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RESEARCH ARTICLE |
a Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina
b Department of Health Behavior and Health Education, University of North Carolina-Chapel Hill
c Center on Minority Aging, University of North Carolina-Chapel Hill
Kristie Long Foley, Wake Forest University School of Medicine, Department of Public Health Sciences, Piedmont Plaza II, Suite 512, Winston-Salem, NC 27157 E-mail: kfoley{at}wfubmc.edu.
Decision Editor: Fredric D. Wolinsky, PhD
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Abstract |
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Methods. Using a cross-sectional telephone survey of caregivers in North Carolina (n = 481), the authors performed a structural equation groups analysis to assess the equality of an a priori caregiving model for African Americans (n = 257) and Whites (n = 224).
Results. Despite a stronger preference for family care among African Americans, traditional caregiving ideology was associated with more self-gain among Whites only; there was no relationship between preference for family care and self-loss for either group. Furthermore, role conflict was unrelated to self-gain but was related to more self-loss for both groups. Three additional relationships differed between African Americans and Whites: age and self-gain, gender and self-gain, and care recipient depression and role conflict. However, 12 proposed relationships were statistically significant and equivalent for African Americans and Whites.
Discussion. The findings suggest that contextual elements that influence preference for family care and role conflict are almost identical for African Americans and Whites. Caregiver demographics are associated with caregiving ideology, whereas care recipient frailty is related to role conflict. However, there are differences between African American and White caregivers, which primarily stem from the role of age, gender, and preference for family care with self-gain.
CAREGIVERS of frail elders are vulnerable to psychological distress such as depression, stress, increased role strain, loss of identity, and burden (Baillie, Norbeck, and Barnes 1988
; Burns, Archbold, Stewart, and Shelton 1993; Lawton, Moss, Kleban, Glicksman, and Rovine 1991; McFall and Miller 1992; Skaff and Pearlin 1992; Thompson, Futterman, Gallagher-Thompson, Rose, and Lovett 1993; see Young and Kahana 1995, for an exception). Although a pessimistic perspective has dominated the caregiving literature, providing care to a loved one may also provide intrinsic rewards, closer kinship ties, and self-efficacy in mastering caregiving tasks (Kramer 1997b). As Seltzer and Greenberg 1999(p. 363) contended, "In fact, for many caregivers, there are positive consequences of assuming this role, such as feelings of gratification that emanate from helping a loved one or a renewed sense of purpose in life. Such positive consequences exist side by side with the more negative outcomes that predominate."
Although positive and negative aspects of caregiving may be aligned, they appear to tap unique components of the stress and coping process (Stuckey, Neundorfer, and Smyth 1996; Stull, Kosloski, and Kercher 1994). Studies specifically examining well-being and burden and their correlates have shown that these constructs are correlated. However, there is some evidence that factors associated with caregiver gain and strain are distinct.
Caring for someone with greater functional, behavioral, or cognitive impairment was more strongly correlated to the negative versus positive aspects of caregiving in two studies (Stuckey et al. 1996; Stull et al. 1994). Stuckey and colleagues 1996 found that gender of the caregiver and behavioral symptoms of the care recipient (CR) were almost equally related to burden and subjective well-being. In a study of husband caregivers, memory and behavioral problems of the wives and use of emotion-focused coping by the caregiver were solely related to burden (Kramer 1997a). However, lower education and problem-focused coping were related to more satisfaction. Satisfaction in social participation was predictive of both positive and negative aspects of caregiving.
In another study, positive affect and depression were assessed simultaneously among relative caregivers (Lawton et al. 1991). Caregiver satisfaction and better health were associated with positive affect for spouses, whereas poor health and greater burden were related to their depression. In contrast, adult children experienced more depression as they increased their level of help. The authors concluded that different factors were associated with positive affect and depression, which may be influenced by the kin relationship of the caregiving dyad.
Ethnicity is another important contextual realm that shapes the caregiving experience. Evidence suggests that African Americans are at less risk than Latinos or Whites of negative caregiving outcomes (Aranda and Knight 1997; Fredman, Daly, and Lazur 1995; Haley et al. 1995, Haley et al. 1996; Hinrichsen and Ramirez 1992; Horwitz and Reinhard 1995; Lawton, Rajagopal, Brody, and Kleban 1992). This finding persists despite the fact that African Americans care for equally or more frail elderly persons than Latinos and Whites do (Fredman et al. 1995; Horwitz and Reinhard 1995; Lawton et al. 1992).
One explanation that has been offered for this disparity is that African American caregivers are protected from negative mental health consequences because of their extended kin and social networks (Fredman et al. 1995; Horwitz and Reinhard 1995). They have and utilize a large number of informal supports that extend beyond the conjugal family, such as second- and third-degree relatives, neighbors, and church parishioners (Wood and Wan 1993). Flexible kinship boundaries afford African Americans with greater caregiving resources and, thus, diffuse the burden.
However, the perception that African Americans are protected from negative consequences of caregiving because of extended kinship networks and social support has not been substantiated (Wood and Wan 1993). Among adult African American noncaregivers, depressive symptoms remained after frequency of contact with network members, durability of network relationships, and reciprocity of network relationships were controlled (Thomas, Milburn, Brown, and Gary 1988). Among caregivers, Haley and colleagues 1995 found that Whites reported more depression and less self-efficacy in caring for family members with Alzheimer's disease compared with African Americans but that African Americans did not have more social supports, satisfaction of support, or more visits with friends and relatives than Whites. Additionally, social network size and other measures of social support only marginally reduced the difference between African Americans' and Whites' burden in caring for adults with mental illness (Stueve, Vine, and Struening 1997).
Others have argued that it is not the presence of kinship ties but rather different appraisal and coping styles that lead to unique valuations of the caregiving role (Goode, Haley, Roth, and Ford 1998; Haley et al. 1996; Horwitz and Reinhard 1995; Knight, Silverstein, McCallum, and Fox 2000). For example, caregiver appraisals and coping responses mediated the relationship between caregiver race and well-being (Haley et al. 1996). Whites were more likely than African Americans to appraise self-care and behavioral and memory deficits as more stressful and to use more diverse coping strategies. Additionally, Goode and colleagues 1998 found that approach coping (such as positive reappraisal and seeking guidance and support) was related to better mental and physical health over time. However, descriptive statistics showed no difference in coping strategies by race.
Another explanation that has been put forth for racial differences is the caregiving ideology of "taking care of one's own" (Wood and Wan 1993; Wright and Mindel 1993). This notion of duty in the African American community has been one of the most relied upon, yet untested, hypotheses. Existentialists would argue that persons have a choice to assume the caregiver role but that the choice to take care of one's own is shaped by moral responsibility (Farran 1997). However, this moral obligation has been discounted by some as a cultural myth, which may be used as an excuse by the formal health care delivery system to avoid provision of much-needed health care services to ethnic families (Wright and Mindel 1993).
Taking care of one's own may also reflect a generational phenomenon. In an ethnographic examination of multigeneration African American families, Burton and Sorensen 1993(p. 53) compared caregivers of different ages. A 64-year-old caregiver rebuffed the interviewer's questions about caregiving stating, "My kin, my friends, all the people my age know this is what they should do... You never question it, you just do it." This is contrasted with a 40-year-old who feels conflicted about her responsibility as a caregiver. She receives messages from her mother's generation that it is dutiful to take care of one's own, as well as messages from her son's generation that she is merely responsible for herself.
Lawton and colleagues 1992 tested the taking care of one's own hypothesis in African American and White caregivers. African American caregivers reported a more favorable caregiving experience than Whites across several indicators: caregiving mastery, traditional caregiving ideology (the take care of one's own philosophy), satisfaction, subjective burden, and intrusion on life. However, traditional ideology was unrelated to depression or positive affect for either group and was positively related to caregiving satisfaction among Whites only. However, most studies have ignored the role of family values or ideology in explorations of caregiver outcomes.
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Theoretical Framework |
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; Kramer 1997a). This reevaluation builds upon the mainstays of stress and coping frameworks: (a) context in which care occurs (e.g., age, gender, and socioeconomic status of the caregiver); (b) demands or stressors of the caregiving situation (e.g., behavioral problems, cognitive decline, or physical frailty of the CR); (c) the caregiver's appraisal of the situation (e.g., satisfaction or burden); (d) mediating factors (e.g., social support and coping); and (e) outcomes of the caregiver, CR, or both (e.g., mental health, physical health, and long-term care placement; Lazarus and Folkman 1984; Pearlin, Mullan, Semple, and Skaff 1990).
In 1997, Kramer 1997b proposed a three-domain adaptation model comprising the background and context of caregiving; the intervening processes, including resources and appraisal of the caregiving role; and well-being outcomes. This model was developed from a review of the literature on positive aspects of caregiving and addressed a gap in the theoretical understanding of caregiver gain (Kramer 1997b; Miller and Lawton 1997). Kramer proposed that positive indicators of well-being are especially relevant to gerontological researchers and that greater attention should be given to the intervening processes of role gains and strains on caregiving outcomes.
Furthermore, researchers have extended the stress-coping paradigm to incorporate a sociocultural dimension (Aranda and Knight 1997; Knight et al. 2000). Knight and colleagues 2000 argued that different ethnic groups, as a result of minority group membership, are exposed to unique caregiving experiences. Structural challenges imposed by society (e.g., access to formal sector services) and cultural identity (e.g., familial obligations) influence how ethnicity interacts with other status variables, the demands and appraisals of caregiving, and coping style to influence physical and mental health outcomes. Pearlin and Zarit 1993(p. 157) argued that comparisons of caregiving outcomes among ethnic groups are "one of the best ways to discern the social and cultural circumstances that undergird patterns of caregiving."
We used the work by Kramer 1997b and Knight and colleagues 2000 within a structural equation modeling (SEM) framework to simultaneously investigate self-gain and self-loss for African Americans and Whites. Our purpose in this study was to evaluate two intervening measures of caregiving appraisal on positive and negative outcomes. Appraisal was measured by preference for family care, which represents a traditional caregiving ideology, and role conflict, which measures the perception that caregiving is discordant with work and family obligations. The context of caregiving was framed by characteristics of the care provider (age, education, income, gender, and role incumbency) and CR (deficits in activities of daily living [ADLs] and instrumental activities of daily living [IADLs] and presence of disease).
On the basis of the literature reviewed and the theoretical framework, our hypotheses were as follows: (a) African American caregivers will have less role conflict and stronger preferences for family care than White caregivers; (b) role conflict and preference for family care will be influenced by the characteristics of the caregiver across both ethnic groups: age, education, income, gender, and role incumbency; (c) greater frailty (ADL/IADL deficits) will have a direct effect on self-loss; (d) caregivers who provide assistance for individuals diagnosed with Alzheimer's disease will experience greater self-loss; (e) family care preference will be especially important for Whites in increasing self-gain and equally important for both races in reducing self-loss; and (f) role conflict will have a direct and positive effect on self-loss for both groups.
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6 per FCH). The counties were stratified into four groups by total population and minority representation (urban high minority, urban low minority, rural high minority, and rural low minority). After the counties were stratified, we randomly selected 20 counties (4 counties from each urban and 6 from each rural stratum) and selected from them two samples of frail elderly persons, community-dwelling and long-term care residents. This strategy ensured that our sample would be heterogeneous by race and geographic location.
For the community-dwelling sample used in this study, we drew a simple random sample of people aged 65 and older from each county using the Health Care Financing Administration's Medicare Beneficiary Utilization tape. A total of 4,236 names were provided, of which 904 (21%) could not be located. Of the remaining 3,332 persons, 411 (12%) refused to be screened for eligibility. To be eligible, the elderly person must require assistance in one or more ADLs or IADLs. Of the 2,921 elderly persons screened, 71% were found to be ineligible for the following reasons: they were not frail (57%); they lived in an institution, had a Department of Social Services address, or had moved out of the study area (10%); or they were deceased (4%). We randomly sampled 683 persons of the remaining 852 elderly persons; of these, 8 refused to participate and 138 were unable to complete the questionnaire because of mental incompetence (a score less than 4 on the Short Portable Mental Status Questionnaire) or physical frailty (unable to verbally communicate; Pfeiffer 1975). Thus, a total of 537 elderly persons completed the telephone interview.
All caregivers of the original sample of 683 elderly persons were eligible to participate in the study regardless of whether or not the frail elderly person participated. Elderly persons identified 563 family caregivers, and 507 (90%) completed an approximately 45-min telephone interview. The principal investigator of this study trained the graduate students who completed the interviews. Of the caregivers called, 6.4% refused to participate and 3.5% could not be contacted or could not verbally communicate. All of the caregivers, each of whom cared for only one elder in the study, provided informed consent over the telephone. No minimum caregiving criteria were necessary to be included in the study. Caregivers were eligible to participate if the older person was frail, the older person identified him or her as the primary caregiver, and the caregiver agreed to participate in the study. Prior to analysis, the following persons were excluded from the study population: 4 Native American caregivers, 1 Asian caregiver, 2 Latin American caregivers, and 8 who did not provide ethnicity. Additionally, 11 cases were excluded because of excessive missing data. Five were excluded because they missed one or both of the self-loss variables, 2 because they missed three or more of the self-gain variables, and 4 because they missed three or more of the family care preference variables. The final sample consisted of 257 African American and 224 White caregivers (n = 481).
Family Caregiver Measures
Caregiving context.
The context of care included characteristics of the caregiver: age (continuous measure), gender (1 = female), education (six categories ranging from 1 = "grade school" to six = "postbaccalaureate"), income (eight categories ranging from 1 = "
$7,500" to 8 = "
$100,001"), and role incumbency (a cumulative role score counting marriage, employment, and child living at home). CR characteristics included a summary score for ADLs and IADLs. We created these scales by asking the caregiver if CR needed help with ADLs (dressing, feeding, bathing, performing personal hygiene, transferring, moving around the house, and toileting) and IADLs (getting to places out of walking distance, preparing meals, grocery shopping, doing housework, doing laundry, taking care of finances, and obtaining and regulating medicine).
Furthermore, we asked the caregiver if CR had ever seen a doctor for 17 conditions ranging from visual impairment to epilepsy. Four conditions were included in the analysis that were potentially emotionally difficult for the caregiver and were prevalent enough for us to detect statistically significant differences between persons with and without the disease: Alzheimer's disease, stroke, cancer, and depression. We included four specific illnesses, rather than a summary score of illnesses, to gain as much information about the role of specific diseases on the caregiving context, yet maximize statistical power (Ferraro and Wilmoth 2000). Although we recognized that some CRs will not or cannot seek treatment for a condition, there was no question that asked about the mere presence of a disease.
Caregiving appraisal.
Preference for family care was a latent construct that tapped a caregiver's perception of familial responsibility of care versus rest home care (Sudha and Mutran 1999). Respondents were given four statements and asked to respond on a 4-point scale from "disagree a lot" (0) to "agree a lot" (3). The statements were (a) rest homes are places where people with no family go; (b) older people are always better off living with their family and friends than they are living in a rest home; (c) adult children should have to take care of their elderly parents; and (d) if a family really loves a relative they would never place them in a rest home. This construct was one of three that emerged during a factor analysis of racial differences in attitudes toward adult care homes and care by families. Sudha and Mutran 1999 found that African American caregivers were more likely than White caregivers to prefer family care. Additionally, family care preference among caregivers was influenced by other contextual factors including age, education, stress of caregiver, and dislike of rest homes.
Role conflict.
We measured role conflict by asking the caregiver to think about how taking care of the CR affected him or her personally. Four questions were used for the latent construct: (a) not enough time to spend with your family; (b) need to take care of CR when you are not feeling well; (c) conflicts with job demands and taking care of CR; and (4) problems that family members, such as your spouse or children, have with CR.
Self-loss and self-gain.
Self-loss and self-gain are psychological constructs that measure the intrinsic rewards and consequences for self as a result of caregiving (Skaff and Pearlin 1992). Self-loss was a latent construct measured by two items that assessed a sense of identity loss in the caregiving role. We asked the caregiver the following question: "As a result of caregiving, would you say that you feel you are losing ... (a) a sense of who you are and (b) a part of yourself?" Response options were "no" (0), "somewhat" (1), and "yes" (2). Gender, relationship status, age, challenges with ADLs, problem behaviors, social contact, and work status of the caregiver were related to self-loss (
= .76) in a study of spouses and adult children caring for a relative with Alzheimer's disease (Skaff and Pearlin 1992).
Skaff and Pearlin 1992 used four questions to measure the latent construct of self-gain that assessed the personal growth aspects of caregiving ( = .76): "As a result of caregiving, do you feel you have ... (a) become aware of your inner strengths; (b) become more self-confident; (c) grown as a person; and (d) learned to do things you didn't do before?" We also included a fifth item, "How much do you believe you have learned to deal with a difficult situation?" Responses ranged from "not at all" (0) to "very much" (3). The last item originally was one of four questions used to measure caregiver competence (Skaff and Pearlin 1992). However, the very high correlation between this item and the other four items of self-gain in our sample prompted us to include it as an indicator of the self-gain construct. Self-gain has been associated with other measures of self-concept such as self-esteem and optimism but was not correlated with self-loss in Skaff and Pearlin's study of role engulfment. Both measures of self-loss and self-gain are specific to the caregiving role and do not represent global measures of self-concept or identity.
The model specified the caregiver and CR characteristics as exogenous variables. Preference for family care and role conflict were specified as intervening variables. Self-gain and self-loss were treated as positive and negative and outcomes of caregiving.
Analysis
We calculated t tests and chi-square tests of association for continuous and categorical variables to determine differences among model elements. We used SEM to test our conceptual model, which allowed us to statistically determine the differential effects of the variables in our model on self-loss and self-gain across groups while simultaneously considering all hypothesized relationships. SEM also allowed us to assess latent constructs of preference for family care, role conflict, self-loss, and self-gain by including observed indicators. Using observed indicators corrects for the measurement error in each item, which we could not have done if we had used a summary scale of the constructs.
All endogenous variables (preference for family care, role conflict, self-loss, and self-gain) were treated as latent constructs (Anderson and Gerbing 1988). The error variances (disturbances) between self-loss and self-gain were correlated because we hypothesized that the two constructs were theoretically related. Although the paths in the diagram represent a "causal" model, they are correlational by nature of our cross-sectional design. The ordering of the variables followed the theoretical framework that has been proposed.
We used LISREL 8 to evaluate the different caregiving experiences by race (Joreskog and Sorbom 1993). We calculated the zero-order correlation among all of the model elements for preliminary examination of relationships (data available upon request). We then conducted a group analysis by fitting the model to each subsample, which tested the moderating effect of race on caregiving outcomes.
First, a cross-group equality constraint was imposed, which constrained all hypothesized paths in the model, all error variances of the indicators for the latent constructs, and the disturbances in the latent constructs to be equal for African Americans and Whites. The overall model fit was significant and indicated a poor fit, 
2 (491, n = 481) = 878.84.
Second, we performed a series of steps to improve the model fit. The constraints imposed on the amount of error in the measurement model and then the disturbances in the equations were removed. Next, several structural paths were freed between African Americans and Whites on the basis of the maximum modification indices (MMI) in the LISREL analysis. The MMI specified the paths that would improve the model fit if allowed to vary across groups (indicating structural differences between the two groups). The 2 for each respecified model was compared with the 2 of the previous model, and we calculated the differences in 2 values and degrees of freedom to determine if the modification made a significant improvement in model fit.
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The final phase of our analysis was to modify four parameters in the structural model: (a) preferences for family care to self-gain, (b) gender to self-gain, (c) age to self-gain, and (d) depression to role conflict. The final goodness-of-fit statistics included a chi-square/degrees of freedom ratio of less than 1.75, a critical n of more than 300, and a goodness-of-fit index of .90. The unstandardized regression coefficients are presented in Fig. 1 for all statistically significant paths and include coefficients for African Americans (in bold) and Whites where the relationships differed across racial groups.
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Indirect Effects Via Caregiving Appraisal
Being male and having less education and income were associated with greater traditional caregiving ideology regardless of race. Additionally, providing care for someone with greater IADL deficits was associated with a lower preference for family care. Caregiver gender and IADLs were not related to self-gain indirectly through family care preference. However, preference for family care mediated the relationship between education, income, and self-gain for Whites only. Those who were less educated and with lower incomes had a preference for family care regardless of race, but socioeconomic status only indirectly influenced self-gain for Whites. The mean differences of income and education between African Americans and Whites helped to explain the distinction in family care by race. It also suggested that self-gain among African American caregivers did not depend on the relationship between socioeconomic status and caregiving ideology. However, among Whites, those with lower education and income were more likely to prefer family care and thus indirectly express more self-gain through traditional caregiving ideology.
We also found that role conflict mediated the relationships between several contextual factors and self-loss. Being young and having greater role incumbency were related to role conflict. Additionally, caring for someone with more IADL deficits and Alzheimer's disease was associated with greater role conflict. White caregivers who provided assistance to an older person previously seen by a health care provider for depression were more likely to report role conflict. However, there was no association with CR depression and role conflict among African Americans. Role incumbency was the only contextual factor that was associated with self-loss both directly and indirectly through role conflict.
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It has been argued that a moral obligation to assist frail kin protects African Americans from the mental health consequences of caregiving (Wood and Wan 1993; Wright and Mindel 1993). However, our findings indicate that African Americans' more pervasive traditional values of caregiving explained neither their lowered sense of self-loss nor the racial differences in self-loss across groups, a finding that has some support in the literature (Lawton et al. 1992).
In addition, Whites (especially lower income Whites) with stronger preferences for family care may experience self-gain when they adapt their other roles to accommodate the added responsibilities of caregiving. African Americans may regard caregiving behavior as central to their lives, regardless of socioeconomic status, and may not give themselves extra credit for activities not perceived as a substantial departure from the norm. Thus, the more pervasive traditional values of care provision neither protect nor benefit African American caregivers.
The factors that influence ideology are the same for African Americans and Whites and are primarily related to caregiver demographics versus care recipient frailty. Men have a stronger preference for family care, suggesting a gender difference in caregiving ideology across both groups. Female caregivers providing assistance to frail men who maintain traditional caregiving values may have more guilt if caregiving values are not shared. Also, caregivers with more education and income report a lower preference for family care. However, this does not appear to be related to the social and economic costs of caregiving given that we do not find a significant association between education, income, and role conflict.
Similar to traditional ideology, most model elements associated with role conflict are the same for African Americans and Whites. However, these factors primarily reflect the caregiving demands (e.g., number of roles or caring for someone with Alzheimer's disease) versus the demographic context in which care occurs. Moreover, role conflict is associated with greater self-loss for both groups and is unrelated to self-gain. The only difference between the two groups is the association between depression and role conflict; caring for a relative who has seen a health care provider for depression is related to greater role conflict for Whites only. This raises a question regarding how depression is manifested across the two groups and how depressive symptomatology could lead to different caregiving demands.
The hypotheses that greater ADL/IADL frailty and caring for someone with Alzheimer's disease would directly affect self-loss are unsupported. ADL dependency is unrelated to any caregiving appraisal or outcome, and IADL impairment and caring for someone with Alzheimer's disease are only indirectly related to self-loss through role conflict. This suggests that the appraisal of the caregiving situation is at least as important as the tangible demands of caregiving itself.
We find two additional differences between African American and White caregivers not hypothesized. First, older African American caregivers report less self-gain, whereas older White caregivers report more self-gain. These findings may reflect a frailty among older African American caregivers that leads to less gainful caregiving or generational differences in caregiving expectations by ethnicity that influence the opportunity for intrinsic rewards across the life course.
Second, we find that White women report significantly more self-gain than White men, but there is no gender difference in self-gain among African Americans. Several studies have documented gender differences in negative mental health outcomes among caregivers (Kramer and Kipnis 1995; Miller and Cafasso 1992; Zarit, Todd, and Zarit 1986). Additionally, Callahan and Wolinsky 1994 found differences in depressive symptomatology among chronically ill racial and gender subgroups, with White women reporting the highest levels of depressive symptoms. Our findings, along with published literature on gender and ethnic differences in mental health, raise questions regarding gender-role socialization of mental health. Are White women exclusively socialized to reap (or admit) the intrinsic consequences and rewards of care provision? Does gender-role socialization vary by race? Gender-role socialization in caregiving deserves further consideration, especially embedded within other contextual realms of race and socioeconomic status.
This study adds to the discourse on ethnic and cultural differences in caregiving appraisals and outcomes across racial groups. Although African American caregivers report less self-loss and more self-gain than Whites, traditional ideology and role conflict are unrelated to "better" mental health outcomes for African Americans when all relationships are tested simultaneously. To our knowledge, this is only the second study to test the commonly held view that traditional caregiving values protect African American caregivers from the psychological consequences of caregiving.
We echo previous studies that have reported the related yet distinct concepts of loss and gain among caregivers (Lawton et al. 1991; Stuckey et al. 1996; Stull et al. 1994). Not only does the context of care uniquely predict the positive and negative aspects of caregiving, but also caregiver appraisal differentially affects self-loss and self-gain. Including positive and negative aspects of caregiving and two different types of appraisal (one grounded in culture that exists outside of the caregiving context and one that is situational and rooted in the caregiving situation) in one study is an important contribution to the caregiving literature. Although we cannot rule out the possibility that discrepancies in mental health outcomes found in our study are merely measurement biases (Dilworth-Anderson and Anderson 1994), we tested "more complex models based on theory and contextual frameworks that reflect racial, ethnic, and cultural differences" (Connell and Gibson 1997, p. 363). Another strength of this study is the generalizability of the findings. We included a heterogeneous sample of elderly persons and their caregivers and oversampled African American caregivers, addressing some of the major methodological concerns in caregiving research (Baumgarten 1989).
Although this study adds to the literature on racial differences in caregiving outcomes, several limitations must be addressed. First, cultural and ethnic hypotheses about caregiving experiences could have been more thoroughly evaluated given the richness of our sample. This is probably the greatest limitation of our study and others that have attempted to explain racial and ethnic differences in caregiver outcomes. In future studies of this nature, investigators should ask questions about cultural and ethnic identity as well as racial prejudice and discrimination. Additionally, including caregiving perspectives on ideology and role conflict from different family members could enhance future caregiving research. Discordant family ideology could affect the mental health of the caregiver and CR. A second limitation is the limited causal interpretations that can be made of the findings because of the cross-sectional data in this study. Future research would be greatly improved and the findings substantiated by use of longitudinal study designs.
To conclude, the context of care must extend beyond the tangible role commitments and conflicts of the caregiver if the sociocultural dimensions of caregiving are to be addressed (Aranda and Knight 1997; Knight et al. 2000). We contribute to the literature on ethnic differences in caregiving outcomes by examining both self-loss and self-gain within the context of role conflict and traditional caregiving ideology for African American and White caregivers. We find that one measure of taking care of one's own could not explain better mental health outcomes among African Americans, a commonly used but rarely tested ideological explanation for racial differences in caregiving outcomes.
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Acknowledgments |
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Received for publication November 21, 2000. Accepted for publication May 21, 2001.
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This article has been cited by other articles:
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  I. C. Williams Emotional Health of Black and White Dementia Caregivers: A Contextual Examination J. Gerontol. B. Psychol. Sci. Soc. Sci., November 1, 2005; 60(6): P287 - P295. [Abstract] [Full Text] [PDF]
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