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The relationship between family obligation and religiosity on caregiving
Geriatric Nursing 35 (2014) 126e131
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Feature Article
The relationship between family obligation and religiosity on caregiving Fayron Epps, PhD, RN * Our Lady of Lake College, School of Nursing, 5414 Brittany Drive, Baton Rouge, LA 70808, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 November 2012 Received in revised form 6 November 2013 Accepted 10 November 2013 Available online 5 December 2013
The purpose of this study was to examine the relationship between family obligation and religiosity on the positive appraisal of caregiving among African-American, Hispanic and non-Hispanic Caucasian family caregivers of older adults. Roy’s adaptation model guided formulation of the aims and study design. A cross-sectional, correlational study design was employed to examine the relationship amongst variables for the family caregiver participants. Study participants (N ¼ 69) completed a demographic tool and four instruments the: (1) Katz index, (2) obligation scale, (3) Duke University religion index, and (4) positive appraisal of care scale. There was a significant correlation between family obligation and positive appraisal of caregiving. However, there was no relationship between the family caregiver’s religiosity and positive appraisal of caregiving overall. Demographic variables were also examined to show a higher marginal mean for Hispanic primary caregivers in relation to the positive appraisal of caregiving. Future studies should consider replicating these findings in a larger sample to provide health care professionals with substantial evidence to incorporate culturally sensitive interventions aimed at promoting positive outcomes and healthy family behaviors. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: Family caregiving Positive appraisal of care Religiosity Cultural values Family obligation Older adults
The United States (U.S.) is experiencing a rapid shift in population demographics that includes more AfricaneAmerican and Hispanic older adults.1 This increase impacts the number of culturally diverse family members caring for an older adult in the home. Projections indicate that the AfricaneAmerican older adults population will quadruple, and the Hispanic population of older adults will increase to 6.5 times its current size by 2050.1 There is now a demand for more research on the beneficial aspects of caregiving to better understand the possible antecedents that facilitate caregivers’ adaptation to the caregiver role among ethnic populations.2,3 There is a need to identify how ethnically diverse family members positively adapt to caregiving for an older adult family member. This article reports the results of a study that examined the relationship of cultural values of obligation and religiosity on the positive appraisal of caregiving of dependent older adults in family caregivers among AfricaneAmericans, Hispanics and non-Hispanic Caucasians. Providing care to a family member is a life-altering experience. Being a caregiver involves changes and sacrifices in order to meet the needs of the dependent older adult. This situation makes caregivers a vulnerable population.4 Caregiving is a multidimensional construct, which includes both positive and negative * Tel.: þ1 225 490 1639; fax: þ1 225 760 1760. E-mail address: [email protected]. 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.11.003
appraisal of the caregiving experience. For the purpose of this research, I focused on positive appraisal that elicits beneficial aspects, including feeling useful, adding meaning to sense of self, strengthening caregivers’ relationship with their relatives, and gaining satisfaction.3,5 Positive appraisal is important because the caregiver’s satisfaction, and finding gratification and meaning in their role as caregiver, influences the caregiver’s motivation for taking on, coping with and sustaining the ongoing responsibility in caring for another person.6 Positive appraisal may extend the length of time that family members are involved in care and delay or prevent the negative effects of caregiving on the family members’ health.6,7 Although normative expectations may influence positive appraisal, little is known about the influence of cultural norms of obligation and religiosity on the positive appraisal of caregiving. Culture is the values, beliefs, behaviors, artifacts and norms of a group that may guide the behavior of family members and their roles within the family.8 For example, within the construct of culture, a normative expectation may include familism. Familism refers to a strong identification and solidarity of individuals with their family, as well as strong normative feelings of allegiance, dedication, reciprocity and attachment to their family members.2 Familism influences a caregiver’s sense of obligation to provide care.4,9 Family obligation is the degree of a person’s expression for a cultural value that modifies the effect of caregiving appraisal and
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perceived obligation to provide material and emotional support to the family.4,9 This sense of obligation to care is often overlooked when exploring ethnic caregivers’ positive appraisal of caregiving for dependent, older adult family members.4 Religious beliefs are connected to a family member’s motivation to provide care for frail older adults.10 Providing care for older adult family members is linked to religious values or more specifically, religiosity; one’s beliefs and practices related to a religious affiliation or to God.11,12 Religiosity reflects behaviors that include participation in religious activities (organizational), religious involvement (non-organizational) and subjective (intrinsic) reports of having a relationship with a higher being.11,13 Many religious belief systems foster a character of responsibility and care for others. This serves as an important resource when one is faced with the realities of responsibility and care and has been found to result in a positive outlook to caregiving.8,12,14 In a study of Africane American and non-Hispanic Caucasian family caregivers, Haley et al12 found that a relationship with a higher being, an increase in religious service attendance and a higher frequency of prayer significantly affected how AfricaneAmericans’ viewed and coped with the caregiver role. This was found to have a largely positive influence on their beliefs and perceptions of caregiving. Previous research supports religious coping as an internal resource used among AfricaneAmerican and Hispanic family caregivers.10,12,14 More specifically, research reports that organizational religiosity elicits a broad range of emotions to include positive or negative, a marker for a multidimensional experience.15 Research on AfricaneAmerican, Hispanic and non-Hispanic Caucasian positive appraisal of caregiving is limited. Due to the nation’s increasing diversity in older persons and their caregivers, it is important to better understand the impact of obligation and religiosity on family caregiving and caregiver appraisal.4 This study assessed the relationship of the cultural values of obligation and religiosity with the positive appraisal of caregiving among AfricaneAmerican, Hispanic and non-Hispanic Caucasians family caregivers for dependent, older adult family members. In order to explore the relationships among the variables, the following aims were addressed in this study: 1) describe obligation, religiosity and positive appraisal of caregiving among Africane American, Hispanic and non-Hispanic Caucasian family caregivers and 2) examine any differences in the relationships of obligation
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and religiosity with positive appraisal of caregiving among Africane American, Hispanic and non-Hispanic Caucasian family caregivers. Based on these aims, the following null hypotheses were tested: 1) there were no differences among AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers in obligation, religiosity, and positive appraisal of caregiving; 2) obligation and religiosity were not associated with the positive appraisal of caregiving, after controlling for demographic characteristics to guard against confounding variables; and 3) there were no differences among AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers in the relationship of obligation and religiosity with positive appraisal of caregiving. Theoretical framework Roy’s adaptation model (RAM) was used as the theoretical framework to support this study (see Fig. 1). RAM, describes individuals as holistic adaptive systems that are capable of responding to internal and external environmental stimuli.16 The relatedness of study variables to Roy’s model guides the view of positive appraisal of caregiving as a continuous process of evaluating coping mechanisms to help re-establish stability between person and environment. AfricaneAmerican, Hispanic and nonHispanic Caucasian family caregivers, along with the independent variables of obligation and religiosity are affected directly by the stimuli of family caregiving, demographic and unknown variables. The phenomena of interest identified in RAM include the study of basic life processes and how nursing maintains adaptive responses or changes ineffective responses, which represents focal, contextual and residual stimuli.16 Focal stimuli, in this study, are represented by the family caregiving variable, which is the stimulus that immediately confronts the family. The demographic variables within this study represent the contextual stimuli, factors that contribute to family caregiving. Residual factors included in this study model are classified as unknown, as recommended by RAM,16 which allows for unknown environmental factors. Overall, the environmental stimuli examined the effect of independent variables upon the expected outcome of positive caregiver appraisal. The culturally relevant variables of obligation and religiosity are conceptualized as cognitive in nature, influencing family caregivers’ assessments of their roles as caregivers and are hypothesized to
Fig. 1. This path model, adopted from Roy’s adaptation model describes the relationship of stressors (stimuli), obligation and religiosity on the positive appraisal of caregiving.
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influence their judgment of positive appraisal ultimately resulting in positive caregiver outcomes. The evaluation of obligation and religiosity on the positive appraisal of caregiving was examined among AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers. Methods Design A descriptive, cross-sectional survey design was used to explore the relationships of the cultural values of obligation and religiosity with the positive appraisal of caregiving among AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers. This design also was used to identify possible differences in the relationships of obligation, religiosity and positive appraisal of caregiving among the three racial/ethnic groups (henceforth, identified as ethnic groups). Sample The population for this study was AfricaneAmerican, Hispanic, and non-Hispanic Caucasian family caregivers of older adult family members from the Southeastern regions of Louisiana. In order to participate in this study, the following inclusion criteria were met: (1) individuals who identified themselves as either Africane American, Hispanic or non-Hispanic Caucasian; (2) 18 years of age or older; (3) individuals who were able to speak, write, read and understand the English language at the eighth grade level; (4) provision of a minimum of one activity of daily living according to the Katz index17 without financial reimbursement; and (5) at least 20 h per week of care to a noninstitutionalized family member who is over the age of 64 and has been diagnosed with a chronic illness. A non-probability purposive quota sampling technique, which is a type of convenience sampling technique, was used to ensure adequate numbers of subjects in each stratum for the planned statistical analysis.18 Quota sampling used in this study increases the representativeness of the sample by maintaining equal cell sizes for the planned statistical analysis, strategizing to ensure inclusion of subject types that are likely to be underrepresented. G*Power 3.119 calculated a sample size of 68 using a power of .80, medium effect size of r ¼ .15, and alpha of .05. An overall sample size of 69 was divided into three equal groups of 23 Africane Americans, Hispanics and non-Hispanic Caucasians family caregivers. The study was conducted in settings that family caregivers used. This included two adult day health care centers, five churches and one caregiver support group located in the greater New Orleans, River Parishes and Baton Rouge area in Louisiana. Instruments The following four instruments were used to screen participants and collect data in this study: (1) Katz index,17 (2) the obligation scale,20 (3) the Duke University religion index21 and (4) the positive appraisal of care scale.22 In addition, a demographic questionnaire was constructed to measure the caregiver’s age, gender, income, educational level, religion, caregiver type and relationship to older adult. Further age, gender and living arrangements of the care recipient were assessed. Katz index The Katz index of independence in activities of daily living ranks adequacy of performance in the six functions of bathing,
dressing, toileting, transferring, continence, and feeding by judging the degree of independence.17,23 Older adults were scored by a family caregiver as yes/no for independence in each of the six functions. A score of six indicated full function, four indicated moderate impairment, and two or less indicated severe functional impairment. The Katz index has been found to have reliability coefficients ranging from .87 to .94.24 The Katz index was used as a screening tool to determine dependency of the older adult. The obligation scale The obligation scale is a seven-item scale that measures general feelings to reflect cultural values about obligation to care for an older adult relative.20,25 Each item on the scale consist of a fivepoint Likert-type response that ranges from strongly agree (5) to strongly disagree (1). The respondents were asked to indicate how important each statement is as a reason for helping their family member with the higher score indicating higher obligation. Sample items included “I feel a sense of obligation to help”; “It’s a child’s duty to help”; and “I would feel ashamed if I didn’t help”. A higher score is associated with a greater feeling of family obligation. The reported internal consistency reliability was .71.25 This study paralleled Lee et al’s9 study which uses the obligation scale to assess the cultural values of caregivers. Duke University religion index The Duke University religion index (DUREL) is a five-item measure of religious involvement that assesses three major dimensions of religiosity: organizational (participation in religious activities), non-organizational (religious involvement in private activities), and intrinsic (having a relationship with a higher being) religiosity.21 The DUREL measures each of these dimensions by subscale to assess particular aspects of religious practice or religious devotion. Subscale number one is the first question in the DUREL that asks about frequency of attendance at religious services (organizational). Subscale number two is the second question that asks about frequency of private activities (non-organizational). Subscale number three consists of the final three items that assess intrinsic religiosity. A higher score indicates a greater sense of religiosity. The overall scale has had a high testeretest reliability (intra-class correlation) of .91 and a high convergent validity with other measures of religiosity (r’s ¼ .71e.86).13 Positive appraisal of care scale The positive appraisal of care scale was developed to evaluate positive appraisal of care among family caregivers within the framework of caregiver adaptation.22 This scale consists of 21 items: relationship satisfaction (five items), role confidence (five items), consequential gain (six items), and normative fulfillment (five items). Participants were instructed to rate “how you have been in the previous two weeks” using a four-point Likert scale. A higher score indicates a more positive appraisal of caregiving. YamamotoMitani et al22 reports Cronbach alphas of the domains and total scales as follows: .84 (relationship satisfaction), .83 (role confidence), .84 (consequential gain), .74 (normative fulfillment), and .92 (total of the positive appraisal of care scale). Procedure Written approval to conduct the study was obtained from the University Institutional Review Board (IRB), and each of the data collection sites according to the site’s research protocol. Written informed consent was obtained from all subjects. Flyers of the proposed study and how to contact the researcher to participate in
F. Epps / Geriatric Nursing 35 (2014) 126e131
the study were posted among the facilities and sent home with care recipients, caregivers, and church members. Potential subjects were screened by telephone interview using the Katz index and demographic questionnaire. A total of 83 family caregivers were screened, with 69 caregivers meeting the inclusion criteria. Arrangements were made to meet with the caregivers for a one time interview at a convenient location to complete the remainder of the questionnaires. Data analysis Data were analyzed using the SPSS version 19 for Windows software. Descriptive statistics including frequency distributions, means, modes, medians, standard deviations, ranges and percentages were run to summarize variables. An analysis of variance (ANOVA) was used to test for differences in family obligation, religiosity, and positive appraisal of caregiving among Africane American, Hispanic and non-Hispanic Caucasian family caregivers. Multiple regression analysis also was used in a stepwise (hierarchical) fashion to evaluate the unique contributions of obligation and religiosity. This helped explain the variance in family caregivers’ positive appraisal of caregiving (among the three ethnic groups), after adjusting for demographic characteristics. Due to the small sample size, the regression model was built in stages to limit the number of independent variables used simultaneously. Following the recommendations of Mickey and Greenland26 for the screening of covariates individually, only demographic characteristics that had a bivariate association with positive appraisal with a p value <.25 were entered into the multiple regression.
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Results The sample consisted of 69 family caregivers. The subjects were between 24 and 79 years of age, with a mean age of 47.9 (SD ¼ 13.3). A total of 86% (n ¼ 59) were females. For AfricaneAmerican family caregivers, the ages ranged from 26 to 79 with a mean age of 49.0 (SD ¼ 13.2) and 91% (n ¼ 21) were female. Among the Hispanic family caregivers, the mean age was 40.0 (SD ¼ 12.0) with ages ranging from 24 to 67 and with 83% (n ¼ 19) being female. The mean age for non-Hispanic Caucasian family caregivers was 54.7 (SD ¼ 10.5) with ages ranging from 28 to 74 and with 83% (n ¼ 19) of these also being female (see Table 1 for additional caregiver demographics). A one-way between subjects ANOVA showed a significant difference in the mean ages among AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers [F(2,66) ¼ 8.8, p < .001]. Post hoc pairwise comparisons using the Bonferroni correction indicate significant differences in the mean ages specifically among Hispanics and AfricaneAmericans (p ¼ .040); and Hispanics and non-Hispanic Caucasians (p < .001). Within the demographics, the majority of the care recipients were female 78% (n ¼ 54), lived at home 62% (n ¼ 43), and received caregiving from their child 70% (n ¼ 48). Overall scores on the obligation scale for all family caregivers ranged from 14 to 35 (a ¼ .83). The mean score was 29.9 (SD ¼ 5.1). The total scores on the DUREL ranged from 5 to 27 (a ¼ .85), which matches the possible score range. The mean score was 22.0 (SD ¼ 4.5). Overall scores on the positive appraisal of care scale ranged from 38 to 100 among the family caregivers (a ¼ .87). The mean score was 86.1 (SD ¼ 13.4). A one-way between subjects
Table 1 Caregiver demographics. Caregiver variables
Education level Elementary High/GED Some college College grad Grad degree Annual income 0e25,999 26e35,999 36e45,999 46e55,999 56e65,999 66e75,999 >76,000 Religion Baptist Catholic Methodist Non-denominational Pentecostal Relationship Child Grandchild Sibling Spouse Niece/nephew Caregiver type Primary Secondary
AA/Black (non-Hispanic)
Hispanic/Latino (of any race)
Caucasian/White (non-Hispanic)
Total
n
n
n
(%)
N
(%)
(%)
(%)
p
.453 0 4 8 6 5
(.0) (17.4) (34.8) (26.1) (21.7)
2 7 7 5 2
(8.7) (30.4) (30.4) (21.8) (8.7)
0 8 5 7 3
(.0) (34.8) (21.8) (30.4) (13.0)
2 19 20 18 10
(2.9) (27.5) (29.0) (26.1) (14.5)
9 5 2 1 5 1 0
(39.1) (21.8) (8.7) (4.3) (21.8) (4.3) .0
14 5 1 1 0 0 2
(60.9) (21.8) (4.3) (4.3) .0 .0 (8.7)
7 6 2 2 2 3 1
(30.4) (26.1) (8.7) (8.7) (8.7) (13.0) (4.3)
30 16 5 4 7 4 3
(43.5) (23.2) (7.2) (5.8) (10.1) (5.8) (4.3)
15 5 0 2 1
(65.2) (21.8) (.0) (8.7) (4.3)
5 12 0 0 6
(21.8) (52.2) .0 .0 (26.1)
4 11 3 5 0
(17.4) (47.8) (13.0) (21.8) .0
24 28 3 7 7
(34.8) (40.6) (4.3) (10.1) (10.1)
18 1 0 0 4
(78.3) (4.3) .0 .0 (17.4)
14 6 1 0 2
(60.9) (26.1) (4.3) .0 (8.7)
16 4 1 2 0
(69.6) (17.4) (4.3) (8.7) .0
48 11 2 2 6
(69.6) (15.9) (2.9) (2.9) (8.7)
18 5
(78.3) (21.7)
15 8
(65.2) (34.8)
12 11
(52.2) (47.8)
45 24
(65.2) (34.8)
.267
<.001a
.113
.178
a Descriptive crosstabs were used to test pairwise differences between races in religion preferences. A Bonferroni-adjusted p value (actual p value multiplied by the number of pairwise comparisons) was calculated to determine the significance level for each pairwise difference. AA were more likely to be Baptist than Hispanic and non-Hispanic Caucasian family caregivers (p ¼ .003, .009 respectively). Hispanic family caregivers were more likely to be Pentecostal than non-Hispanic Caucasians (p ¼ .027). Non-Hispanic Caucasian family caregivers were slightly above the set significance level with p ¼ .054 in determining their likelihood of classifying themselves as non-denominational in comparison to Hispanic family caregivers. No other pairwise comparisons were statistically significant.
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Table 2 Means (SDs) for obligation, religiosity, and positive appraisal of caregiving.
Obligation Religiosity (DUREL) Positive appraisal of care
AA/Black (nonHispanic)
Hispanic/ Latino (of any race)
Caucasian/ White (nonHispanic)
Total
p
30.1 (6.2) 22.4 (3.1) 90.0 (11.5)
30.0 (4.3) 22.5 (5.3) 84.9 (13.0)
29.5 (4.9) 21.1 (4.8) 83.4 (15.3)
29.9 (5.1) .915 22.0 (4.5) .496 86.1 (13.4) .214
ANOVA did not show any differences among the means for AfricaneAmerican, Hispanic, and non-Hispanic Caucasian family caregivers in obligation, religiosity, or positive appraisal of caregiving (see Table 2). Three demographic variables, income, caregiver type, and ethnicity were entered in the first step of the hierarchical multiple regression analysis to assess the relationships of obligation and religiosity with positive caregiving appraisal. These variables were selected for inclusion as independent variables because all had a bivariate association with positive appraisal of caregiving with p values <.25, while age (p ¼ .68), education (p ¼ .80), relationship (p ¼ .56), and religion (p ¼ .86) all had much higher p values and were excluded. The demographic variables, including the interaction of ethnicity and caregiver type, accounted for 20% of the variance in positive appraisal of caregiving (Table 3). The addition of obligation and religiosity in the second step increased the explained variance to 37%. However, only obligation was found to make a statistically significant contribution to R2, with an increase in obligation score being associated with an increase in positive appraisal. Additionally, interaction terms added to the regression model to test whether the associations of either obligation or religiosity with positive appraisal varied by ethnic group were not statistically significant (p ¼ .51 and p ¼ .46, respectively). On the other hand, the hierarchical regression did find a significant interaction (p ¼ .023) between ethnicity and caregiver type (primary or secondary). Table 4 shows the estimated marginal means for positive appraisal of caregiving within combinations of caregiver type and ethnicity. Among primary caregivers, the positive appraisal mean for AfricaneAmerican caregivers was significantly higher than it was for non-Hispanic Caucasian caregivers (p ¼ .035), and there was a nonsignificant trend (p ¼ .08) for positive appraisal to be higher among Hispanic caregivers than among non-Hispanic caregivers. Furthermore, among secondary caregivers, both AfricaneAmericans and non-Hispanic Caucasians had significantly higher positive appraisal ratings than Hispanics (p ¼ .035 and .012, respectively), while the two groups did not differ between each other (p ¼ .99).
Table 3 Hierarchical multiple regression model for the association of obligation and religiosity with positive appraisal, controlling for demographic characteristics.
Step 1 (control variables) Incomea Race/ethnicity Caregiver type Race caregiver type Step 2 Obligationc Religiosity (DUREL)
R2
DR2
.20
.20
F
Sig. 4.21 1.62 1.41 4.02
.37
.17b 15.10 .28
.026 .044 .206 .240 .023 <.001 <.001 .597
a The relationship of income to positive appraisal of caregiving is negative. Higher income is associated with lower positive appraisal scores. b The unique contribution of obligation to explained variance ¼ .16. c In the regression model the effect of obligation did not vary significantly be race (no interaction).
Table 4 Estimated marginal means (SE) for positive appraisal of caregiving by race/ethnicity and caregiver type. Caregiver type
AA/Black (non-Hispanic)
Hispanic/Latino (of any race)a
Caucasian/White (non-Hispanic)
Primary Secondary Difference
91.0 (3.0) 87.4 (5.6) 3.6
89.1 (3.3) 74.2 (4.5) 14.9
81.0 (3.7) 87.7 (3.8) 6.7
Note: Estimated marginal means are for a caregiver at the average income level among the caregiver participants. a Caregiving appraisal scores for Hispanic/Latino caregivers differed significantly by type (p ¼ .005). In comparisons of caregiver types for Hispanic/Latino and Caucasian/White caregivers, the differences were not statistically significant.
Discussion The findings of this study showed AfricaneAmerican family primary caregivers positively appraised their caregiving experience to a greater extent than non-Hispanic Caucasian primary caregivers, with Hispanic primary caregivers having a similar, though not statistically significant, pattern in relation to non-Hispanic Caucasians. This finding is consistent with published studies reporting AfricaneAmericans having higher levels of reward in comparison to non-Hispanic Caucasian family caregivers.11,12,27 The positive appraisal by ethnic minorities has been attributed to their culture of greater participation in a larger extended family context and its influence on family member roles and perceived obligations.12,28 In addition, many AfricaneAmericans have previous experience with adversity, which allows them to reframe the often challenging caregiver role into a more positive experience.29 Nevertheless, this study also found that AfricaneAmericans and non-Hispanic Caucasian secondary caregivers had levels of positive appraisal that were very similar to one another and significantly higher than the level for Hispanic secondary caregivers. Therefore, these findings suggest more investigation should be made of the interaction between the caregiver relationship and ethnicity in relation to positive appraisal of caregiving. Overall, family caregivers in this study that had an increased sense of family obligation also expressed a positive appraisal of care. This is consistent with other studies reporting caregivers who identify with the concept of family obligation to interpret family caregiving as rewarding.9,30 Anngela-Cole and Hilton4 reported non-Hispanic Caucasians to have strong beliefs and positive attitudes about family obligation. Thus, this study suggests that the same may be said of AfricaneAmerican and Hispanic caregivers. The findings in this study noted that there was no association between religiosity and positive appraisal of caregiving among family caregivers. However, this finding is inconsistent with previous research. Prior studies describe how family caregivers’ religiosity positively influences their perception of caregiving.10,12,29 Much literature expounds on how religion is a coping mechanism used to help with the stressors of family caregiving.8,10,31 Additionally, studies report AfricaneAmerican family caregivers as a having higher level of religiosity resulting in experiencing perceived benefits of caregiving compared to non-Hispanic Caucasians,10,11,28 although no significant difference was noted among the ethnic groups in this study. There is a need for research, which explores the dimensions of religiosity among minority family caregivers to improve the conceptualization of religiosity and its impact on caregiving. For this reason, a qualitative study may be necessary to gain a better understanding of these concepts and how they are operationalized within these diverse ethnic groups. In summary, this study challenges the assumption that religiosity increases positive appraisal of caregiving. In particular, religiosity may be a strong motivation in caring for an older adult, but may feel more burdensome and/or neutral to the caregiver. This
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notion needs be studied further and interventions implemented to support the role of family obligation and/or religiosity for family caregivers. Health care professionals working with family caregivers in providing support services could assist caregivers in understanding the role of religion and obligation in their commitment to care and facilitate positive aspects of the caregiving experience. Limitations There were several limitations in this study. The first limitation is the sampling technique used. Data were collected by using a quota sampling technique recruiting from a convenience sample. The study participants are not representative of AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers in the U.S.; therefore the findings cannot be generalized to all family caregivers within these ethnic groups. Also, this is a small study (N ¼ 69) and should be replicated with a larger sample. Additionally, acculturation of AfricaneAmerican and Hispanic caregivers was not measured or controlled for within this study. Thus, attitudes regarding care of older adults could be more traditional among first-generation African and Hispanic caregivers than among third-generation. The influence of acculturation on caregiver’s attitudes and behaviors is an important factor to consider in future studies. Recruitment of study participants from faith-based organizations also limits the generalizability of study findings resulting in potential bias for the religiosity score. Furthermore, the use of surveys with self-reported data is a limitation for this study. Conclusion To improve family outcomes currently, and in the future, it is important for an evidence-based approach to be used in the development of the plan of care by using culturally sensitive interventions. Information obtained from this study revealed an understanding of family caregivers’ appraisal of caregiving. However, future work should consider replicating these findings in a larger sample, along with other indicators to provide health care professionals with substantial evidence to incorporate culturally sensitive interventions aimed at promoting positive outcomes and healthy family behaviors, such as increased well-being and motivation and decreased burnout, stress and depression. Acknowledgments Special thanks to Meridean Maas PhD, RN, FAAN, Lisa Skemp PhD, RN, David Reed PhD, and Karen Clark MSN, RN, for their contributions to this paper. Data analysis in this manuscript was supported by the National Hartford Centers of Gerontological Nursing Excellence Fellowship Award (2013-2015) & Our Lady of the Lake College Sr. Julie O’Donovan Professorship I. References 1. United States Census Bureau. Overview of race and Hispanic origin: 2010. Web site. http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf; Accessed 07.07.11.
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2. Knight B, Sayegh P. Cultural values and caregiving: the updated sociocultural stress and coping model. J Gerontol Psychol Sci. 2010;65:5e13. 3. Shirai Y, Silverberg S, Kenyon D. Reaping caregiver feelings of gain: the roles of socio-emotional support and mastery. Aging Ment Health. 2009;13(1): 106e117. 4. Anngela-Cole L, Hilton J. The role of attitudes and culture in family caregiving for older adults. Home Health Care Serv Q. 2009;28:59e83. 5. Hunt C. Concepts in caregiver research. J Nurs Scholarsh. 2003;35(1):27e32. 6. Andren S, Elmstahl S. Family caregivers’ subjective experiences of satisfaction in dementia care: aspects of burden, subjective health and sense of coherence. Scand J Caring Sci. 2005;9(4):157e168. 7. Jensen C, Ferrari M, Cavanaugh J. Building on the benefits: assessing satisfaction and well-being in elder care. Ageing Int. 2004;29(1):88e110. 8. Yarry S, Stevens E, McCallun T. Cultural influences on spousal caregiving. Generations. 2007;31(3):24e29. 9. Lee J, Yoo M, Jung D. Caregiving appraisal of family caregivers for older stroke patients. Int Nurs Rev. 2010;57(1):107e112. 10. Dilworth-Anderson P, Boswell G, Cohen M. Spiritual and religious coping values and beliefs among African-American caregivers: a qualitative study. J Appl Gerontol. 2007;26(4):355e369. 11. Picot S, Debanne S, Namazi K, Wykle M. Religiosity and perceived rewards of black and white caregivers. Gerontologist. 1997;37(1):89e101. 12. Haley W, Gitlin L, Wisniewski S, et al. Well-being, appraisal, and coping in African-American and Caucasian dementia caregivers: findings from the REACH study. Aging Ment Health. 2004;8(4):316e329. 13. Koenig HG, Bussing A. The Duke University Religion Index (DUREL): a five-item measure for use in epidemiological studies. Religions. 2010;1:78e85. 14. Hodge D, Sun F. Positive feelings of caregiving among Latino Alzheimer’s family caregivers: understanding the role of spirituality. Aging Ment Health. 2012;16(6):689e698. 15. Rote S, Hill T, Ellison C. Religious attendance and loneliness in later life. Gerontologist. 2013;53(1):39e50. 16. Roy C, Andrews H. The Roy Adaptation Model. 2nd ed. Stanford: Appleton and Lange; 1999. 17. Katz S, Down T, Cash H, Grotz R. Progress in the development of the index of ADL. Gerontologist. 1970;10(1):20e30. 18. Burns N, Grove S. The Practice of Nursing Research: Conduct, Critique, & Utilization. Philadelphia, PA: W. B. Saunders Company; 2009. 19. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009;41:1149e1160. 20. Cicirelli V. Family Caregiving: Autonomous and Paternalistic Decision Making. Newbury Park: Sage Publications; 1991. 21. Koenig HG, Meador K, Parkerson G. Religion index for psychiatric research: a 5item measure for use in health outcome studies. Am J Psychiatry. 1997;154: 885e886. 22. Yamamoto-Mitani K, Sugishita C, Ischigaki K, Hasegawa K, Maekawa N. Development of instruments to measure appraisal of care among japanese family caregivers of the elderly. Sch Inq Nurs Pract Int J. 2001;15(2): 113e135. 23. Wallace M, Shelkey M. Monitoring functional status in hospitalized older adults. Am J Nurs. 2008;108(4):64e71. 24. Cisesla J, Shi L, Stoskopf C, Samuels M. Reliability of Katz’s activities of daily living scale when used in telephone interviews. Eval Health Prof. 1993;16(2): 190e203. 25. Cicirelli V. Attachment and obligation as daughters’ motives for caregiving behavior and subsequent effect on subjective burden. Psychol Aging. 1993;8: 144e155. 26. Mickey RM, Greenland S. The impact of confounder selection criteria on effect estimation. Am J Epidemiol. 1989;129(1):125e137. 27. Roff L, Burgio L, Gitlin L, et al. Positive aspects of Alzheimer’s caregiving: the role of race. J Gerontol. 2004;59B(4):185e190. 28. Giunta N, Chow J, Scharlach A, Dal Santo T. Racial and ethnic differences in family caregiving in California. J Hum Behav Soc Environ. 2004;9:85e109. 29. Vroman K, Morency J. “I do the best I can”: caregivers’ perceptions of informal caregiving for older adults in Belize. Int J Aging Hum Dev. 2011;72(1):1e25. 30. Lai D. Filial piety, caregiving appraisal, and caregiver burden. Res Aging. 2010;32(2):200e223. 31. Coon D, Rubert M, Solano N, et al. Well-being, appraisal, and coping in Latina and Caucasion female dementia caregivers: findings from REACH study. Aging Ment Health. 2004;8(4):330e345.
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Feature Article
The relationship between family obligation and religiosity on caregiving Fayron Epps, PhD, RN * Our Lady of Lake College, School of Nursing, 5414 Brittany Drive, Baton Rouge, LA 70808, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 November 2012 Received in revised form 6 November 2013 Accepted 10 November 2013 Available online 5 December 2013
The purpose of this study was to examine the relationship between family obligation and religiosity on the positive appraisal of caregiving among African-American, Hispanic and non-Hispanic Caucasian family caregivers of older adults. Roy’s adaptation model guided formulation of the aims and study design. A cross-sectional, correlational study design was employed to examine the relationship amongst variables for the family caregiver participants. Study participants (N ¼ 69) completed a demographic tool and four instruments the: (1) Katz index, (2) obligation scale, (3) Duke University religion index, and (4) positive appraisal of care scale. There was a significant correlation between family obligation and positive appraisal of caregiving. However, there was no relationship between the family caregiver’s religiosity and positive appraisal of caregiving overall. Demographic variables were also examined to show a higher marginal mean for Hispanic primary caregivers in relation to the positive appraisal of caregiving. Future studies should consider replicating these findings in a larger sample to provide health care professionals with substantial evidence to incorporate culturally sensitive interventions aimed at promoting positive outcomes and healthy family behaviors. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: Family caregiving Positive appraisal of care Religiosity Cultural values Family obligation Older adults
The United States (U.S.) is experiencing a rapid shift in population demographics that includes more AfricaneAmerican and Hispanic older adults.1 This increase impacts the number of culturally diverse family members caring for an older adult in the home. Projections indicate that the AfricaneAmerican older adults population will quadruple, and the Hispanic population of older adults will increase to 6.5 times its current size by 2050.1 There is now a demand for more research on the beneficial aspects of caregiving to better understand the possible antecedents that facilitate caregivers’ adaptation to the caregiver role among ethnic populations.2,3 There is a need to identify how ethnically diverse family members positively adapt to caregiving for an older adult family member. This article reports the results of a study that examined the relationship of cultural values of obligation and religiosity on the positive appraisal of caregiving of dependent older adults in family caregivers among AfricaneAmericans, Hispanics and non-Hispanic Caucasians. Providing care to a family member is a life-altering experience. Being a caregiver involves changes and sacrifices in order to meet the needs of the dependent older adult. This situation makes caregivers a vulnerable population.4 Caregiving is a multidimensional construct, which includes both positive and negative * Tel.: þ1 225 490 1639; fax: þ1 225 760 1760. E-mail address: [email protected]. 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.11.003
appraisal of the caregiving experience. For the purpose of this research, I focused on positive appraisal that elicits beneficial aspects, including feeling useful, adding meaning to sense of self, strengthening caregivers’ relationship with their relatives, and gaining satisfaction.3,5 Positive appraisal is important because the caregiver’s satisfaction, and finding gratification and meaning in their role as caregiver, influences the caregiver’s motivation for taking on, coping with and sustaining the ongoing responsibility in caring for another person.6 Positive appraisal may extend the length of time that family members are involved in care and delay or prevent the negative effects of caregiving on the family members’ health.6,7 Although normative expectations may influence positive appraisal, little is known about the influence of cultural norms of obligation and religiosity on the positive appraisal of caregiving. Culture is the values, beliefs, behaviors, artifacts and norms of a group that may guide the behavior of family members and their roles within the family.8 For example, within the construct of culture, a normative expectation may include familism. Familism refers to a strong identification and solidarity of individuals with their family, as well as strong normative feelings of allegiance, dedication, reciprocity and attachment to their family members.2 Familism influences a caregiver’s sense of obligation to provide care.4,9 Family obligation is the degree of a person’s expression for a cultural value that modifies the effect of caregiving appraisal and
F. Epps / Geriatric Nursing 35 (2014) 126e131
perceived obligation to provide material and emotional support to the family.4,9 This sense of obligation to care is often overlooked when exploring ethnic caregivers’ positive appraisal of caregiving for dependent, older adult family members.4 Religious beliefs are connected to a family member’s motivation to provide care for frail older adults.10 Providing care for older adult family members is linked to religious values or more specifically, religiosity; one’s beliefs and practices related to a religious affiliation or to God.11,12 Religiosity reflects behaviors that include participation in religious activities (organizational), religious involvement (non-organizational) and subjective (intrinsic) reports of having a relationship with a higher being.11,13 Many religious belief systems foster a character of responsibility and care for others. This serves as an important resource when one is faced with the realities of responsibility and care and has been found to result in a positive outlook to caregiving.8,12,14 In a study of Africane American and non-Hispanic Caucasian family caregivers, Haley et al12 found that a relationship with a higher being, an increase in religious service attendance and a higher frequency of prayer significantly affected how AfricaneAmericans’ viewed and coped with the caregiver role. This was found to have a largely positive influence on their beliefs and perceptions of caregiving. Previous research supports religious coping as an internal resource used among AfricaneAmerican and Hispanic family caregivers.10,12,14 More specifically, research reports that organizational religiosity elicits a broad range of emotions to include positive or negative, a marker for a multidimensional experience.15 Research on AfricaneAmerican, Hispanic and non-Hispanic Caucasian positive appraisal of caregiving is limited. Due to the nation’s increasing diversity in older persons and their caregivers, it is important to better understand the impact of obligation and religiosity on family caregiving and caregiver appraisal.4 This study assessed the relationship of the cultural values of obligation and religiosity with the positive appraisal of caregiving among AfricaneAmerican, Hispanic and non-Hispanic Caucasians family caregivers for dependent, older adult family members. In order to explore the relationships among the variables, the following aims were addressed in this study: 1) describe obligation, religiosity and positive appraisal of caregiving among Africane American, Hispanic and non-Hispanic Caucasian family caregivers and 2) examine any differences in the relationships of obligation
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and religiosity with positive appraisal of caregiving among Africane American, Hispanic and non-Hispanic Caucasian family caregivers. Based on these aims, the following null hypotheses were tested: 1) there were no differences among AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers in obligation, religiosity, and positive appraisal of caregiving; 2) obligation and religiosity were not associated with the positive appraisal of caregiving, after controlling for demographic characteristics to guard against confounding variables; and 3) there were no differences among AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers in the relationship of obligation and religiosity with positive appraisal of caregiving. Theoretical framework Roy’s adaptation model (RAM) was used as the theoretical framework to support this study (see Fig. 1). RAM, describes individuals as holistic adaptive systems that are capable of responding to internal and external environmental stimuli.16 The relatedness of study variables to Roy’s model guides the view of positive appraisal of caregiving as a continuous process of evaluating coping mechanisms to help re-establish stability between person and environment. AfricaneAmerican, Hispanic and nonHispanic Caucasian family caregivers, along with the independent variables of obligation and religiosity are affected directly by the stimuli of family caregiving, demographic and unknown variables. The phenomena of interest identified in RAM include the study of basic life processes and how nursing maintains adaptive responses or changes ineffective responses, which represents focal, contextual and residual stimuli.16 Focal stimuli, in this study, are represented by the family caregiving variable, which is the stimulus that immediately confronts the family. The demographic variables within this study represent the contextual stimuli, factors that contribute to family caregiving. Residual factors included in this study model are classified as unknown, as recommended by RAM,16 which allows for unknown environmental factors. Overall, the environmental stimuli examined the effect of independent variables upon the expected outcome of positive caregiver appraisal. The culturally relevant variables of obligation and religiosity are conceptualized as cognitive in nature, influencing family caregivers’ assessments of their roles as caregivers and are hypothesized to
Fig. 1. This path model, adopted from Roy’s adaptation model describes the relationship of stressors (stimuli), obligation and religiosity on the positive appraisal of caregiving.
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F. Epps / Geriatric Nursing 35 (2014) 126e131
influence their judgment of positive appraisal ultimately resulting in positive caregiver outcomes. The evaluation of obligation and religiosity on the positive appraisal of caregiving was examined among AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers. Methods Design A descriptive, cross-sectional survey design was used to explore the relationships of the cultural values of obligation and religiosity with the positive appraisal of caregiving among AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers. This design also was used to identify possible differences in the relationships of obligation, religiosity and positive appraisal of caregiving among the three racial/ethnic groups (henceforth, identified as ethnic groups). Sample The population for this study was AfricaneAmerican, Hispanic, and non-Hispanic Caucasian family caregivers of older adult family members from the Southeastern regions of Louisiana. In order to participate in this study, the following inclusion criteria were met: (1) individuals who identified themselves as either Africane American, Hispanic or non-Hispanic Caucasian; (2) 18 years of age or older; (3) individuals who were able to speak, write, read and understand the English language at the eighth grade level; (4) provision of a minimum of one activity of daily living according to the Katz index17 without financial reimbursement; and (5) at least 20 h per week of care to a noninstitutionalized family member who is over the age of 64 and has been diagnosed with a chronic illness. A non-probability purposive quota sampling technique, which is a type of convenience sampling technique, was used to ensure adequate numbers of subjects in each stratum for the planned statistical analysis.18 Quota sampling used in this study increases the representativeness of the sample by maintaining equal cell sizes for the planned statistical analysis, strategizing to ensure inclusion of subject types that are likely to be underrepresented. G*Power 3.119 calculated a sample size of 68 using a power of .80, medium effect size of r ¼ .15, and alpha of .05. An overall sample size of 69 was divided into three equal groups of 23 Africane Americans, Hispanics and non-Hispanic Caucasians family caregivers. The study was conducted in settings that family caregivers used. This included two adult day health care centers, five churches and one caregiver support group located in the greater New Orleans, River Parishes and Baton Rouge area in Louisiana. Instruments The following four instruments were used to screen participants and collect data in this study: (1) Katz index,17 (2) the obligation scale,20 (3) the Duke University religion index21 and (4) the positive appraisal of care scale.22 In addition, a demographic questionnaire was constructed to measure the caregiver’s age, gender, income, educational level, religion, caregiver type and relationship to older adult. Further age, gender and living arrangements of the care recipient were assessed. Katz index The Katz index of independence in activities of daily living ranks adequacy of performance in the six functions of bathing,
dressing, toileting, transferring, continence, and feeding by judging the degree of independence.17,23 Older adults were scored by a family caregiver as yes/no for independence in each of the six functions. A score of six indicated full function, four indicated moderate impairment, and two or less indicated severe functional impairment. The Katz index has been found to have reliability coefficients ranging from .87 to .94.24 The Katz index was used as a screening tool to determine dependency of the older adult. The obligation scale The obligation scale is a seven-item scale that measures general feelings to reflect cultural values about obligation to care for an older adult relative.20,25 Each item on the scale consist of a fivepoint Likert-type response that ranges from strongly agree (5) to strongly disagree (1). The respondents were asked to indicate how important each statement is as a reason for helping their family member with the higher score indicating higher obligation. Sample items included “I feel a sense of obligation to help”; “It’s a child’s duty to help”; and “I would feel ashamed if I didn’t help”. A higher score is associated with a greater feeling of family obligation. The reported internal consistency reliability was .71.25 This study paralleled Lee et al’s9 study which uses the obligation scale to assess the cultural values of caregivers. Duke University religion index The Duke University religion index (DUREL) is a five-item measure of religious involvement that assesses three major dimensions of religiosity: organizational (participation in religious activities), non-organizational (religious involvement in private activities), and intrinsic (having a relationship with a higher being) religiosity.21 The DUREL measures each of these dimensions by subscale to assess particular aspects of religious practice or religious devotion. Subscale number one is the first question in the DUREL that asks about frequency of attendance at religious services (organizational). Subscale number two is the second question that asks about frequency of private activities (non-organizational). Subscale number three consists of the final three items that assess intrinsic religiosity. A higher score indicates a greater sense of religiosity. The overall scale has had a high testeretest reliability (intra-class correlation) of .91 and a high convergent validity with other measures of religiosity (r’s ¼ .71e.86).13 Positive appraisal of care scale The positive appraisal of care scale was developed to evaluate positive appraisal of care among family caregivers within the framework of caregiver adaptation.22 This scale consists of 21 items: relationship satisfaction (five items), role confidence (five items), consequential gain (six items), and normative fulfillment (five items). Participants were instructed to rate “how you have been in the previous two weeks” using a four-point Likert scale. A higher score indicates a more positive appraisal of caregiving. YamamotoMitani et al22 reports Cronbach alphas of the domains and total scales as follows: .84 (relationship satisfaction), .83 (role confidence), .84 (consequential gain), .74 (normative fulfillment), and .92 (total of the positive appraisal of care scale). Procedure Written approval to conduct the study was obtained from the University Institutional Review Board (IRB), and each of the data collection sites according to the site’s research protocol. Written informed consent was obtained from all subjects. Flyers of the proposed study and how to contact the researcher to participate in
F. Epps / Geriatric Nursing 35 (2014) 126e131
the study were posted among the facilities and sent home with care recipients, caregivers, and church members. Potential subjects were screened by telephone interview using the Katz index and demographic questionnaire. A total of 83 family caregivers were screened, with 69 caregivers meeting the inclusion criteria. Arrangements were made to meet with the caregivers for a one time interview at a convenient location to complete the remainder of the questionnaires. Data analysis Data were analyzed using the SPSS version 19 for Windows software. Descriptive statistics including frequency distributions, means, modes, medians, standard deviations, ranges and percentages were run to summarize variables. An analysis of variance (ANOVA) was used to test for differences in family obligation, religiosity, and positive appraisal of caregiving among Africane American, Hispanic and non-Hispanic Caucasian family caregivers. Multiple regression analysis also was used in a stepwise (hierarchical) fashion to evaluate the unique contributions of obligation and religiosity. This helped explain the variance in family caregivers’ positive appraisal of caregiving (among the three ethnic groups), after adjusting for demographic characteristics. Due to the small sample size, the regression model was built in stages to limit the number of independent variables used simultaneously. Following the recommendations of Mickey and Greenland26 for the screening of covariates individually, only demographic characteristics that had a bivariate association with positive appraisal with a p value <.25 were entered into the multiple regression.
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Results The sample consisted of 69 family caregivers. The subjects were between 24 and 79 years of age, with a mean age of 47.9 (SD ¼ 13.3). A total of 86% (n ¼ 59) were females. For AfricaneAmerican family caregivers, the ages ranged from 26 to 79 with a mean age of 49.0 (SD ¼ 13.2) and 91% (n ¼ 21) were female. Among the Hispanic family caregivers, the mean age was 40.0 (SD ¼ 12.0) with ages ranging from 24 to 67 and with 83% (n ¼ 19) being female. The mean age for non-Hispanic Caucasian family caregivers was 54.7 (SD ¼ 10.5) with ages ranging from 28 to 74 and with 83% (n ¼ 19) of these also being female (see Table 1 for additional caregiver demographics). A one-way between subjects ANOVA showed a significant difference in the mean ages among AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers [F(2,66) ¼ 8.8, p < .001]. Post hoc pairwise comparisons using the Bonferroni correction indicate significant differences in the mean ages specifically among Hispanics and AfricaneAmericans (p ¼ .040); and Hispanics and non-Hispanic Caucasians (p < .001). Within the demographics, the majority of the care recipients were female 78% (n ¼ 54), lived at home 62% (n ¼ 43), and received caregiving from their child 70% (n ¼ 48). Overall scores on the obligation scale for all family caregivers ranged from 14 to 35 (a ¼ .83). The mean score was 29.9 (SD ¼ 5.1). The total scores on the DUREL ranged from 5 to 27 (a ¼ .85), which matches the possible score range. The mean score was 22.0 (SD ¼ 4.5). Overall scores on the positive appraisal of care scale ranged from 38 to 100 among the family caregivers (a ¼ .87). The mean score was 86.1 (SD ¼ 13.4). A one-way between subjects
Table 1 Caregiver demographics. Caregiver variables
Education level Elementary High/GED Some college College grad Grad degree Annual income 0e25,999 26e35,999 36e45,999 46e55,999 56e65,999 66e75,999 >76,000 Religion Baptist Catholic Methodist Non-denominational Pentecostal Relationship Child Grandchild Sibling Spouse Niece/nephew Caregiver type Primary Secondary
AA/Black (non-Hispanic)
Hispanic/Latino (of any race)
Caucasian/White (non-Hispanic)
Total
n
n
n
(%)
N
(%)
(%)
(%)
p
.453 0 4 8 6 5
(.0) (17.4) (34.8) (26.1) (21.7)
2 7 7 5 2
(8.7) (30.4) (30.4) (21.8) (8.7)
0 8 5 7 3
(.0) (34.8) (21.8) (30.4) (13.0)
2 19 20 18 10
(2.9) (27.5) (29.0) (26.1) (14.5)
9 5 2 1 5 1 0
(39.1) (21.8) (8.7) (4.3) (21.8) (4.3) .0
14 5 1 1 0 0 2
(60.9) (21.8) (4.3) (4.3) .0 .0 (8.7)
7 6 2 2 2 3 1
(30.4) (26.1) (8.7) (8.7) (8.7) (13.0) (4.3)
30 16 5 4 7 4 3
(43.5) (23.2) (7.2) (5.8) (10.1) (5.8) (4.3)
15 5 0 2 1
(65.2) (21.8) (.0) (8.7) (4.3)
5 12 0 0 6
(21.8) (52.2) .0 .0 (26.1)
4 11 3 5 0
(17.4) (47.8) (13.0) (21.8) .0
24 28 3 7 7
(34.8) (40.6) (4.3) (10.1) (10.1)
18 1 0 0 4
(78.3) (4.3) .0 .0 (17.4)
14 6 1 0 2
(60.9) (26.1) (4.3) .0 (8.7)
16 4 1 2 0
(69.6) (17.4) (4.3) (8.7) .0
48 11 2 2 6
(69.6) (15.9) (2.9) (2.9) (8.7)
18 5
(78.3) (21.7)
15 8
(65.2) (34.8)
12 11
(52.2) (47.8)
45 24
(65.2) (34.8)
.267
<.001a
.113
.178
a Descriptive crosstabs were used to test pairwise differences between races in religion preferences. A Bonferroni-adjusted p value (actual p value multiplied by the number of pairwise comparisons) was calculated to determine the significance level for each pairwise difference. AA were more likely to be Baptist than Hispanic and non-Hispanic Caucasian family caregivers (p ¼ .003, .009 respectively). Hispanic family caregivers were more likely to be Pentecostal than non-Hispanic Caucasians (p ¼ .027). Non-Hispanic Caucasian family caregivers were slightly above the set significance level with p ¼ .054 in determining their likelihood of classifying themselves as non-denominational in comparison to Hispanic family caregivers. No other pairwise comparisons were statistically significant.
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Table 2 Means (SDs) for obligation, religiosity, and positive appraisal of caregiving.
Obligation Religiosity (DUREL) Positive appraisal of care
AA/Black (nonHispanic)
Hispanic/ Latino (of any race)
Caucasian/ White (nonHispanic)
Total
p
30.1 (6.2) 22.4 (3.1) 90.0 (11.5)
30.0 (4.3) 22.5 (5.3) 84.9 (13.0)
29.5 (4.9) 21.1 (4.8) 83.4 (15.3)
29.9 (5.1) .915 22.0 (4.5) .496 86.1 (13.4) .214
ANOVA did not show any differences among the means for AfricaneAmerican, Hispanic, and non-Hispanic Caucasian family caregivers in obligation, religiosity, or positive appraisal of caregiving (see Table 2). Three demographic variables, income, caregiver type, and ethnicity were entered in the first step of the hierarchical multiple regression analysis to assess the relationships of obligation and religiosity with positive caregiving appraisal. These variables were selected for inclusion as independent variables because all had a bivariate association with positive appraisal of caregiving with p values <.25, while age (p ¼ .68), education (p ¼ .80), relationship (p ¼ .56), and religion (p ¼ .86) all had much higher p values and were excluded. The demographic variables, including the interaction of ethnicity and caregiver type, accounted for 20% of the variance in positive appraisal of caregiving (Table 3). The addition of obligation and religiosity in the second step increased the explained variance to 37%. However, only obligation was found to make a statistically significant contribution to R2, with an increase in obligation score being associated with an increase in positive appraisal. Additionally, interaction terms added to the regression model to test whether the associations of either obligation or religiosity with positive appraisal varied by ethnic group were not statistically significant (p ¼ .51 and p ¼ .46, respectively). On the other hand, the hierarchical regression did find a significant interaction (p ¼ .023) between ethnicity and caregiver type (primary or secondary). Table 4 shows the estimated marginal means for positive appraisal of caregiving within combinations of caregiver type and ethnicity. Among primary caregivers, the positive appraisal mean for AfricaneAmerican caregivers was significantly higher than it was for non-Hispanic Caucasian caregivers (p ¼ .035), and there was a nonsignificant trend (p ¼ .08) for positive appraisal to be higher among Hispanic caregivers than among non-Hispanic caregivers. Furthermore, among secondary caregivers, both AfricaneAmericans and non-Hispanic Caucasians had significantly higher positive appraisal ratings than Hispanics (p ¼ .035 and .012, respectively), while the two groups did not differ between each other (p ¼ .99).
Table 3 Hierarchical multiple regression model for the association of obligation and religiosity with positive appraisal, controlling for demographic characteristics.
Step 1 (control variables) Incomea Race/ethnicity Caregiver type Race caregiver type Step 2 Obligationc Religiosity (DUREL)
R2
DR2
.20
.20
F
Sig. 4.21 1.62 1.41 4.02
.37
.17b 15.10 .28
.026 .044 .206 .240 .023 <.001 <.001 .597
a The relationship of income to positive appraisal of caregiving is negative. Higher income is associated with lower positive appraisal scores. b The unique contribution of obligation to explained variance ¼ .16. c In the regression model the effect of obligation did not vary significantly be race (no interaction).
Table 4 Estimated marginal means (SE) for positive appraisal of caregiving by race/ethnicity and caregiver type. Caregiver type
AA/Black (non-Hispanic)
Hispanic/Latino (of any race)a
Caucasian/White (non-Hispanic)
Primary Secondary Difference
91.0 (3.0) 87.4 (5.6) 3.6
89.1 (3.3) 74.2 (4.5) 14.9
81.0 (3.7) 87.7 (3.8) 6.7
Note: Estimated marginal means are for a caregiver at the average income level among the caregiver participants. a Caregiving appraisal scores for Hispanic/Latino caregivers differed significantly by type (p ¼ .005). In comparisons of caregiver types for Hispanic/Latino and Caucasian/White caregivers, the differences were not statistically significant.
Discussion The findings of this study showed AfricaneAmerican family primary caregivers positively appraised their caregiving experience to a greater extent than non-Hispanic Caucasian primary caregivers, with Hispanic primary caregivers having a similar, though not statistically significant, pattern in relation to non-Hispanic Caucasians. This finding is consistent with published studies reporting AfricaneAmericans having higher levels of reward in comparison to non-Hispanic Caucasian family caregivers.11,12,27 The positive appraisal by ethnic minorities has been attributed to their culture of greater participation in a larger extended family context and its influence on family member roles and perceived obligations.12,28 In addition, many AfricaneAmericans have previous experience with adversity, which allows them to reframe the often challenging caregiver role into a more positive experience.29 Nevertheless, this study also found that AfricaneAmericans and non-Hispanic Caucasian secondary caregivers had levels of positive appraisal that were very similar to one another and significantly higher than the level for Hispanic secondary caregivers. Therefore, these findings suggest more investigation should be made of the interaction between the caregiver relationship and ethnicity in relation to positive appraisal of caregiving. Overall, family caregivers in this study that had an increased sense of family obligation also expressed a positive appraisal of care. This is consistent with other studies reporting caregivers who identify with the concept of family obligation to interpret family caregiving as rewarding.9,30 Anngela-Cole and Hilton4 reported non-Hispanic Caucasians to have strong beliefs and positive attitudes about family obligation. Thus, this study suggests that the same may be said of AfricaneAmerican and Hispanic caregivers. The findings in this study noted that there was no association between religiosity and positive appraisal of caregiving among family caregivers. However, this finding is inconsistent with previous research. Prior studies describe how family caregivers’ religiosity positively influences their perception of caregiving.10,12,29 Much literature expounds on how religion is a coping mechanism used to help with the stressors of family caregiving.8,10,31 Additionally, studies report AfricaneAmerican family caregivers as a having higher level of religiosity resulting in experiencing perceived benefits of caregiving compared to non-Hispanic Caucasians,10,11,28 although no significant difference was noted among the ethnic groups in this study. There is a need for research, which explores the dimensions of religiosity among minority family caregivers to improve the conceptualization of religiosity and its impact on caregiving. For this reason, a qualitative study may be necessary to gain a better understanding of these concepts and how they are operationalized within these diverse ethnic groups. In summary, this study challenges the assumption that religiosity increases positive appraisal of caregiving. In particular, religiosity may be a strong motivation in caring for an older adult, but may feel more burdensome and/or neutral to the caregiver. This
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notion needs be studied further and interventions implemented to support the role of family obligation and/or religiosity for family caregivers. Health care professionals working with family caregivers in providing support services could assist caregivers in understanding the role of religion and obligation in their commitment to care and facilitate positive aspects of the caregiving experience. Limitations There were several limitations in this study. The first limitation is the sampling technique used. Data were collected by using a quota sampling technique recruiting from a convenience sample. The study participants are not representative of AfricaneAmerican, Hispanic and non-Hispanic Caucasian family caregivers in the U.S.; therefore the findings cannot be generalized to all family caregivers within these ethnic groups. Also, this is a small study (N ¼ 69) and should be replicated with a larger sample. Additionally, acculturation of AfricaneAmerican and Hispanic caregivers was not measured or controlled for within this study. Thus, attitudes regarding care of older adults could be more traditional among first-generation African and Hispanic caregivers than among third-generation. The influence of acculturation on caregiver’s attitudes and behaviors is an important factor to consider in future studies. Recruitment of study participants from faith-based organizations also limits the generalizability of study findings resulting in potential bias for the religiosity score. Furthermore, the use of surveys with self-reported data is a limitation for this study. Conclusion To improve family outcomes currently, and in the future, it is important for an evidence-based approach to be used in the development of the plan of care by using culturally sensitive interventions. Information obtained from this study revealed an understanding of family caregivers’ appraisal of caregiving. However, future work should consider replicating these findings in a larger sample, along with other indicators to provide health care professionals with substantial evidence to incorporate culturally sensitive interventions aimed at promoting positive outcomes and healthy family behaviors, such as increased well-being and motivation and decreased burnout, stress and depression. Acknowledgments Special thanks to Meridean Maas PhD, RN, FAAN, Lisa Skemp PhD, RN, David Reed PhD, and Karen Clark MSN, RN, for their contributions to this paper. Data analysis in this manuscript was supported by the National Hartford Centers of Gerontological Nursing Excellence Fellowship Award (2013-2015) & Our Lady of the Lake College Sr. Julie O’Donovan Professorship I. References 1. United States Census Bureau. Overview of race and Hispanic origin: 2010. Web site. http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf; Accessed 07.07.11.
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