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RESEARCH ARTICLE |
a University of Southern California
Bob G. Knight, Andrus Gerontology Center, University of Southern California, Los Angeles, California 90089-0191 E-mail: bknight{at}usc.edu.
Decision Editor: Toni C. Antonucci, PhD
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Abstract |
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CARING for an older relative who has dementia has been recognized for some time as a source of burden and distress for the family caregiver (Zarit, Reever, and Bach-Peterson 1980
). A large amount of literature documents the effects of caregiving on self-reported emotional distress, mostly in White caregiver samples (Schulz, O'Brien, Bookwala, and Fleissner 1995). In contrast, African American caregivers have often been reported to appraise caregiving as less burdensome than do White caregivers (Morycz, Malloy, Bozich, and Martz 1987; Lawton, Rajagopal, Brody, and Kleban 1992; Haley et al. 1995), and the lowered stress appraisal has been related to lower depression outcomes (Haley et al. 1996). Thus, with regard to caregiving, African Americans would seem to enjoy the protective benefits of ethnicity as culture, rather than the additive effects of disadvantaged minority group status and caregiving stress (Aranda and Knight 1997).
The understanding of caregiver distress is based on the stress and coping theory developed by Lazarus and Folkman and their colleagues (Folkman, Lazarus, Pimley, and Novacek 1987; Lazarus and Folkman 1984) and first applied to caregivers by Haley, Levine, Brown, and Bartolucci 1987. In general, stress and coping models include the following categories of variables: (a) context variables such as gender, age, caregiver's health, relationship of the caregiver to the patient, and so forth; (b) demands on the caregiver, including care recipient behavior problems and functional disability; (c) the caregiver's appraisal of demands as stressful or satisfying, for example, subjective caregiver burden; (d) the potential mediators between appraisal and outcomes, that is, coping styles and social support, and (e) the consequences of caregiving demands, that is, emotional distress and health outcomes. In general, emotional distress outcomes have been found to be strongly affected by negative appraisals of caregiving-related stressors and by the use of emotion-focused coping styles, with weaker evidence for the role of social support and of active coping styles having an inverse effect on emotional distress outcomes (Haley et al. 1987; Pruchno and Resch 1989; Stephens, Norris, Kinney, Ritchie, and Grotz 1988).
Drawing upon a review by Aranda and Knight 1997, we propose a sociocultural stress and coping model that argues that ethnicity implies specific cultural differences that will directly affect the appraisal of caregiving as stressful and that will change mediating variables such as coping skills (Fig. 1). The sociocultural view of stress and coping adds to the typical interpretation of ethnicity as a structural status variable (i.e., ethnicity as mainly reflecting disadvantaged minority group status, which in turn is confounded with socioeconomic status; Markides, Liang, and Jackson 1990) and reinterprets the influence of ethnicity on stress and coping as affecting (a) other status variables, because of differences between ethnic groups in the gender, relationship, and other characteristics of who provides care; (b) the demands of caregiving that may differ by group; (c) the appraisal of caregiving by means of the cultural values related to the appraisal of caregiving as stressful; (d) coping styles that are affected by cultural differences; and (e) the mental health outcomes of the stress and coping process. These "ethnicity as culture" influences can affect each stage of the stress and coping model simultaneously and in differing directions. That is, appraisal might ameliorate emotional distress outcomes, while at the same time greater frailty in the care recipient and the use of nonproductive coping styles may exacerbate distress. This conceptualization of the effects of ethnicity has the advantage of explaining the finding that African American caregivers report lower levels of burden than White caregivers, a finding that contradicts the expectation of higher burden based on the disadvantaged minority group model.
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reported the results of a structural equation model that showed that race affected stressfulness appraisals, which in turn affected depression outcomes. They also reported that African American caregivers were less likely to use both approach-coping and avoidance-coping strategies. Avoidance coping was positively associated with depression outcomes, whereas approach coping was inversely associated with depression, although the connection was smaller than for avoidance, as would be suggested by the studies summarized earlier. They speculated that White caregivers perceived caregiving as unexpected and disruptive, whereas African American caregivers perceived it as expected and natural. These same cultural influences would be expected to result in lower usage of coping strategies.
Several studies have found that the lower appraisal of caregiving as stressful by African Americans is related to lower levels of emotional distress outcomes. Mintzer and Macera 1992 found that 62% of the White caregivers but only 30% of the African American sample had Center for Epidemiologic Studies Depression Scale (CES—D) scores greater than 16 (means were 19.3 and 12.4, respectively). No differences were found in background variables. Haley and colleagues 1995 reported lower levels of depression for African Americans (mean CES—D score of 11.9 vs. 16.4 for Whites) and found no differences between African American caregivers and noncaregivers on depression. In contrast, Hinrichsen and Ramirez 1992 found lower levels of burden, but similar levels of psychological symptoms (as measured by Symptom Checklist [SCL]–90) between African Americans and Whites. In an earlier report on the same sample used in this analysis, Knight and McCallum 1998 reported finding nearly equal levels of depression between African American and White caregivers. The contrast between the consistent finding across studies of lower burden among African American caregivers and less consistent reports of lower emotional distress points to unanswered questions regarding the operation of stress and coping models in explaining emotional distress outcomes in African American caregivers. Exploring these differences within a sociocultural stress and coping framework will enhance the understanding of cultural differences and of the stress and coping process more generally.
Drawing on the preceding discussion, we propose the following conceptual model as a representation of the causal process that leads from race to psychological distress among caregivers to older dementia victims (Fig. 1).
The paths of the figure imply the following hypotheses:
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Methods |
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study of coping styles, depression, and cardiovascular reactivity. This sample included 41 African American caregivers and 128 non-African American caregivers of whom 110 were non-Hispanic White, 12 were Hispanic, and 5 were Asian/Pacific Islander. This sample was collected between 1990 and 1993 under the auspices of the Research Training and Information Transfer Core of the Alzheimer's Disease Research Center—Southern California consortium. These caregivers were recruited from a variety of referral sources including the Alzheimer's Association of Los Angeles County, the Los Angeles Caregiver Resource Center, and the Tingstad Older Adult Counseling Center. To minimize the chance of selection pressures discouraging more stressed caregivers from participating, the interviews and cardiovascular reactivity CVR stress sessions were conducted in the caregiver's home or at the lab, with the choice being the caregiver's. More than 90% chose home interviews. Appointments were arranged to assure minimal possible disruption of the caregiver's schedule and to choose times when the patient was not likely to be disruptive of the sessions.
In terms of demographic differences, African American caregivers were younger than non-African American caregivers (57.3 years vs. 62.9 years), 
They were also more likely to be children rather than spouses: 51% of African Americans were children caring for parents, whereas 61% of non-African Americans were spouses. See Table 1 for descriptive information on the sample.
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), which is a 22-item scale that can either be self-administered or included in an interview. Items are scored from 0 to 4, with higher scores indicative of greater caregiver distress. Use of the scale is recommended for a single summary measure of the caregiver's appraisal of the impact that caregiving has had on their lives. Internal reliability has been estimated with Cronbach's alpha at .88 and .91, and test–retest reliability was reported at .71. Validity has been estimated by correlating the total score with a single global rating of burden (
; Zarit and Zarit 1990). The Cronbach's alpha for our sample was .92. Knight, Fox and Chou in press selected 14 items from the total of 22 that tap three factors of Embarrassment–Anger, Reaction to Patient Dependency, and Self-Criticism. The Cronbach's alpha for the 14-item Burden Scale was .88.
Emotional distress.
Anxiety was measured by the Trait Anxiety Scale from the Spielberger State–Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, and Jacobs 1985). The STAI—Trait (STAI—T) is a 20-item self-administered scale that measures general anxiety level. Responses to each item in the anxiety questionnaire are given a score from 1 to 4. The scores for trait anxiety range from 20 to 80, with higher scores indicating more anxiety. The overall median alpha coefficient for the Trait Anxiety Scale in normative samples was .92. The STAI has been shown to have excellent psychometric properties for the assessment of anxiety in elderly persons (Patterson, O'Sullivan, and Spielberger 1980). In this sample, 
.
Depression was measured by the CES—D (Radloff 1977). The CES—D scale is a 20-item self-report scale developed to screen for depressive symptomology in the general population. Each response is scored from 0 to 3. Total scores range from 0 to 60, with higher scores indicating more depressive symptomology. Radloff and Teri 1986 concluded that the reliability and validity of the scale is as good or better with older adults as it is with younger adults. In this sample, 
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The Brief Symptom Inventory (BSI; Derogatis and Spencer 1985) is a short measure which can be used to calculate a measure of psychological symptoms called the General Symptom Index (GSI). The 2 week test–retest reliability for the GSI was .90. Convergent validity has been demonstrated between BSI subscales and Minnesota Multiphasic Personality Inventory (MMPI) scales (Derogatis and Spencer 1985). In this sample, 
.
Although it has been a fairly common practice to measure and report anxiety, depression, and BSI scores separately, the scales are typically highly correlated. Hooker, Monahan, Bowman, Frazier, and Shifren 1998 reported a structural equation model in which CES—D, STAI, and an affect balance measure were modeled as a single mental health latent variable. We followed this approach in our modeling and considered depression, anxiety, and BSI summary scores as indicators of a latent variable of emotional distress.
Caregiver stressors.
The Memory and Behavior Problems Checklist (Zarit et al. 1980) served as the measure of patient problems or caregiver stressors. The scale asks the caregiver to report how frequently a patient who has dementia engages in problematic behaviors. This scale is an estimate of current behavioral and cognitive disruption, and not of severity of dementia. The instrument is designed to be administered by an interviewer with each item having a frequency rating from 0 to 4. Test–retest reliability has been reported as .80. Validity has been estimated by correlating the frequency measure with global estimates of the severity of cognitive impairment of patients 
; Zarit & Zarit, 1990). Following the logic of Pruchno and Resch 1989 and of the revised version of this scale, we divided the measure into subscales assessing activities of daily living (ADLs; eating, bathing, continence, applying make-up, or shaving; 
, instrumental activities of daily living (IADLs; meal preparation, phone use, money handling, cleaning house, and shopping; 
), memory problems (unable to do simple tasks, not recognizing familiar people, forgetting the day, and not talking; 
), and behavior problems (wandering, asking repetitive questions, displaying suspiciousness, losing things, not finishing things, destroying property, behaving embarrassingly, waking at night, displaying restlessness, talking excessively, endangering self or others, reliving the past, and having illusions/hallucinations; 
).
The Ways of Coping Questionnaire was used to measure coping styles (Folkman and Lazarus 1988). This revised questionnaire assesses thoughts and actions individuals use to cope with stressful encounters of everyday living. The participants were asked to complete the scale, keeping in mind caregiving in general. The subscales are Confrontive Coping, Distancing, Self-Control, Seeking Social Support, Accepting Responsibility, Escape–Avoidance, Planful Problem Solving, and Positive Reappraisal. The 63-item self-administered scale used a 4-point Likert scale to indicate the participant's frequency of using each strategy. Reliability of the coping scales was established with Cronbach's alphas of .61–.79. Folkman and Lazarus 1988 cited evidence of construct validity in the fact that the results of their studies were consistent with their theoretical predictions.
The eight subscales of the Ways of Coping Questionnaire have been described as forming two second-order factors: Problem-Focused (or active) Coping and Emotion-Focused Coping. There has been some inconsistency in the reported relationship of the subscales to the second-order factors (see Folkman and Lazarus 1988; Folkman, Lazarus, Gruen, and DeLongis 1986).
Conceptually, these subscales represent two underlying dimensions: active or approach coping styles (confronting the problem, seeking social support, planful problem solving, and positive reappraisal of the situation) and emotionally focused or avoidance coping styles (distancing, self-control, accepting responsibility, and escape–avoidance).
Control variables.
To control for factors that may confound the relationship between race and burden or distress outcomes, we control for the following characteristics: care-provider's age (in years), gender 
and self-rated health 
. Because income is not significantly different between the two race groups and does not predict burden, distress, or coping factors, we omit this variable from the models for the sake of parsimony.
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Results |
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, replicating findings from other studies. African American caregivers used more positive reappraisal, 
(one-tailed test), but also used more escape–avoidance coping than did non-African American caregivers, 
. Depression (CES—D scores) and anxiety (Spielberger Trait Anxiety Scale scores) were essentially equal between the two groups in this sample, indicating that African American caregivers in our sample reported higher levels of emotional distress than did African American caregivers in other samples reported in the literature. This could be due to differences in recruitment strategies or to regional differences. However, African American caregivers reported worse perceived physical health, 
Measurement Models for Constructs of Burden, Coping, and Distress
We used the statistical program AMOS (Arbuckle 1997) to estimate parameters for the latent constructs and structural equations implied in the model. Models are assessed by inspecting the statistical significance of estimated path coefficients and goodness-of-fit statistics for the model as a whole. These statistics include the adjusted goodness-of-fit index (AGFI), the normed fit index (NFI), the root mean square error of approximation (RMSEA), and the expected cross-validation index (ECVI). Better fitting models have higher AGFI and NFI values and lower RSMEA and ECVI values. Although rules of thumb vary for these indexes, it is desirable for the AGFI and NFI values to exceed .9 (Bentler and Bonett 1980) and the RMSEA to be below .08 (Browne and Cudeck 1993).
All endogenous variables are standardized as z scores in order to impose a common metric on measurement coefficients. The measurement model for the latent factor Emotional Distress is manifest by the three additive scale scores for the CES—D, the GSI, and the STAI—T. The latent factor Burden is indicated by the single scale score ZBI-14, but with a factor loading fixed at .971 and the error variance fixed at .014 to account for the less than perfect reliability of the scale.
Two latent factors are estimated for the construct of coping. These correspond to Emotion-Focused Coping, indicated by four manifest variables (Distancing, Self-Control, Accepting Responsibility, and Escape–Avoidance subscales of the Ways of Coping Questionnaire) and to Active Coping, which is also indicated by four manifest variables (Confrontive Behavior, Seeking Social Support, Planful Problem Solving, and Positive Reappraisal subscales). A key strategy of the later stages of the data collection effort was to minimize respondent workload whenever possible by intentionally skipping items for some subscales. Of the manifest variables in the current analysis, the coping factors Planning, Distancing, and Self-Control were not asked of 50 subjects. A list-wise deletion of cases with any incomplete data is not desirable, because valuable information would be discarded. Thus, the skip pattern introduces complexities into the analysis if the intention is to use the full sample of 169 participants. An approach for analyzing all available data when items are intentionally omitted through the use of alternative "short" forms is outlined by McArdle 1994. In this approach the analysis is treated as a multiple group design, with each group defined by the configuration of complete and incomplete data on the variables of interest. In the current application, two samples can be so identified, one consisting of 119 participants with complete data on all variables, and another consisting of 50 participants with complete data on all except the three coping variables. In the latter sample the three variables with missing data are modeled as latent in the model, whereas the other variables are treated as manifest. To identify the model and derive summary estimates for the full sample, all parameter estimates are constrained to be equal across the two groups.
We test the adequacy of the two-dimensional structure of coping styles by comparing the fit of a model in which all eight of the coping variables load on one factor to a more restricted alternative model that loads only four variables on each factor as shown in Fig. 2. The former model has a reasonable fit 
but the two-dimensional model fits substantially better based on all goodness-of-fit indices 
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and all factors are significantly associated with each other. The measurement model coefficients are reported in Table 2 . It is important to note that the three indicators representing distress (CES—D, GSI, and STAI) are approximately of the same magnitiude (1.00, 1.02, and 0.80, respectively) signifying that a good factor solution has been obtained.
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, though it should be noted that the model includes many insignificant structural paths. When insignificant paths are restricted to zero and the model re-estimated, this fitted model yields a better overall fit than the previous one 
Although some of the fit statistics of this model, particularly the NFI, could use improvement, it is noteworthy that the RMSEA is below the recommended threshold of .08 for deciding model preference. Further, the ratio of chi-square to degrees of freedom is 1.65, well below the value of 5.0 suggested by Marsh and Hocevar 1985 for deciding on model adequacy. Indeed, we obtained AGFI and ECVI values comparable to those of other researchers estimating similar models to detect race differences in coping and well-being among caregivers (see Haley et al. 1996). See Table 3 for the unstandardized structural coefficients.
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Discussion |
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in that the effects of ethnicity are mediated through appraisal of stress (Burden in this study and stressfulness appraisal in theirs) and through coping styles. This finding adds to the literature that supports a cultural view of the effects of African American ethnicity on caregiving in that appraisal and coping styles are examples of culturally transmitted values and behaviors, rather than being indexes of disadvantaged minority group status.
The direction of the effects of ethnicity on coping styles, and, therefore, indirectly on emotional distress, are different between this study and the Haley and colleagues 1996 report, however. African American ethnicity was positively related to the greater use of Emotion-Focused Coping in this study and, therefore, indirectly increased emotional distress. Haley and colleagues found that African Americans in their study used lower levels of all coping styles. In this sample, the use of Emotion-Focused Coping appears to counterbalance the effects of lower appraisal of caregiving as stressful and, therefore, yields a net result of equal emotional distress.
The measures, and therefore the constructs used to describe coping styles, differ between the two studies. Although Emotion-Focused Coping and Avoidance Coping seem to be similar conceptually, the scales composing these latent factors differ. Emotion-Focused Coping was comprised of the Self-Control, Distancing, Accepting Responsibility, and Escape-Avoidance subscales of the Ways of Coping measure. In the Haley and colleagues 1996 study, Avoidance Coping loaded on Cognitive Avoidance, Resigned Acceptance, Alternative Rewards, and Emotional Discharge scales from the Coping Responses Inventory (Moos 1988). Emotion-Focused Coping describes a style of emotional control, self-blame, and escapist thinking and behavior, whereas Avoidance Coping appears to include a mix of avoidant thinking, acceptance, and emotional expression.
Although the difference is likely due in part to the different constructs assessed, the outcomes with regard to emotional distress differ between the samples as well. Since this sample of African American caregivers shows a level of depression and of the latent construct of Emotional Distress, which is equal to that of non-African Americans, the difference in the models is more than simple measurement differences. Although the measurement differences preclude direct comparisons of the coping mechanisms, we would speculate that the difference in outcomes may in fact be due to a greater use of ineffective Emotion-Focused Coping styles by African American caregivers in our sample. Further research is needed to determine whether this could be due to regional differences (Southern vs. Western states, with differing histories and social contexts for African Americans) or large metropolitan areas compared with midsize urban areas (Los Angeles vs. Birmingham and vicinity). In either case, the discrepancies remind researchers that generalizing to all African American caregivers in the United States from existing research samples would be premature.
The relationship of ethnicity to control variables is also of interest. African Americans tend to be younger, which in turn tends to increase Burden and the use of Emotion-Focused Coping. They also report poorer subjective health, which in turn increases Burden and the level of emotional distress. The direct, presumably culturally based, effect of ethnicity on Burden appears to be partly compensated for by the younger age and the poorer health of African American caregivers. If they were of equal age and health as non-African American caregivers, the mean level difference in Burden would be even larger. In this instance, other background differences between the groups partly disguise the true difference in Burden between the two groups.
The relative youthfulness of African American caregivers may help to explain the greater use of Emotion-Focused Coping. The use of escapist coping strategies has been found to be more common among younger adults (e.g., Aldwin, Sutton, Chiara, and Spiro 1996; McCrae 1989), although it is unclear whether this is a developmental change in coping or is related to changes in stressors, cohort effects, or other influences. The direct and indirect effects of increased poor health on emotional distress provides an additional reason for the nearly equal emotional distress outcomes between African Americans and other caregivers, given the lower Burden appraisals among the former.
Limitations
As is characteristic of much of caregiving research on cultural issues, this study relies on the comparison of relatively small convenience samples. Caution should be used in generalizing these results to the larger populations of African American and non-African American caregivers. These caregivers were recruited through social service agencies and a research center offering a variety of services to caregivers. Generalizing to non-help-seeking caregivers would not be advisable. The relatively small size of the samples limits the power of comparisons between groups and, therefore, failures to find statistically significant differences should not be seen as indicating similarity of the groups. Finally, the use of cross-sectional data calls for caution in interpreting the directionality of covariance relationships.
Summary
Nonetheless, the results of this analysis confirm and extend modeling of stress and coping processes among caregivers and add to previous research on African American caregivers of family members with dementia. In general, these results support the hypotheses and the sociocultural stress and coping model. The appraisal of caregiving as stressful is considerably lower among African American caregivers and is related to lower levels of emotional distress. However, as predicted by the model, other aspects of ethnicity and other group differences counterbalance this influence and explain the equivalence of emotional outcomes between the two groups. In this sample, African American caregivers are in poorer health and use more Emotion-Focused Coping strategies, both of which lead to higher levels of emotional distress.
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Acknowledgments |
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Received for publication August 10, 1999. Accepted for publication December 14, 1999.
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