positive subscales. Although the positive aspect of the PGCCAS was omitted due to its low Cronbach’s alpha (Lawton et al., 1989), several researches have emphasized the benefits of its theoretical background (Sevick et al., 1997; Struchen et al., 2002). However, the model of Lawton et al. (1991) failed to support the theoretical model of Lazarus and Folkman (1984), and several studies that followed Lawton et al. (1991) also failed to provide sufficient evidence for the model based on the psychological stress theory (Lawton et al., 1991; Smith, 1996; Sevick et al., 1997; Struchen et al., 2002). 1.1. CSA scale Abe (2001) developed the CSA scale based on the findings of the abovementioned researches on caregiving burden and stress. In the previous study, analyses of structural equation modeling revealed that the stress appraisal of family caregivers functioned as a mediated variable between the stressor and depression. Based on the results of factor analysis, the CSA is suggested to comprise two factors— ‘‘social constraints’’ and ‘‘physical exhaustion.’’ Each factor has six items; therefore, the
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scale comprises a total of 12. Assessment by the family caregiver is possible in a short period of time, and its validity in terms of the stress-coping theory has been demonstrated in the previous study. The CSA is one of the useful scales in this area of study; however, on further examination, several problems arise. In particular, the information on its criterion validity and its association with social services is inadequate. In order to improve the social services provided to older people, more useful and effective, information on the reliability and criterion validity of the scale as well as the association between the scale and the variables based on the social services are required. The purpose of the present study is to examine the criterion validity of the CSA and explore its association with the variables used for assessing long-term care insurance in Japan.
2. Methods 2.1. Participants Three cities in Osaka—Suita, Ibaraki, and Toyonaka—that are located in the central part of Japan, were chosen for the survey in December 2001. The populations of these three cities ranged from 200,000 to 300,000. The participants were recruited through the caregiving service offices of the respective local governments. A total of 260 family caregivers agreed to participate in the survey and submitted their signed agreements. After the survey offices received their agreements, questionnaires were mailed to the caregivers, who were requested to complete the questionnaire at their residences. In the present study, two types of questionnaires were randomly administered to the participants. Questionnaire type A included the CSA, the J-ZBI (Arai et al., 1997), and characteristic variables. On the other hand, questionnaire type B included only the CSA and characteristic variables. In order to minimize the participants’ burden to answer the questionnaire and to ensure the statistical power of the correlational analysis (Hulley et al., 2001), the number of the questionnaire types administered was unbalanced with consideration: type A (long version) was administered to only 58 participants; type B (short version), to 202 participants. A total of 239 completed questionnaires were returned; however 20 of these were considered inappropriate for the study (response rate was 90.4). No significant difference was observed for the response rate between the types of questionnaires. In the present study, the data from both types of questionnaires was used. First, the data from the participants who received questionnaire type A was used to examine the criterion validity (N = 50). Second, the data from the participants who received questionnaire type B was used to examine the construct validity (N = 169). 2.2. Informed consent Written informed consent was obtained from all the participants. The documents of consent were sent to the research center where they were stored separately from the questionnaires.
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2.3. Measures This study measured the characteristics of the sample—age, gender, kin relationships, education level, and economic status of family caregivers. In the category of education level, the respondents were asked to state the last school from which they graduated; their economic status was measured on a 5-point Likert scale (where 1 denotes poor and 5 denotes sufficient). With regard to older people, the characteristics of gender and age were measured. In addition, a simple 6-point Likert scale (where 1 denotes full-time caregiving and 6 denotes almost never) was used to measure restrictions in caregiving. 2.4. Items in the long-term care insurance in Japan In Japan, services are allocated based on the government-certified disability index (GCDI) (Arai et al., 2003). The items to compute the GCDI included cognitive impairments, activities of daily living (ADL), and behavioral and psychological symptoms in dementia (BPSD). The GCDI scores range from 0 to 6, indicating the severity of impairment and the maximum coverage of services in a month. The GCDI score of 1 indicates that an older person experiences difficulty in ADL and a score of 5 indicates that he/she is bedridden with special needs. In the present study, the participants whose GCDI scores were 0 were omitted prior to the analysis. Since the GCDI assessment is a complex one and the concept of disabilities among older people is ambiguous, in the present study, only the items of cognitive impairments and ADL were selected from all the GCDI assessment items. The cognitive impairment scale that consists of six dichotomous items (where 1 denotes not impaired and 2 denotes impaired) was based on several major neuropsychiatric measures such as the Mini-Mental State Exam (Folstein et al., 1975) and the Dementia Rating Scale (Mattis, 1988). The items on the cognitive impairment scale include questions concerning personal information (name, age, and date of birth), orientation to time (season), orientation to place (dwelling), and recall (recalling daily tasks and the previous activities). The reliability of these items was found to be sufficient (a = 0.76). The ADL scale used in this study consisted of six items—movement, meal, bathing, excretion, clothing, and dressing—and was based on a short ADL scale (Kitajima et al., 1993) and the Barthel Index (Wade and Collin, 1988). The scale was a 4-point Likert scale (where 1 denotes independence and 4 denotes that full assistance is needed), and the reliability of the scale was found to be considerably high (a = 0.94). Therefore, the total score of the six items was used for the analysis. 2.5. CSA The CSA (Abe, 2001) was developed on the basis of several studies that referred to the multiple structure of caregiving stress or burden (Kosberg and Cairl, 1986; Kinney and Stephens, 1989; Novak and Guest, 1989; Stull, 1996). This scale is composed of two subscales—social constraint and physical exhaustion—and each subscale has six items (4point Likert scale). The scale reliabilities for this data were a = 0.93, 0.95, 0.96 for social constraint, physical exhaustion, and the total score, respectively. Therefore, each subscale and the total score were used in the analysis.
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2.6. J-ZBI In the present study, the J-ZBI was used to measure the caregiving burden. The analysis made use of the total score of the J-ZBI and a single global rating of the burden that measured the overall burden in an item. The reliability of the J-ZBI in the data was found to be sufficient (a = 0.93). 2.7. CES-D The CES-D (Radloff, 1977) is often used as an outcome measurement tool in caregiving studies (Schulz et al., 1995). The reliability of the Japanese version of the CES-D (Shima et al., 1985) for this data was sufficient (a = 0.93).
3. Results 3.1. Descriptive analysis Table 1 lists the characteristics of the two types of the samples (questionnaire type A and questionnaire type B) used in the present study. Female caregivers accounted for 74% and 82% in the type A and type B samples, respectively. The average age of the family caregivers was 59.9 11.9 (S.D.) years and 60.7 10.5 for the type A and type B samples, respectively. With regard to kin relationships, the sons and daughters (of older people) comprised the largest proportion of caregivers in both the samples (type A sample: 46.0%; type B sample: 42.6%), followed by the spouses (type A sample: 32.0%; type B sample: 29.6%). The average economic status was 2.88 0.77 and 3.08 0.87 in the type A and type B samples, respectively. No significant differences were observed between the sample types with regard to the abovementioned sample characteristics. The average of the J-ZBI score, which was measured only in the type A sample, was 40.86 16.56. The average of the CES-D score for the type A sample was slightly higher (18.66 12.05) than that for the type B sample (15.52 9.64); however, no significant difference was observed between the sample types. Moreover, no significant difference in the average CSA score (scores of both the subscales and the total score) was observed between the samples. The average of the subscale social constraint was 18.13 5.08 and 18.30 4.75 for the type A and type B samples, respectively; the average of the subscale physical exhaustion was 15.18 5.71 and 14.91 4.98 for the type A and type B samples, respectively. In addition, the average of the total score was 33.31 10.20 and 33.22 8.95 for the type A and type B samples, respectively. 3.2. Criterion validity In order to examine the criterion validity of the CSA, its correlation with a simple measure of caregiving restriction, the total score of the J-ZBI, and a single global rating of
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Table 1 Characteristics of the samples Variable
Questionnaire type A sample (N = 50) N
Family caregivers Gender Female Male Kin relationship Daughter/son Spouse Daughter-in-law Other Education Junior high school High school Junior college College/university Age Economic status (5-point) Caregiving restriction (6-point) J-ZBI CES-D
S.D.
Range
N
37 13
139 30
23 16 8 3
72 50 40 7
6 21 14 9
24 77 35 33
CSA Social constraint Physical exhaustion Total score Older people Gender Female Male Age GCDI Cognitive impairments ADL
Mean
Questionnaire type B sample (N = 169) Mean
S.D.
Range
59.9 2.88 3.10 40.86 18.66
11.9 0.77 1.05 16.56 12.05
33–86 1–4 1–6 9–77 0–57
60.7 3.08 3.30
10.5 0.87 1.31
33–91 1–5 1–6
15.52
9.64
0–45
18.13 15.18 33.31
5.08 5.71 10.20
6–24 6–24 13–48
18.30 14.91 33.22
4.75 4.98 8.95
6–24 6–24 12–48
82.0 2.80 7.80 16.42
9.3 1.41 2.04 5.39
54–103 1–5 6–12 6–24
40 10
110 59 82.2 2.94 7.75 16.74
9.2 1.35 1.78 5.10
59–101 1–5 6–11 8–24
burden were analyzed. Table 2 shows the results of the Pearson correlation analysis for the type A sample; those for the type B sample are shown in Table 3. Significant correlations were observed between the social constraint and the simple measure of caregiving restriction in both the samples (type A: r = 0.30, p < 0.05; type B: r = 0.44, p < 0.01). The results of the type A sample showed significant correlations between the CSA (social constraint, physical exhaustion, and total score) and the J-ZBI (social constraint: r = 0.77, p < 0.01; physical exhaustion: r = 0.78, p < 0.01; total score: r = 0.77, p < 0.01). Significant correlations were also found between the CSA and the single global rating of burden that was included in the J-ZBI (social constraint: r = 0.67, p < 0.01; physical exhaustion: r = 0.76, p < 0.01; total score: r = 0.75, p < 0.01).
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Table 2 Correlation coefficients among CSA, ZBI, CES-D, and disabilities of older people in type A sample J-ZBI
CSA Social constraint
Physical exhaustion
Total score
Caregiving restriction J-ZBI Global rating of burden CES-D
0.18 – 0.79** 0.75**
0.30* 0.71** 0.67** 0.66**
0.19 0.77** 0.76** 0.80**
0.26 0.78** 0.75** 0.77**
Disabilities of older people GCDI Cognitive impairments ADL
0.21 0.38** 0.26
0.30* 0.36** 0.43**
0.19 0.24 0.40**
0.26 0.31* 0.44**
* **
p < 0.05. p < 0.01.
3.3. Construct validity of the CSA and its relationships with the items of social services In order to examine the construct validity of the CSA and its relationships with the items of social services, correlations among the CSA, CES-D, GCDI, and the disabilities of older people (cognitive impairments and ADL) were analyzed. Significant correlations were observed between the CES-D and CSA (the subscales and the total score) for both the sample types. Although the GCDI scores were not correlated with those of the J-ZBI, CSA scores (social constraints) significantly correlated with those of the GCDI in both the sample types (type A: r = 0.30, p < 0.05; type B: r = 0.16, p < 0.05). In the section on the analysis of disabilities of older people and the CSA, significant correlations were examined among social constraints and cognitive impairments in both sample types (type A: r = 0.36, p < 0.01; type B: r = 0.19, p < 0.05) and also among the total score of the CSA and cognitive impairments (type A: r = 0.31, p < 0.05; type B: r = 0.17, p < 0.05). The ADL score was not correlated with the J-ZBI score; however, in both sample types, the ADL score was significantly correlated with the CSA score—CSA Table 3 Correlation coefficients among CSA, ZBI, CES-D, and disabilities of older people in type B sample CSA Social constraint
Physical exhaustion
0.44 0.36**
0.30 0.58**
0.40** 0.51**
Disabilities of older people GCDI Cognitive impairments ADL
0.16* 0.19* 0.24**
0.07 0.13 0.16*
0.12 0.17* 0.21**
*
p < 0.05. p < 0.01.
**
Total score
Caregiving restriction CES-D
**
**
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subscales (type A: social constraints: r = 0.43, p < 0.01; physical exhaustion: r = 0.44, p < 0.01; type B: social constraints: r = 0.24, p < 0.05; physical exhaustion: r = 0.16, p < 0.05) and the total score (type A: r = 0.44, p < 0.01; type B: r = 0.21, p < 0.05).
4. Discussion The results of the present study revealed that the CSA has a significant correlation with the J-ZBI, which is a standard caregiving burden scale. In addition, the CSA has a significant correlation with a single global rating of burden (Zarit et al., 1980). Since criterion validity is an important criterion for clinical assessments, new development scales are required in order to examine validity. Although several caregiving burden and stress scales have already been developed in this area (Kinney and Stephens, 1989; Lawton et al., 1989; Vitaliano et al., 1991; Stull, 1996), few scales have examined the relationship with the standard scale (i.e., ZBI or a single global rating of burden). In the present study, the results of the correlational analysis in the type A sample suggests that the CSA is one of the alternative scales used for measuring the burden and stress of family caregivers. Compared with the J-ZBI, the CSA subscale social constraints revealed significant correlations with caregiving restriction. This result suggests a divergent validity of the CSA subscale social constraints that measures the increase in psychosocial stress due to caregiving restrictions (Thommessen et al., 2002). Historically, it was assumed that the scale for assessing caregiving stress should be associated with the disabilities of older people (cognitive impairments, ADL, or BPSD) (Zarit et al., 1986; Vitaliano et al., 1991). In the present study, the analyses were conducted on the basis of two aspects of the disabilities of older people, namely, cognitive impairments and the ADL. The results indicated that the CSA has a significant relationship with both types of the disabilities, while the relationship between the ADL and J-ZBI is not observed from this data. The statistical power for the analysis between the J-ZBI and the disabilities may be insufficient for this data due to the small sample size (Schulz et al., 1995). However, it is clear that the ADL and the CSA were significantly correlated between the sample types. Moreover, the social constraints subscale has a significant relationship with the GCDI score that was assessed on the basis of the long-term care insurance system in Japan. This result implies that an increase in the integrated disabilities of older people was one of the causes for the increase in psychosocial stress, especially in terms of social activities. At present, since the long-term care insurance in Japan did not account for the psychosocial stress of family caregivers (Tsutsui and Muramatsu, 2005), if strong connections between the restriction on social activities and the stress-related symptoms such as depression of family caregivers are established, as seen in the many studies (e.g., Abe, 2001), the promotion of the use of the service efficiently (Zarit et al., 1998) and opportunities to meet other caregivers such as self-help groups (Hosaka and Sugiyama, 2003) would be beneficial options for the social services. The CSA could play an important role in assessing such relationships between the variables of the social services and stress of family caregivers in future examinations, because in this study, the responsiveness of the CSA was observed to be more sensitive than the standard burden scale.
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4.1. Limitations and future research The main limitations of the present study are the small sample size of those administered the type A questionnaire, assessments of the disabilities of older people, and the factor structure of the CSA. From the viewpoint of statistical power and restriction of the survey, the type A questionnaire, which aimed to examine the criterion validity, was administered to a small sample. The results of the analyses suggested that the sample size was sufficient to achieve the purpose of the present study; however, because the sample size between the two groups was unbalanced, it is not suitable to compare the scores between the two samples. The cognitive impairments and ADL items from the GCDI were used to assess the disabilities of older people. Currently, many scales that measure the disabilities of older people with confirmed reliability and validity (Folstein et al., 1975; Mattis, 1988; Wade and Collin, 1988) are available. Although the items included in the present study have a similar construct to the standard measures, in the future study, it will be necessary to analyze the relationships between the CSA and the standard disability-related measures. Stull (1996) highlighted that a caregiving burden and stress scale should include several factors to assess the complex feeling of burden. Although some previously developed measurements have a multidimensional factor structure (Green et al., 1982; Kosberg and Cairl, 1986; Lawton et al., 1989; Novak and Guest, 1989; Stull, 1996), the scale developed in the present study has a simple and robust two-factor structure for clinical use. Most of the multidimensional measures can assess the complex aspect of the burden; however, these measurements do not have the correct items since the concept of the stress appraisal is based on the stress-coping theory (Lazarus and Folkman, 1984). The CSA was originally intended to adapt the stress-coping theory; therefore, it does not have construct redundancy from the other concepts (e.g., stressor, appraisal and stress response) in that theory (Abe, 2001). The CSA may also be suitable for the future studies that examine the stress of family caregivers from the viewpoint of the stress-coping theory. It has been 25 years since Zarit et al. (1980) developed the ZBI; the scale has been translated into several languages for the purpose of exploring the applicability to nonWestern countries (The 10/66 Dementia Research Group, 2004). However, it might be also important to develop a new caregiving stress scale that suits the current situation such as the psychosocial aspects of family caregivers and the social service system of the respective countries.
Acknowledgements The author thanks all the family caregivers who participated in the present study. Thanks are also due to Professor Tetsuo Kashiwagi (Kinjyo Gakuin University), Associate Professor Satoru Tsuneto (Osaka University), and Professor Ayako Fujita (Osaka University) for their comments on the early draft of the paper. The present study was supported by the Research Fellowships of the Japan Society for the Promotion of Science (H15–3667).
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Appendix A. CSA scale
1. I am unable to go out when I want because of caregiving 2. I feel drained because of caregiving 3. I have had to make adjustments in my work or personal schedule because of caregiving 4. I think that continuing with caregiving is not good for my health 5. I feel a constraint on my private time because of caregiving 6. I think that my physical health has suffered because of caregiving 7. I have had to sacrifice my vacations or trips because of caregiving 8. I feel tired when I get up in the morning and have to face another day of caregiving 9. I do not have the time to do the things I need to do because of caregiving 10. I think that I can not afford to do other things as a result of caregiving 11. I am very tired as a result of caregiving 12. Caregiving has negatively affected my health
Disagree
Somewhat disagree
Somewhat agree
Agree
1
2
3
4
1 1
2 2
3 3
4 4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1 1
2 2
3 3
4 4
Subscale: social constraints: 1, 3, 5, 7, 9, 11; physical exhaustion: 2, 4, 6, 8, 10, 12.
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Reconsidering the Caregiving Stress Appraisal scale: Validation and examination of its association with items used for assessing long-term care insurance in Japan Koji Abe * Department of Gerontological Policy, National Institute for Longevity Sciences (NILS), 36-3 Gengo, Morioka-cho, Aichi 474-8522, Japan Received 7 October 2005; received in revised form 31 May 2006; accepted 6 June 2006 Available online 4 August 2006
Abstract The Caregiving Stress Appraisal (CSA) scale is a simple scale for measuring family caregiver stress. However, information on its validity and association with new social welfare systems in Japan is inadequate. The purpose of the present study is to examine the criterion validity of the CSA and to explore its association with the variables used for assessing long-term care insurance in Japan. In the present study, 219 family caregivers completed a self-administered questionnaire. Of these, 50 and 202 caregivers were used for the analysis of the criterion validity and construct validity, respectively. The CSA, the Japanese version of the Zarit Burden Interview (J-ZBI), the Center for Epidemiological Studies-Depression (CES-D), and the items used for assessing long-term care insurance in Japan were used for the analyses. The results revealed that the CSA had significant correlations with the JZBI and the CES-D. Despite the small sample size, the CSA had significant correlations with the items used for assessing long-term care insurance in Japan. These results suggest sufficient criterion and construct validity of the CSA for the future study. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Family caregivers; Caregiving burden; Stress-coping theory; Validation study
* Tel.: +81 562 46 2311x5716; fax: +81 562 46 8429. E-mail address: [email protected]. 0167-4943/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2006.06.001
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1. Introduction Recently, several countries have witnessed the growth of the problem concerning the stress experienced by the family members who care for older people (Torti et al., 2004). Therefore, several studies have been conducted in this area to enhance social services both for older people and family caregivers (Lieberman and Fisher, 1995; Newcomer et al., 1999). In the nascent stage of the studies, Zarit et al. (1980) formulated the concept of ‘‘burden’’ among family caregivers and developed the ‘‘Zarit Burden Interview’’ (ZBI) for psychological assessment. The ZBI is currently being widely used in many studies and has been translated into several languages (The 10/66 Dementia Research Group, 2004; Torti et al., 2004). However, there remain several unsolved problems in measuring the burden of family caregivers. First, Lawton et al. (1989) indicated an assortment of the ZBI items that described the symptoms of older people and the subjective feelings of family caregivers. The difficulty in distinguishing between the concepts of ‘‘objective’’ burden and ‘‘subjective’’ burden has also been discussed (Thommessen et al., 2002). Second, Vitaliano et al. (1991) presented the difficulties in capturing the complex feeling of burden in a single dimension. Therefore, some multidimensional caregiver burden or stress scales have been developed for this assessment (Green et al., 1982; Stull, 1996). Although these multidimensional scales have certain psychometric advantages, not many reports have used these scales (e.g., Thommessen et al., 2002). Third, it is necessary to reexamine the construct that accompanies the recent developments in social services provided to older people and their families. Few studies have examined the association among the variables based on social services, caregiving burden, and disabilities of older people (Zarit et al., 1998; Arai et al., 2003). In order to reexamine the concept of burden from a psychological perspective, attempts have been made to analyze the problems faced by family caregivers by using the stresscoping theory. Lawton et al. (1989) developed the Philadelphia Geriatric Center Caregiving Appraisal Scales (PGCCAS) based on the stress-coping theory put forth by Lazarus and Folkman (1984). The PGCCAS considers burden as a cognitive appraisal and has negative and positive subscales. Although the positive aspect of the PGCCAS was omitted due to its low Cronbach’s alpha (Lawton et al., 1989), several researches have emphasized the benefits of its theoretical background (Sevick et al., 1997; Struchen et al., 2002). However, the model of Lawton et al. (1991) failed to support the theoretical model of Lazarus and Folkman (1984), and several studies that followed Lawton et al. (1991) also failed to provide sufficient evidence for the model based on the psychological stress theory (Lawton et al., 1991; Smith, 1996; Sevick et al., 1997; Struchen et al., 2002). 1.1. CSA scale Abe (2001) developed the CSA scale based on the findings of the abovementioned researches on caregiving burden and stress. In the previous study, analyses of structural equation modeling revealed that the stress appraisal of family caregivers functioned as a mediated variable between the stressor and depression. Based on the results of factor analysis, the CSA is suggested to comprise two factors— ‘‘social constraints’’ and ‘‘physical exhaustion.’’ Each factor has six items; therefore, the
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scale comprises a total of 12. Assessment by the family caregiver is possible in a short period of time, and its validity in terms of the stress-coping theory has been demonstrated in the previous study. The CSA is one of the useful scales in this area of study; however, on further examination, several problems arise. In particular, the information on its criterion validity and its association with social services is inadequate. In order to improve the social services provided to older people, more useful and effective, information on the reliability and criterion validity of the scale as well as the association between the scale and the variables based on the social services are required. The purpose of the present study is to examine the criterion validity of the CSA and explore its association with the variables used for assessing long-term care insurance in Japan.
2. Methods 2.1. Participants Three cities in Osaka—Suita, Ibaraki, and Toyonaka—that are located in the central part of Japan, were chosen for the survey in December 2001. The populations of these three cities ranged from 200,000 to 300,000. The participants were recruited through the caregiving service offices of the respective local governments. A total of 260 family caregivers agreed to participate in the survey and submitted their signed agreements. After the survey offices received their agreements, questionnaires were mailed to the caregivers, who were requested to complete the questionnaire at their residences. In the present study, two types of questionnaires were randomly administered to the participants. Questionnaire type A included the CSA, the J-ZBI (Arai et al., 1997), and characteristic variables. On the other hand, questionnaire type B included only the CSA and characteristic variables. In order to minimize the participants’ burden to answer the questionnaire and to ensure the statistical power of the correlational analysis (Hulley et al., 2001), the number of the questionnaire types administered was unbalanced with consideration: type A (long version) was administered to only 58 participants; type B (short version), to 202 participants. A total of 239 completed questionnaires were returned; however 20 of these were considered inappropriate for the study (response rate was 90.4). No significant difference was observed for the response rate between the types of questionnaires. In the present study, the data from both types of questionnaires was used. First, the data from the participants who received questionnaire type A was used to examine the criterion validity (N = 50). Second, the data from the participants who received questionnaire type B was used to examine the construct validity (N = 169). 2.2. Informed consent Written informed consent was obtained from all the participants. The documents of consent were sent to the research center where they were stored separately from the questionnaires.
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2.3. Measures This study measured the characteristics of the sample—age, gender, kin relationships, education level, and economic status of family caregivers. In the category of education level, the respondents were asked to state the last school from which they graduated; their economic status was measured on a 5-point Likert scale (where 1 denotes poor and 5 denotes sufficient). With regard to older people, the characteristics of gender and age were measured. In addition, a simple 6-point Likert scale (where 1 denotes full-time caregiving and 6 denotes almost never) was used to measure restrictions in caregiving. 2.4. Items in the long-term care insurance in Japan In Japan, services are allocated based on the government-certified disability index (GCDI) (Arai et al., 2003). The items to compute the GCDI included cognitive impairments, activities of daily living (ADL), and behavioral and psychological symptoms in dementia (BPSD). The GCDI scores range from 0 to 6, indicating the severity of impairment and the maximum coverage of services in a month. The GCDI score of 1 indicates that an older person experiences difficulty in ADL and a score of 5 indicates that he/she is bedridden with special needs. In the present study, the participants whose GCDI scores were 0 were omitted prior to the analysis. Since the GCDI assessment is a complex one and the concept of disabilities among older people is ambiguous, in the present study, only the items of cognitive impairments and ADL were selected from all the GCDI assessment items. The cognitive impairment scale that consists of six dichotomous items (where 1 denotes not impaired and 2 denotes impaired) was based on several major neuropsychiatric measures such as the Mini-Mental State Exam (Folstein et al., 1975) and the Dementia Rating Scale (Mattis, 1988). The items on the cognitive impairment scale include questions concerning personal information (name, age, and date of birth), orientation to time (season), orientation to place (dwelling), and recall (recalling daily tasks and the previous activities). The reliability of these items was found to be sufficient (a = 0.76). The ADL scale used in this study consisted of six items—movement, meal, bathing, excretion, clothing, and dressing—and was based on a short ADL scale (Kitajima et al., 1993) and the Barthel Index (Wade and Collin, 1988). The scale was a 4-point Likert scale (where 1 denotes independence and 4 denotes that full assistance is needed), and the reliability of the scale was found to be considerably high (a = 0.94). Therefore, the total score of the six items was used for the analysis. 2.5. CSA The CSA (Abe, 2001) was developed on the basis of several studies that referred to the multiple structure of caregiving stress or burden (Kosberg and Cairl, 1986; Kinney and Stephens, 1989; Novak and Guest, 1989; Stull, 1996). This scale is composed of two subscales—social constraint and physical exhaustion—and each subscale has six items (4point Likert scale). The scale reliabilities for this data were a = 0.93, 0.95, 0.96 for social constraint, physical exhaustion, and the total score, respectively. Therefore, each subscale and the total score were used in the analysis.
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2.6. J-ZBI In the present study, the J-ZBI was used to measure the caregiving burden. The analysis made use of the total score of the J-ZBI and a single global rating of the burden that measured the overall burden in an item. The reliability of the J-ZBI in the data was found to be sufficient (a = 0.93). 2.7. CES-D The CES-D (Radloff, 1977) is often used as an outcome measurement tool in caregiving studies (Schulz et al., 1995). The reliability of the Japanese version of the CES-D (Shima et al., 1985) for this data was sufficient (a = 0.93).
3. Results 3.1. Descriptive analysis Table 1 lists the characteristics of the two types of the samples (questionnaire type A and questionnaire type B) used in the present study. Female caregivers accounted for 74% and 82% in the type A and type B samples, respectively. The average age of the family caregivers was 59.9 11.9 (S.D.) years and 60.7 10.5 for the type A and type B samples, respectively. With regard to kin relationships, the sons and daughters (of older people) comprised the largest proportion of caregivers in both the samples (type A sample: 46.0%; type B sample: 42.6%), followed by the spouses (type A sample: 32.0%; type B sample: 29.6%). The average economic status was 2.88 0.77 and 3.08 0.87 in the type A and type B samples, respectively. No significant differences were observed between the sample types with regard to the abovementioned sample characteristics. The average of the J-ZBI score, which was measured only in the type A sample, was 40.86 16.56. The average of the CES-D score for the type A sample was slightly higher (18.66 12.05) than that for the type B sample (15.52 9.64); however, no significant difference was observed between the sample types. Moreover, no significant difference in the average CSA score (scores of both the subscales and the total score) was observed between the samples. The average of the subscale social constraint was 18.13 5.08 and 18.30 4.75 for the type A and type B samples, respectively; the average of the subscale physical exhaustion was 15.18 5.71 and 14.91 4.98 for the type A and type B samples, respectively. In addition, the average of the total score was 33.31 10.20 and 33.22 8.95 for the type A and type B samples, respectively. 3.2. Criterion validity In order to examine the criterion validity of the CSA, its correlation with a simple measure of caregiving restriction, the total score of the J-ZBI, and a single global rating of
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Table 1 Characteristics of the samples Variable
Questionnaire type A sample (N = 50) N
Family caregivers Gender Female Male Kin relationship Daughter/son Spouse Daughter-in-law Other Education Junior high school High school Junior college College/university Age Economic status (5-point) Caregiving restriction (6-point) J-ZBI CES-D
S.D.
Range
N
37 13
139 30
23 16 8 3
72 50 40 7
6 21 14 9
24 77 35 33
CSA Social constraint Physical exhaustion Total score Older people Gender Female Male Age GCDI Cognitive impairments ADL
Mean
Questionnaire type B sample (N = 169) Mean
S.D.
Range
59.9 2.88 3.10 40.86 18.66
11.9 0.77 1.05 16.56 12.05
33–86 1–4 1–6 9–77 0–57
60.7 3.08 3.30
10.5 0.87 1.31
33–91 1–5 1–6
15.52
9.64
0–45
18.13 15.18 33.31
5.08 5.71 10.20
6–24 6–24 13–48
18.30 14.91 33.22
4.75 4.98 8.95
6–24 6–24 12–48
82.0 2.80 7.80 16.42
9.3 1.41 2.04 5.39
54–103 1–5 6–12 6–24
40 10
110 59 82.2 2.94 7.75 16.74
9.2 1.35 1.78 5.10
59–101 1–5 6–11 8–24
burden were analyzed. Table 2 shows the results of the Pearson correlation analysis for the type A sample; those for the type B sample are shown in Table 3. Significant correlations were observed between the social constraint and the simple measure of caregiving restriction in both the samples (type A: r = 0.30, p < 0.05; type B: r = 0.44, p < 0.01). The results of the type A sample showed significant correlations between the CSA (social constraint, physical exhaustion, and total score) and the J-ZBI (social constraint: r = 0.77, p < 0.01; physical exhaustion: r = 0.78, p < 0.01; total score: r = 0.77, p < 0.01). Significant correlations were also found between the CSA and the single global rating of burden that was included in the J-ZBI (social constraint: r = 0.67, p < 0.01; physical exhaustion: r = 0.76, p < 0.01; total score: r = 0.75, p < 0.01).
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Table 2 Correlation coefficients among CSA, ZBI, CES-D, and disabilities of older people in type A sample J-ZBI
CSA Social constraint
Physical exhaustion
Total score
Caregiving restriction J-ZBI Global rating of burden CES-D
0.18 – 0.79** 0.75**
0.30* 0.71** 0.67** 0.66**
0.19 0.77** 0.76** 0.80**
0.26 0.78** 0.75** 0.77**
Disabilities of older people GCDI Cognitive impairments ADL
0.21 0.38** 0.26
0.30* 0.36** 0.43**
0.19 0.24 0.40**
0.26 0.31* 0.44**
* **
p < 0.05. p < 0.01.
3.3. Construct validity of the CSA and its relationships with the items of social services In order to examine the construct validity of the CSA and its relationships with the items of social services, correlations among the CSA, CES-D, GCDI, and the disabilities of older people (cognitive impairments and ADL) were analyzed. Significant correlations were observed between the CES-D and CSA (the subscales and the total score) for both the sample types. Although the GCDI scores were not correlated with those of the J-ZBI, CSA scores (social constraints) significantly correlated with those of the GCDI in both the sample types (type A: r = 0.30, p < 0.05; type B: r = 0.16, p < 0.05). In the section on the analysis of disabilities of older people and the CSA, significant correlations were examined among social constraints and cognitive impairments in both sample types (type A: r = 0.36, p < 0.01; type B: r = 0.19, p < 0.05) and also among the total score of the CSA and cognitive impairments (type A: r = 0.31, p < 0.05; type B: r = 0.17, p < 0.05). The ADL score was not correlated with the J-ZBI score; however, in both sample types, the ADL score was significantly correlated with the CSA score—CSA Table 3 Correlation coefficients among CSA, ZBI, CES-D, and disabilities of older people in type B sample CSA Social constraint
Physical exhaustion
0.44 0.36**
0.30 0.58**
0.40** 0.51**
Disabilities of older people GCDI Cognitive impairments ADL
0.16* 0.19* 0.24**
0.07 0.13 0.16*
0.12 0.17* 0.21**
*
p < 0.05. p < 0.01.
**
Total score
Caregiving restriction CES-D
**
**
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subscales (type A: social constraints: r = 0.43, p < 0.01; physical exhaustion: r = 0.44, p < 0.01; type B: social constraints: r = 0.24, p < 0.05; physical exhaustion: r = 0.16, p < 0.05) and the total score (type A: r = 0.44, p < 0.01; type B: r = 0.21, p < 0.05).
4. Discussion The results of the present study revealed that the CSA has a significant correlation with the J-ZBI, which is a standard caregiving burden scale. In addition, the CSA has a significant correlation with a single global rating of burden (Zarit et al., 1980). Since criterion validity is an important criterion for clinical assessments, new development scales are required in order to examine validity. Although several caregiving burden and stress scales have already been developed in this area (Kinney and Stephens, 1989; Lawton et al., 1989; Vitaliano et al., 1991; Stull, 1996), few scales have examined the relationship with the standard scale (i.e., ZBI or a single global rating of burden). In the present study, the results of the correlational analysis in the type A sample suggests that the CSA is one of the alternative scales used for measuring the burden and stress of family caregivers. Compared with the J-ZBI, the CSA subscale social constraints revealed significant correlations with caregiving restriction. This result suggests a divergent validity of the CSA subscale social constraints that measures the increase in psychosocial stress due to caregiving restrictions (Thommessen et al., 2002). Historically, it was assumed that the scale for assessing caregiving stress should be associated with the disabilities of older people (cognitive impairments, ADL, or BPSD) (Zarit et al., 1986; Vitaliano et al., 1991). In the present study, the analyses were conducted on the basis of two aspects of the disabilities of older people, namely, cognitive impairments and the ADL. The results indicated that the CSA has a significant relationship with both types of the disabilities, while the relationship between the ADL and J-ZBI is not observed from this data. The statistical power for the analysis between the J-ZBI and the disabilities may be insufficient for this data due to the small sample size (Schulz et al., 1995). However, it is clear that the ADL and the CSA were significantly correlated between the sample types. Moreover, the social constraints subscale has a significant relationship with the GCDI score that was assessed on the basis of the long-term care insurance system in Japan. This result implies that an increase in the integrated disabilities of older people was one of the causes for the increase in psychosocial stress, especially in terms of social activities. At present, since the long-term care insurance in Japan did not account for the psychosocial stress of family caregivers (Tsutsui and Muramatsu, 2005), if strong connections between the restriction on social activities and the stress-related symptoms such as depression of family caregivers are established, as seen in the many studies (e.g., Abe, 2001), the promotion of the use of the service efficiently (Zarit et al., 1998) and opportunities to meet other caregivers such as self-help groups (Hosaka and Sugiyama, 2003) would be beneficial options for the social services. The CSA could play an important role in assessing such relationships between the variables of the social services and stress of family caregivers in future examinations, because in this study, the responsiveness of the CSA was observed to be more sensitive than the standard burden scale.
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4.1. Limitations and future research The main limitations of the present study are the small sample size of those administered the type A questionnaire, assessments of the disabilities of older people, and the factor structure of the CSA. From the viewpoint of statistical power and restriction of the survey, the type A questionnaire, which aimed to examine the criterion validity, was administered to a small sample. The results of the analyses suggested that the sample size was sufficient to achieve the purpose of the present study; however, because the sample size between the two groups was unbalanced, it is not suitable to compare the scores between the two samples. The cognitive impairments and ADL items from the GCDI were used to assess the disabilities of older people. Currently, many scales that measure the disabilities of older people with confirmed reliability and validity (Folstein et al., 1975; Mattis, 1988; Wade and Collin, 1988) are available. Although the items included in the present study have a similar construct to the standard measures, in the future study, it will be necessary to analyze the relationships between the CSA and the standard disability-related measures. Stull (1996) highlighted that a caregiving burden and stress scale should include several factors to assess the complex feeling of burden. Although some previously developed measurements have a multidimensional factor structure (Green et al., 1982; Kosberg and Cairl, 1986; Lawton et al., 1989; Novak and Guest, 1989; Stull, 1996), the scale developed in the present study has a simple and robust two-factor structure for clinical use. Most of the multidimensional measures can assess the complex aspect of the burden; however, these measurements do not have the correct items since the concept of the stress appraisal is based on the stress-coping theory (Lazarus and Folkman, 1984). The CSA was originally intended to adapt the stress-coping theory; therefore, it does not have construct redundancy from the other concepts (e.g., stressor, appraisal and stress response) in that theory (Abe, 2001). The CSA may also be suitable for the future studies that examine the stress of family caregivers from the viewpoint of the stress-coping theory. It has been 25 years since Zarit et al. (1980) developed the ZBI; the scale has been translated into several languages for the purpose of exploring the applicability to nonWestern countries (The 10/66 Dementia Research Group, 2004). However, it might be also important to develop a new caregiving stress scale that suits the current situation such as the psychosocial aspects of family caregivers and the social service system of the respective countries.
Acknowledgements The author thanks all the family caregivers who participated in the present study. Thanks are also due to Professor Tetsuo Kashiwagi (Kinjyo Gakuin University), Associate Professor Satoru Tsuneto (Osaka University), and Professor Ayako Fujita (Osaka University) for their comments on the early draft of the paper. The present study was supported by the Research Fellowships of the Japan Society for the Promotion of Science (H15–3667).
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Appendix A. CSA scale
1. I am unable to go out when I want because of caregiving 2. I feel drained because of caregiving 3. I have had to make adjustments in my work or personal schedule because of caregiving 4. I think that continuing with caregiving is not good for my health 5. I feel a constraint on my private time because of caregiving 6. I think that my physical health has suffered because of caregiving 7. I have had to sacrifice my vacations or trips because of caregiving 8. I feel tired when I get up in the morning and have to face another day of caregiving 9. I do not have the time to do the things I need to do because of caregiving 10. I think that I can not afford to do other things as a result of caregiving 11. I am very tired as a result of caregiving 12. Caregiving has negatively affected my health
Disagree
Somewhat disagree
Somewhat agree
Agree
1
2
3
4
1 1
2 2
3 3
4 4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1 1
2 2
3 3
4 4
Subscale: social constraints: 1, 3, 5, 7, 9, 11; physical exhaustion: 2, 4, 6, 8, 10, 12.
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