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Dementia caregiving and ethnicity: African American caregivers and the sociocultural stress and coping model

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Dementia caregiving and ethnicity: African American caregivers and the sociocultural stress and coping model

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Content DEMENTIA CAREGIVING AND ETHNICITY:
AFRICAN AMERICAN CAREGIVERS AND
THE SOCIOCULTURAL STRESS AND COPING MODEL
by
Todd J. McCallum
A Dissertation Presented to the
Faculty of the Graduate School
University of Southern California
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PSYCHOLOGY)
August 2002
Copyright 2002 Todd J. McCallum
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UMI Number: 3094358
Copyright 2002 by
McCallum, Todd Jason
All rights reserved.
®
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UMI Microform 3094358
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UNIVERSITY OF SOUTHERN CALIFORNIA
The Graduate School
University Park
LOS ANGELES, CALIFORNIA 90089-1695
This dissertation, w ritte n b y
U n der th e d ire c tio n o f h.i J.... D issertatio n
C om m i ttee, an d approved b y a ll its m em bers,
has been presen ted to an d accepted b y The
G raduate School , in p a rtia l fu lfillm e n t o f
: S i i _
requirem ents fo r th e degree o f
D O C TO R O F P H IL O S O P H Y
D a te
August 6 , 2002
DI SSER TA H O N C O M M IT T E E
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DEDICATION
This work is dedicated to my father, Walter E. McCallum. I can feel
your proud smile shining down from heaven in this moment, as I do
in every moment of every day.
This work is also dedicated to the five most important people in my
life, Gwen, Mom, Robin, Danny, and Miles. I take lessons in
creativity, faith, persistence, joyfulness, and triumph over hardship
from all of you.
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ACKNOWLEDGEMENTS
While conducting this research, the author was sponsored through
a National Institute on Aging multidisciplinary training grant. I
gratefully acknowledge the invaluable assistance and guidance of
my advisor and chair, Bob G. Knight. I would also like to thank
Margy Gatz, Richard John, Merril Silverstein, Lauren Fox, Brian
Kaskie, Gia Robinson, and Crystal Flynn-Longmire for invaluable
editorial assistance, as well as assistance in dealing with the ever
present intangibles in the life of a dissertation.
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TABLE OF CONTENTS
Dedication ii
Acknowledgements iii
List of Tables/Figures vi
Abstract vii
Introduction 1
Caregiver Stress Models 2
The Sociocultural Stress and Coping Model 3
The African American Caregiving Cultural Context 7
A Cultural Tradition of Support 7
Role of the Church 10
African American Caregivers, Coping Style,
and Stress Appraisal 11
A Summary of Findings from the Empirical Literature 16
Mental Health Outcomes 16
Physical Health Outcomes 17
Hypotheses 21
Methods 22
Participants 22
Measures 24
Results 31
Demographic and Care Recipient Factors 34
Depression, Burden, Familism, and Coping Style 34
Social Support 36
Cardiovascular Measures 38
Correlational Analysis 41
iv
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Discussion 45
Introduction 45
Differences in Burden 46
Familism 47
Coping Styles and Ethnicity 49
Religious Coping 49
CVR and Social Support Data Inclusion 50
CVR Measures 51
Social Support 52
Summary 53
Limitations 54
Ideas for Future Research 56
References 59
v
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LIST OF TABLES/ LIST OF FIGURES
Figure 1: The Sociocultural Stress and Coping Model
Table 1: Demographic and Care Recipient Factor mean
comparisons between African American and
White caregivers
Table 2: Summary table of Depression, Burden, Familism,
and Coping means comparison of African American
and White caregivers
Table 3: Summary table of Social Support means
comparison of African American and White caregivers
Table 4: Summary table of Cardiovascular Measure means
comparison of African American and White caregivers
Table 5: Summary table of Cardiovascular Measures
descriptive statistics for African Americans
Table 6: Summary table of Cardiovascular Measures
descriptive statistics for Whites
Table 7: Summary table of Cardiovascular Measures
difference scores
Table 8: Pearson correlation matrix for African American
caregivers
Table 9: Pearson correlation matrix for White caregivers
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ABSTRACT
Despite consistent findings of ethnic differences in dementia caregiver
burden, only cursory attempts have been made to examine the cultural
mechanisms underlying these differences. This study examines 70 African
American and White female dementia caregivers in a sociocultural stress and
coping context, by attempting to uncover the role of cultural mechanisms in
beliefs about familial support and coping strategies, and to compare
cardiovascular reactivity (CVR) between the groups. African American
caregivers reported higher levels of familism, lower levels of burden and
utilized more religious coping than White caregivers. The groups both
reported diverse social support networks, with Whites reporting a larger
social support network. No ethnic differences in CVR were found. The study
finds evidence for ethnic differences in cultural factors related to caregiving.
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INTRODUCTION
Research evidence has made it clear that caring for a disabled older
adult, particularly one suffering from Alzheimer's Disease, is extremely
stressful. For more than twenty years, caring for a demented older relative
has been recognized as a source of burden for the caregiver (Zarit, Reever,
& Bach-Peterson, 1980). Dozens of studies have documented the negative
effects that caregiving has on the health and well-being of the caregiver and
their family (Anthony-Bergstone, Zarit, and Gatz, 1988; Kiecolt-Glaser, Dura,
Speicher, Trask, and Glaser, 1991; Schulz, O’Brien, Bookwalla, and
Fleissner, 1995). Studies with matched non caregiver comparison groups
have further indicated that caregivers are more likely to be depressed and
show poorer immune function than non-caregiving controls (Anthony-
Bergstone et al., 1988; Kiecolt-Glaser et al., 1991). Additionally, as the
dementia caregiving career can span decades, the process has become a
prime exemplar of the effects of chronic stress on mental and physical health
outcomes.
Accordingly, researchers continue to seek out factors that may assist
caregivers in lessening the mental and physical toll the role can exact. Thus
far, the literature documenting the effects of caregiving on self-reported
emotional distress, as well as the handful of studies examining physical
health, have largely been a literature of White caregivers (Schulz et al.,1995;
Kiecolt-Glaser et al., 1991). Results from a number of research studies, on
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the other hand, strongly suggest that African American caregivers appraise
caregiving as less burdensome than do White caregivers (Lawton,
Rajagopal, Brody, & Kleban, 1992; Morycz, Malloy, & Bozich, 1987;
Fredman, Daly, & Lazur, 1995; Knight & McCallum, 1998), and that lowered
stress appraisal relates to lower rates of depression (Haley, Roth, Coleton,
Ford, West, Collins, & Isobe, 1996). As research evidence sheds more light
on comparatively positive outcomes among African American caregivers,
caregiver stress models based on predominantly White caregivers need to
expand to incorporate cultural aspects related to caregiving.
Caregiver Stress Models
The stress models employed in caregiving research can be traced
back to the stress and coping framework put forth by Lazarus and Folkman
(1984). Lazarus, Folkman, and their colleagues put forth the idea that stress
results from an interaction between intrapersonal variables and the situation
the individual faces. Haley, Levine, Brown, and Bartolucci (1987) first
applied this framework to caregivers. Caregiver stress and coping models
generally include context variables, variables assessing demands on the
caregiver, caregiver appraisal of those demands as stressful or satisfying,
mediating variables between appraisal and outcomes, and mental and
physical health outcomes. Context variables often include caregiver age,
gender, and relationship to the care recipient. Variables designed to assess
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the demands on the caregiver include care recipient behavior and function,
and subjective burden measures have been used to assess caregiver
appraisal of the caregiving situation as satisfying or stressful. Caregiver
coping style and social support are the most common mediators employed in
caregiver stress and coping research. Mental health outcome variables have
included depression and occasionally well-being, while physical health
outcomes have included cardiovascular reactivity (CVR) and immune
response.
Caregiver stress models have rarely been applied to African American
caregivers, despite their potential usefulness with this population. In
comparison with White caregivers, there are several stress process variables
of interest. Social support from family and friends, support of the church
community, religious coping, appraisal of caregiving as satisfying versus
burdensome and physical health status have all been theorized to be more
salient to African American caregivers (Haley et al., 1996). Though several
studies have attempted to identify moderator effects for these variables
related to dementia caregiving and ethnicity, few significant effects have
been found (Lawton et al., 1992; Wood & Parham, 1990)). Thus far, only
two studies have examined whether ethnic differences in dementia
caregiving depression are mediated by these stress process variables (Haley
et al., 1996, Knight, Silverstein, McCallum, & Fox, 2000). The sociocultural
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stress and coping model provides a solid framework from which to assess
these variables of interest.
The Sociocultural Stress and Coping Model
Two broad theories of dementia caregiving applicable to African
Americans have been posited to address these ethnic differences thus far.
In 1994, Dilworth-Anderson and Anderson proposed that researchers use a
model unique to African Americans which encompasses the sociocultural,
personal, temporal, situational, and interpersonal contexts that the African
American caregiver occupies at any given time. The sociocultural context
describes African Americans’ status in society and explores cultural factors,
while the personal context envelopes psychological characteristics that
influence the African American caregiver's well-being such as coping style.
The temporal context denotes the place in the caregiver's lifecycle at which
the caregiving role begins. The situational context is composed of variables
that create the caregiver's proximal caregiving environment, and the
interpersonal context for African American caregivers is comprised of family,
friends, and the church. Various studies have focused upon some of these
contexts, but no published work has encompassed them all.
Acting on Dilworth-Anderson and Anderson’s call for an exploration of
context, Aranda and Knight (1997) added a stress and coping framework to
contextual theory and posited several arguments. The sociocultural stress
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and coping model is intended to assist researchers in examining aspects of
culture that have historically been overlooked in the dementia caregiving
literature. These authors argue that culture can affect the caregiving role at
multiple points within the stress and coping process. Ethnicity, as defined by
minority group status, may imply differences in type and degree of dementia
as well as demographic differences in who becomes the caregiver (younger,
more likely to be extended family or fictive kin). Further, ethnicity as culture
implies differences in the appraisal of caregiving stressors, possibly due to
more holistic worldviews in which dementia is viewed as less of a disruption
of life than in White, American culture. Finally, ethnicity as culture implies
potential differences in choice and efficacy of coping strategies as well as in
the size, composition, and quality of social support. These multiple
influences of ethnicity may influence the mental and physical health
outcomes of caregivers in different directions. For example, caring for a
demented elder with a greater number of health problems may make
caregiving more stressful, whereas positive coping strategies and a stronger
family allegiance may lessen the stresses of caregiving. The sociocultural
stress and coping model is employed as a background from which specific
hypotheses about group differences in the stress and coping process in
relation to dementia caregiving are delineated.
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Figure 1 Sociocultural Stress and Coping Model
Spouse/Child
Coping
Strategies
Care
Recipient
Factors
Income
Appraisal of
caregiving as
stressful
Gender
Emotional
Distress
Social
Support
Ethnicity as
subgroup
Cultural
Values
G )
The African American Caregiving Sociocultural Context
A discussion of the dementia caregiving and ethnicity would not be
complete without an understanding of the larger body of research on African
American older adults and the African American family. Such research
serves as a backdrop and provides important background information
connected to caregiving in the African American community. A cultural
tradition of support, defined by a diverse social support network including
family, friends and the church community may lead to specific coping styles
utilized by African American caregivers.
A Cultural Tradition of Social Support
Many cultural characteristics of African Americans related to social
support can be traced to African culture and traditions (Nobles, 1980). One
such African tradition present in African American culture is the importance of
the extended family, which often includes both blood relatives and non-blood
related individuals, who may be given similar status to blood relatives
(Nobles, 1974). This is in sharp contrast to the concept of the nuclear family
prevalent in White American culture, a family structure which may create
clear and distinct roles for relatives and lesser or nonexistent roles for those
outside of the immediate family. These group differences in familial
organization may suggest structural differences in social support networks.
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Social support, defined here as those interpersonal transactions
involving aid, affect, or affirmation (Kahn & Antonucci, 1980) has been
extensively examined in the context of caregiving over the last two decades.
Within this context, a number of studies investigating the social support
networks of African American caregivers, as well as a few on network
comparisons between African American and White caregivers have been
conducted. Despite evidence of more variation within social support
networks (Gibson, 1982; Burton, Kasper, Shore, Cagney, LaVeist, Cubbin, &
German, 1995), African American caregiver networks have not been shown
to be significantly larger than those of White caregivers (Haley, West,
Wadley, Ford, White, Barrett, Harrell, & Roth, 1995; Burton et al., 1995).
Other aspects have also been examined in relation to cultural support.
Lawton et al. (1992) examined "traditional caregiving ideology," and found
that African Americans scored higher than Whites in this category.
Traditional caregiving ideology is based on the Barresi and Menon (1990)
notion that African Americans are socialized or inculcated with attitudes that
encourage providing respect and assistance to elderly family members.
Lawton et al. (1992) describe the ideology as continuing a family tradition of
mutual concern. Lawton et al.’s suggestion of a stronger mutual concern
within the African American community has been described by Johnson and
Barer (1990). In their study of elderly inner city African Americans and
Whites selected from medical clinics, they found that the former group had a
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more active social support network. Theoretically, this more active support
network results from mechanisms within African American families, which
serve to expand network membership in two distinct ways. Networks
expand through the mobilization of relatives on the periphery of the kinship
network (cousins, nieces, and nephews), and the extension of the kinship
network through the creation of 'fictive kin1 , or individuals given the status
and responsibilities of relatives, who are not blood relations. A 1995 study
found that older disabled African Americans had a greater likelihood of
having at least one caregiver who was not part of the immediate family,
controlling for variables such as network size (Burton et al., 1995). An
example of this could be grandparents raising the offspring of distant
relatives or friends, who, in later life, may come to serve as caregivers even
though they do not possess biological ties. Such fictive kin may serve
important emotional and instrumental needs for African American elderly that
biological relations may not.
As mentioned earlier, studies of African American families over the
past twenty five years suggest that kinship connections as indicated by joint
residency, visiting, and the exchange of mutual aid among kin, are stronger
than they are for Whites (Hays & Mindel, 1973). In fact, African Americans
of all ages are more likely to live in an extended family household (Bumpass,
Sweet, & Cherlin, 1991). Extended family support becomes crucial to
African American elders and their caregivers because many of them may not
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have sufficient financial resources to cope with the provision of informal care
for extended periods of time (Taylor, Chatters, & Jackson 1997).
However, contradictory results concerning overall familial support
emerge from this literature. Two studies indicated that African Americans
reported receiving more informal support from relatives than did White or
caregivers (Wood & Parham, 1990; Cox & Monk, 1996), but one study
reported the reverse (Hinrichsen & Ramirez). A third study found no
difference in the reliance on familial support (Haley et al., 1996).
Nevertheless, it is clear that while fictive kin and the importance of
extended family may have roots in African tradition, it is the African American
church community that most commonly supports this overall network.
The Role of the Church
A major source of assistance for African American elderly is the
church, whose importance reflects another cultural remnant from Africa with
ramifications for caregiving. Evidence suggests that dating back to slavery,
the African American church has been a major institution in African American
communities which has served to spur social and economic self-help among
its congregates and extended out into the broader community (Lincoln &
Mamiya, 1990). The church has been described as the vehicle through
which many African Americans developed and then articulated group
consciousness, and for many older African Americans, the place turned to for
assistance before many other formal organizations (Taylor, 1985). The
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church, along with support from family and friends, compose the mutual aid
system of which many elderly African Americans are a part. Within the
mutual-aid system, aged African Americans and their adult children provide
care and support to each other, at higher rates than do elderly Whites and
their offspring (Mutran, 1985). Walls and Zarit (1991) concluded that African
American churches serve as a strong support network for elderly African
Americans, as well. Though they found that the family was the strongest
source of support, the informal networks derived through the church tended
to complement that support, with both networks predicting well being. More
specifically, they found that perception of support from the church, as much
as the more spiritual aspects of religion or involvement in organized religious
actives, was predictive of well being.
The church, therefore, may add both qualitative and quantitative social
support to African American elders. Lastly, there is evidence that the church
also facilitates the utilization of specific coping styles in the African American
community.
African American Caregivers. Coping Stvle. and Stress Appraisal
Just as social support based in the church is hypothesized to
differentiate African American and White caregivers, there is some evidence
that coping style may differentiate the groups as well. Past research in the
field has demonstrated that a caregiver’s negative appraisal of the situation,
more than specific situational characteristics, leads to distress and
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depression (Picot, Debanne, Namazi & Wykle, 1997). It follows that the
style or method by which a caregiver copes may be linked to their appraisal
of the situation and, in the case of caregiving, perhaps to their view of illness.
According to Landrine and Klonoff (1992), important cultural
differences in health-related beliefs and schemas exist between African
American and White Americans in that many White Americans tend to view
illness as a person-centered, temporally bounded, and discontinuous event,
whereas many ethnic-cultural minority groups in the U.S. view illness as a
long term, fluid, and continuous manifestation of changing relationships and
dysfunctions in the family, the community, or nature. Landrine and Klonoff
further suggest that many minority groups view treatment as a long term,
informal, highly personal and cooperative process in which the healer, victim,
and family atone for the wrongdoing and improve the habits and relationships
that are construed to be the cause of illness. This view may begin to explain
differences between African American and White caregivers in the perception
and appraisal of stress in the caregiving role. In other words, if African
Americans view dementing illness as fluid and long term, and White
Americans view the illness as discrete, then African American caregivers
may better adjust psychologically to the role strains inherent in long term
caregiving.
A number of caregiving researchers have found several differences
between African American and White caregivers that support the idea that
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African American caregivers do in fact appraise the caregiving role differently
than White caregivers. Morycz et al. (1987) found that African American
caregivers experienced less strain, were less likely to institutionalize, and
differed from White caregivers in the factors that predicted burden. In their
1992 study, Lawton et al. found that African American caregivers scored
higher than White caregivers on scales of mastery and satisfaction, and
scored lower on scales designed to test subjective burden, sense of
intrusion, and depression. More recently, Haley and his colleagues (1995)
found higher levels of stress appraisal in White caregivers when compared
with African American caregivers. Knight & McCallum (1998) found similar
evidence of differences in the appraisal of caregiving between ethnicities.
Appraisal of a situation however, according to Lazarus and Folkman
(1984), is only part of the equation when facing a stressor. Individuals also
actively choose how to cope when placed in a potentially stressful situation.
The coping style literature contains little research on older African
Americans, and even less on ethnic caregiving. Nevertheless, work that has
been done suggests that older African Americans employ coping styles quite
different from those used by White older adults. Picot, Debanne, Namazi,
and Wykle (1997) found significant differences in the relationship between
caregiver ethnicity and the perceived rewards and comfort attained from
prayer. This is not surprising in light of earlier findings from religiosity studies
indicating higher levels of religiosity among African Americans, females, and
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older adults (Chatters, Levin, & Taylor, 1992). Specifically, the group found
that African American caregivers scored higher on prayer and comfort from
religion scales. This result lead Picot and her colleagues to suggest that
religiosity serves as a coping resource variable, which in turn operates as a
stress deterrent as opposed to a stress buffer. As a resource variable, the
function of religious coping may be to raise the African American caregivers’
threshold for stress. African American caregivers in this study prayed more
frequently, a behavior which may have preceded their caregiving career, and
therefore they may have perceived less stress than White caregivers when
confronted by the same objective caregiving situation. Similarly, Krause &
Van Tran (1992) found that older African Americans use religious
involvement as a counterbalance to offset deleterious effects of stressful
circumstances. Though their research indicated that life stresses tended to
erode feelings of mastery and self-worth, the negative effects were offset
when religious involvement was high. In a study of older African Americans,
Neighbors and his colleagues (1984) found prayer to be the most frequently
mentioned coping resource utilized among this group when faced with a
serious personal problem. They also found that the tendency to report
prayer as most helpful was highest among those with the most severe
personal problems. Lastly, they reported that after physicians, ministers
were ranked highest among professionals from whom to seek help. Though
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the aforementioned study didn’t examine it directly, coping with caregiving is
commonly considered a serious personal problem.
Religious coping has also been considered a path through which
African American caregivers cognitively redefine a stressful situation (Skaff,
1995). Cognitive redefinition, also known as positive reappraisal, is the act
of reframing a potentially stressful event into a more positive light. Though
theorized to be utilized more frequently by African Americans, there has been
little empirical work on the subject. In perhaps the only study to examine
this type of coping with African American caregivers, Knight and McCallum
(1998), found significant differences between African American and White
caregivers. African American caregivers were found to use positive
reappraisal more often than their White counterparts. Moreover, positive
reappraisal appeared to be an effective coping style for African American
caregivers, but positively correlated with heart rate reactivity for White
caregivers. In other words, while positive reappraisal was associated with
positive coping for African American caregivers, it posed a potentially
negative health risk when used by White caregivers. Thus the same coping
style may have quite different effects based upon ethnicity.
Other studies have found evidence of ethnic differences and of
similarities in coping with caregiving. African American caregivers frequently
used prayer, faith, and religious coping strategies to deal with the stresses of
caregiving (Wood & Parham, 1990; Wykle & Segall, 1991), whereas White
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caregivers were more likely to seek help from professionals and attend
support groups (Wood & Parham, 1990; Wykle & Segall, 1991). Hinrichsen
& Ramirez (1992) however, reported that African American and White
caregivers were similar in their propensity to seek out help from
professionals, with each group seeking out similar levels of assistance from
mental health professionals. Finally, Knight et al., (2000) found that African
American caregivers used more escape-avoidance coping than Whites in
their sample.
There is mounting evidence that African American caregivers possess
more varied support networks, utilize formal and informal religious practices
and appraise and cope with the stress inherent in the caregiving role
differently from White caregivers. Accordingly, positive reappraisal and
religious coping are two related styles of coping with the stresses of
caregiving that may be used more often and with greater success by African
American caregivers than by their White counterparts. The following section
details further findings from research on dementia caregiving and ethnicity.
Summary of Findings from the Empirical Literature
While the previous section reviewed the dementia caregiving and
ethnicity literature in the relation to social support, church support, religious
coping and the appraisal of the caregiving role, this section reports on ethnic
comparisons from a broader range of measures.
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Mental Health Outcomes
In a majority of the dementia caregiving and ethnicity studies, African
American caregivers reported less burden or strain (Hinrichsen & Ramirez,
1992; Lawton etal, 1992; Macera etal, 1992; Miller et al., 1995; Cox &
Monk, 1996) and higher levels of caregiving mastery and satisfaction
(Lawton et al, 1992; Millet et al., 1995) than White caregivers. However, not
all studies find differences. One study reported no ethnic differences in
hassles (Wykle & Segall, 1991), and another reported no differences in
stress (Wood & Parham, 1990). The first of two studies by the same authors
examining African American and Hispanic caregivers also failed to find
burden differences (Cox & Monk, 1990).
Clear ethnic differences in mental health outcomes, most often
depression, were also apparent. African American caregivers reported less
depression in three out of four comparisons with White caregivers employing
the CES-D (Lawton et al, 1992; Haley et al., 1995; Miller et al., 1995).
Compared to Hispanics, African American caregivers reported lower CES-D
scores, as well (Cox & Monk, 1990). Knight & McCallum (1998) reported no
ethnic differences in CES-D scores, and in another study using the Symptom
Checklist-90, no differences were found in psychiatric symptomatology
between African Am erican and W hite caregivers (Hinrichsen & Ramirez,
1992). Regional differences may account for some of these discrepancies.
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Physical Health Outcomes
Furthermore, the data from these studies do not suggest a risk to the
caregiver’s health due to the caregiving role (Macera et al., 1992; Wykle &
Segall, 1991; Haley et al., 1996). Caregivers rated their own health as good
or excellent, and did not differ from non-caregivers in symptoms of poor
health (Wykle & Segall, 1991; Haley et al., 1996).
Studies examining physiological markers of caregiver stress, while few
in number, contradict the aforementioned results based on subjective health
ratings. Kiecolt-Glaser and her colleagues are the most prolific group in this
area, and their studies were also the first to examine physiological changes
occurring in caregivers. Using entirely White samples, this research group
found caregivers to have poorer immunilogical function than matched non-
caregiving controls in both cross sectional and longitudinal studies (Kiecolt-
Glaser, Dura, Speicher, Trask, & Glaser, 1991; Kiecolt-Glaser, Glaser,
Shuttleworth, Dyer, Ogrocki, & Speicher, 1987).
A few years later, Uchino, Kiecolt-Glaser, & Cacioppo (1994)
examined cardiovascular function as related to preillness affection for and
cohesion with the care recipient. Preillness affection measured how well the
caregiver and care recipient got along before the illness using a five point
scale, and cohesion looked at the amount of and quality of time the caregiver
and care recipient spent together before the illness. They found that those
caregivers high in preillness affection for the care recipient showed lower
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resting heart rate reactivity and resting diastolic blood pressure. Conversely,
those caregivers high in preillness cohesion were characterized by higher
resting systolic and diastolic blood pressure. The authors suggest that the
loss of cohesiveness in the caregiver-care recipient relationship may itself
become a stressor, thus leading to these physiological responses. Because
higher rates of resting blood pressure are associated with negative health
consequences, their findings suggest that caregivers high in preillness
affection for and cohesion with the care recipient may receive physiological
benefits and sustain physiological damage simultaneously.
The handful of studies comparing CVR in African American and
Whites has spanned all age groups, finding ethnic differences in some age
groups but not in others. Ethnic differences in CVR have been shown in
children, with African Americans reporting more reactivity (Gump, Matthews,
& Raikkonen, 1999). Reactivity was also associated with lower family and
neighborhood socioeconomic status in this study. Comparisons of African
American and White young adult males absent of chronic stress have thus
far failed to find ethnic differences in CVR (Delahanty, Dimsdale, & Mills,
1991; Johnson, Nazzaro, Gilbert, Weder, & Jamerson, 1992). In the only
study to date investigating CVR, caregiver stress and ethnicity, Knight &
McCallum (1998) found ethnic differences in the relationship between coping
style and CVR. African American caregivers showed an inverse relationship
between positive reappraisal coping and CVR and White caregivers showed
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a positive relationship between the two. The results of this study also
showed a similar distinction in relationship to self-reported depressed mood,
which has implications for the connection of psychological and physiological
stress indicators differing by ethnicity.
The past studies on dementia caregiving and ethnicity identified a
number of ethnic differences between African American caregivers and other
ethnic groups. Specifically, African American caregivers report less
depression and burden, and higher mastery and satisfaction in the caregiving
role. African American caregivers also report higher levels of traditional
caregiving ideology, and more frequent use of religious coping strategies and
positive reappraisal than White caregiver samples. The findings concerning
social support are less clear, with little empirical evidence to back up
suggested ethnic differences in social support networks. Studies on
physiological stress and caregiving, and on caregiving and ethnicity suggest
several points. First, they provide some evidence that caregivers display
poorer immune function than matched non-caregiving controls. They also
uncover potentially beneficial and harmful cardiovascular reactions to the
caregiving role based on their preillness relationship with the care recipient.
Finally, past research suggests that ethnic differences exist in the
relationship between coping style and CVR.
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HYPOTHESES
The sociocultural stress and coping model provides the conceptual
background from which to explore ethnic differences and enhance the overall
understanding of the stress and coping process among African American
caregivers. Based upon the existing research on African American
caregivers and rooted in the sociocultural stress and coping model of
dementia caregiving, the following hypotheses of dementia caregiving,
ethnicity, and stress will be assessed:
1) African American caregivers will score significantly lower on measures
of burden (appraisal of caregiving as stressful).
2) African Americans caregivers will score significantly higher on
measures of familism.
3) African American caregivers will utilize “positive interpretation” coping
strategies including positive reappraisal and religious coping
techniques significantly more than White caregivers.
4) African American caregivers will report a more diverse network of
support, including more peripheral relatives and fictive kin.
5) African American caregivers will show significantly greater
cardiovascular reactivity than will White caregivers.
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METHODS
Participants
The data for this project were taken from a larger data set collected
under the auspices of the Research Training and Information Transfer (RTIT)
core of the Alzheimer’s Disease Research Center (ADRC). This study
consisted of 40 African American and 54 White caregivers caring for a
demented family member in the home. Participants were interviewed
between 1994 and 1996. The approximately two hour long interviews were
conducted by graduate students in gerontology, and the vast majority of the
sessions took place in the caregiver’s home. A small percentage of the
caregivers chose to be interviewed at the university. This convenience
sample was recruited from a variety of sources, including the Alzheimer’s
Association, the Los Angeles Caregiver Resource Center, as well as Los
Angeles area churches, senior centers, and counseling centers. In order to
increase the number of African Americans in the sample, print and radio
advertisements were run on media outlets which targeted the African
American community in Los Angeles County.
The sample’s age range was restricted to 50 and above in order to
reduce age related variance and potential confounds between age and
ethnicity on CVR. There were no significant age differences by ethnicity in
the sample. Just under 52% of the African Americans in the sample were
spouses of the care recipient, while 68% of the Whites were spousal
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caregivers. The remainder of each group was composed of children of the
care recipient. A higher number of African American caregivers were female
compared to the White caregivers (89% versus 61 %). After the initial review
of the demographic data, men were removed from the sample. The number
of African American men in the sample (n=6) was not enough to adequately
perform gender/ethnicity group comparisons. Further, the White men in the
sample were significantly older than both groups of women, as all were
spousal caregivers. These factors could also confound aspects of the
analysis. This left a total of 70 female caregivers in the analysis equally
divided by ethnicity.
The demographic variable coding was as follows: race was coded as
1 for White caregivers and 2 for African American caregivers; relationship to
the caregiver was coded as 0 for spouses and 1 for children; and age and
years caregiving were reported in years. Employment status was
ascertained by asking if the participant was working full time, working part
time, unemployed, retired, retired but working part time, a homemaker, or
other. Income was coded in ranges of between $2,000 and $10,000 and
each range was assigned a number. Range 1 represented between 0 and
$5,500, 2 represented between $5,501 and $9,500, 3 represented between
$9,501 and $11,500, 4 represented between $11,501 and $13,500, 5
represented between $13,501 and $15,500, 6 represented between $15,501
and $17, 500, 7 represented between $17, 501 and $19,500, 8 represented
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between $19,501 and $28,500, 9 represented between $28, 501 and
$38,500, 10 represented between $38,501 and $48,500, and 11 represented
$48, 501 and above.
Another important issue of the study warrants addressing at this point.
For different reasons, complete data was not reported for heart rate and
some of the social support variables. In the case of heart rate, the
monitoring equipment was inconsistent in reporting this particular
measurement and yielded usable responses for 19/35 African Americans and
18/35 Whites. In the case of the social support variables, all participants
were asked if they had a main helper. Those who reported no main helper
were not given the positive and negative support questions about their main
helper. This greatly decreased the number of responses recorded
concerning positive and negative support, as those with no main helper were
dropped from the analysis. The usable social support data ranged from 9 to
28 for both groups. Despite these obvious deficiencies, the decision was
made to analyze the incomplete data. This topic is addressed in greater
detail in the discussion section of the paper.
Measures
Em otional Distress M easures
Depression. Depression was measured by the Center for
Epidemiological Studies Depression Scale (CES-D; Radloff, 1977). The
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CES-D is a 20 item self-report scale developed to screen for depressive
symptomotology in the general population. Each response is scored from
zero to three. Total scores range from zero to 60 with higher scores
indicating more depressive symptomotology. Validity of the scale was
tested through correlation with other self-report measures and with clinical
ratings of depression. Reliability was established through inter-item and
item-scale correlations. The corrected split-halves correlation and
coefficient alpha were satisfactorily high (.85 to.92)(Radloff, 1977). In an
analysis of the CES-D with older adults, Radloff and Teri (1986) concluded
that the sensitivity and specificity of the scale is as good or better with older
adults as it is with younger adults. In this caregiving sample Cronbach’s a =
.67.
Burden. Subjective burden was measured by the Burden Interview
(Zarit & Zarit, 1980). The Burden Interview is a 22 item scale that can be
either self administered or given as part of an interview. Items are scored
from 0 to 4 with higher scores indicative of greater depressed mood. 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 is reported at .71. Validity has been estim ated by correlating
the total score with a single global rating of burden (r = .71 )(Zarit & Zarit,
1990). Cronbach’s a for this sample was .92.
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Coping Styles. The COPE scale (Carver, Scheier, & Weintraub, 1989;
Carver & Scheier, 1992) is a 60 item measure of ways of coping with
stressors. The measure is composed of 15 subscales with four items each.
The response choices include “I didn’t do this at all,””l did this a little bit,””l did
this a medium amount,” and “I did this a lot” (scored from 1 to 4). The scales
were derived intending to tap into problem focused and emotion focused
coping. The subscales include acceptance, active coping, behavioral
disengagement, denial, use of humor, mental disengagement, planning,
positive reappraisal, use of restraint, use of religion, seeking emotional
support, seeking instrumental support, substance use, suppression of other
activities, and venting of emotions.
Carver, Scheier, and Weintraub (1989) reported on the reliability and
validity of the COPE and concluded that it had good psychometric properties
on an undergraduate sample. Cronbach’s alphas were reported for each
scale, but not the measure as a whole; these values ranged from .62 to .92,
except for one scale, mental disengagement, which had an alpha of .45.
Test-retest reliabilities for each scale were computed for 6 and 8 week
intervals. These values ranged from .42 to .89, demonstrating a wide range
of stabilities. The scales did not correlate highly with one another,
demonstrating they represent conceptually and empirically distinct ways of
coping, although they clustered into groups of adaptive and maladaptive
coping strategies.
26
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Care Recipient Factors
The Revised Memory and Behavior Problems Checklist (RMBPC;
Teri, Truax, Logsdon, Uomoto, Zarit & Vitaliano, 1992). The RMBPC served
as a measure of care recipient problems. The scale asks the caregiver to
report how frequently the dementia patient engages in problematic behaviors
and the caregiver’s reaction to these behaviors. Only the frequency was
reported in this sample. The RMBPC is an estimate of current behavioral
and cognitive disruption, and not a rating of dementia severity. The 24-item
instrument was designed for self-administration or interviewer administration.
Each item has a frequency rating from (never occurs) 0 to (occurs daily or
more often) 4. Test-retest reliability has been reported at .75, and validity
measurements have been estimated by correlating the frequency measure
with the Hamilton Depression Rating Scale (HDRS), and the Mini Mental
State Exam (MMSE). The depression and behavior problems subscales
compared favorably and significantly with the HDRS (r = .44, r = .19), and the
memory problems subscale correlated inversely with the MMSE (r = -.48).
The RMBPC was divided into three subscales; behavior problems, memory
problems, and care recipient depression. The behavior problems subscale
includes items assessing care recipient wandering, asking repetitive
questions, and losing things (a = .62), while the memory problems scale
includes items assessing the care recipient’s ability to recognize faces,
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remember the day of the week, and their ability to complete simple tasks (a =
.63). The care recipient depression subscale included items assessing care
recipient hopelessness, crying, comments about being a burden, and suicidal
threats (a = .44).
Social Support Measures
Social Network List. The Social Network List (SNL; developed by Ken
Heller, Ph.D. at Indiana University) describes the composition of one’s social
support network. The scale asks for a list of the people that the caregiver
talks to on a regular basis about things going on in their life. The caregiver
must talk to the person at least once a month in order to include them on the
list, and the person must be more than an acquaintance. First the caregiver
must list the names of the people, then their sex, age, relationship to the
caregiver, how often they see the person, talk to them over the phone and
whether the person is a caregiver also. The scale measures quantity of
supports, relationship to the caregiver, frequency of contact, mode of contact,
whether or not the person is of the same gender, in the same age group
and/or in a similar caregiving situation. The list includes questions to
separate nuclear from extended family members. Friends and hired
professionals are also identified separately. All of the responses, aside form
the person’s name, are coded.
Support Questionnaire. The Support Questionnaire contains six
questions regarding instrumental and emotional main helpers. The
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questions ask for numbers of instrumental and emotional helpers a caregiver
has. Then the caregiver has to identify the one person who provides the
most emotional support and the one person who provides the most
instrumental support, and these persons are referred to as the emotional
main helper and the instrumental main helper. The caregiver is asked for
the name(s) and relationship(s), (either family, friend, church member,
neighbor, hired professional for emotional support, or hired professional for
instrumental support), of the emotional and instrumental main helpers. Due
to errors in data collection, these distinctions were not recorded in this data
set. A caregiver may identify the same person as the main helper in both
categories, or may leave either or both categories empty. The Support
Questionnaire works in conjunction with the SNL to further identify if main
helpers are also members of the caregiver’s support network.
Main Helper Questionnaires 1 & 2. The Main Helper Questionnaire
contains 17 items. The caregiver answers questions regarding the specified
instrumental main helper (MH1) and the specified emotional main helper
(MH2). The caregiver fills out two questionnaires if they have two main
helpers. If the caregiver has only one person as a main source of support,
they fill out just one questionnaire. If the participant did not identify a main
helper, they were given a score of zero for this variable. The questions are
rated on a 5 point Likert scale with answers ranging from 1 to 5 with 1 being
“a great deal” and 5 being “not at all”. Twelve of the questions measure
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perceived support, while the remaining five assess perceived conflict. For
positive support, the range of scores is from 12 to 60 with larger scores
equivalent to less perceived positive support. For negative emotional
support the range of possible scores is from 5 to 25 and larger scores are
equivalent to less perceived conflict. In order to avoid confusion, the positive
support and the negative support scales were recoded so that larger scores
represent more perceived positive or negative support. In this sample the
Cronbach’s a were .86 for positive support and .84 for negative support.
Physiological Measure
Cardiovascular Reactivity. Measures of cardiovascular reactivity
(CVR) were taken as follows: heart rate, systolic and diastolic blood pressure
were measured with an SD700A automatic blood pressure cuff attached to
the non-dominant arm. Each variable is sampled once per three minute
interval during each of the three 12 minute periods ( a rest period and two
task periods) with the mean of the four three minute samples used as the
measure for that time period. Kamarck (1992) has shown that the
reliabilities for CVR measures based on averages such as these ranged
between .85 and .95. The mental arithmetic task is serial subtractions from
500. The caregiving story task asks the caregiver to relate the most
stressful caregiving problem that occurred in the preceding month. The
order of the two stress tasks was randomized across participants, using a
random number table to determine the order.
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Cultural Values Measure
Familism Scale. This is a 16 item scale measuring ideal-typical
familism which refers to strong-in group feelings, emphasis on family goals,
common property, mutual support, and the desire to pursue the perpetuation
of the family (Bardis, 1959). Responses choices range from strongly
disagree (1) to strongly agree (5), with higher scores representing stronger
attitude towards ideal-typical familism. In the scale’s development samples
(University of Michigan college students) Spearman-Brown split-half reliability
coefficients ranged from .77 to .84 with a thirty day retest reliability of .90
(Bardis, 1959a, 1959b, 1959c). Validity was established by report of
expected mean differences between reference groups (the Michigan college
students with Greek students “in a familistic community”, Bardis, 1959b).
Cronbach’s a for this sample was .85.
RESULTS
The analysis is presented in six parts. First, participant demographic
information is presented, followed by the results concerning the hypotheses
questions. Next, the correlational analyses of all the variables included in the
study is presented. Subsequently, the social support results are presented,
followed by the CVR analysis.
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Demographic and Care Recipient Factors
African American caregivers averaged 60.73 years and Whites
averaged 65.42 years. African Americans spent an average of just under 3
years as caregivers, while Whites averaged just under 4 years of caregiving
experience. In regards to highest level of education achieved, African
Americans averaged 13.37 years and Whites averaged 15.42 years (t(68) =
2.63, £ <.05). A Mann-Whitney non-parametric test was run to determine
potential differences in income. African American caregiver/care recipient
household income averaged between $15,501 and $17,500 per year, while
White caregiver/care recipient annual household income averaged between
$19, 501 and $28,500 per year (z (69) = -2.55,p < .05). Approximately 29%
of the African Americans sampled were employed in either full or part time
positions, whereas only 19% of the Whites were employed in full or part time
positions % 2 (6, N = 66) = 13.34, p_<.05. Similarly, African American
caregivers reported being retired less frequently than White caregivers, 43%
versus 53%.
African American caregivers were nearly evenly divided between
spouses and children in this sample (18 spousal caregivers and 17 children
caregivers), while the majority of Whites were spousal caregivers (24 spousal
caregivers and 11 children caregivers).
Care recipient factors were examined with the Revised Behavior and
Memory Problems Checklist. The groups reported nearly identical means of
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care recipient memory problems and behavior problems. African American
caregivers reported a mean of 21.6 (5.7) on the memory problems subscale,
versus 22.47 (4.48) for White caregivers. On the behavior problems
subscale, both groups reported means of 11.5 (6.15 AA, 6.67 W). White
caregivers reported more care recipient depression, 10.80 (7.41) versus 8.11
(5.14) but the difference did not reach significance (f) = .08). The complete
demographic and care recipient factor means are listed in Table 1.
Table 1
Demographic and Care Recipient Factor Mean Comparisons Between
________________________ African American and White Caregivers_______ _ _ _
Demographics
African
American
(N=35)
White
(N=35)
t
X2
df
P
Age of Caregiver 60.73 (14.30) 65.42(10.22) 1.5
67
.12
Spouse Caregivers
51.52 68.63
. 19 1
.21
(%)
Years as Caregiver 2.92(1.78) 3.93 (3.17) 1.5
69
.11
Years of Education 13.37 (3.44) 15.42 (5.28) 2.6
68
.01
Care Recipient
21.60 (5.76) 22.47 (4.48) .71
69
.47
Memory Problems
Care Recipient
11.57 (6.15) 11.58 (6.67) .08
69
.99
Behavior Problems
Care Recipient
8.11 (5.14) 10.80 (7.41) 1.7
69
.08
Depression
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Depression, Burden, Familism, and Coping Style
Due to significant group differences in caregiver income and trends
toward differences in age and relationship to the caregiver between African
American and White caregivers, these variables were controlled for in the
following mean comparisons. A multivariate general linear model was run
with caregiver age and income, as well as relationship to the care recipient
as covariates with burden, familism, positive reappraisal, and religious coping
as dependent in the equation. The model resulted in no between subjects
effects for White caregivers, but did yield an effect for relationship to the care
recipient and religious coping among African American caregivers.
In this sample, African American caregivers scored significantly lower
on a measure of burden. Replicating the findings of the majority of studies
examining burden, ethnicity, and caregiving, African American caregivers (M
= 39.62, SD = 15.43) in this study scored significantly lower on the Zarit
Burden Inventory than their White counterparts (M = 45.77, SD = 15.85), t
(69) = 1.60, e < .05.
The concept of familism was employed in this study as a cultural value
and used to examine broad beliefs with possible implications for caregiving
mental or physical health outcomes. This hypothesis question posited that
African American caregivers, believing the caregiving role to be more of an
expected familial duty than White caregivers, would score significantly higher
on the measure of familism. In this sample, African American caregivers (M
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= 30.17, SD = 8.88), scored significantly higher on the familism measure than
did White caregivers (M_= 24.80, SD = 8.93), t (69) = -2.52, £ < .05.
The next section pertains to the question of whether African American
caregivers would utilize ‘positive interpretation’ strategies such as positive
reappraisal and religious coping techniques significantly more than White
caregivers. The results concerning coping styles showed evidence of ethnic
differences in this sample. African American caregivers reported more
religious coping, (M = 14.32, SD = 2.95), than did White caregivers (M =
11.02, SD = 4.55), t (69) = -3.56, £ < .01. The two groups used virtually the
same amount of positive reappraisal. The coping results represent data
based solely upon the two subscales of interest, not the entire set of coping
subscales.
Table 2
Summary Table of Depression, Burden, Familism, and Coping Means
_________________ Comparison of African American and White Caregivers______
Measure
African Americans
(n=35)
M(S.D.)
Whites
(n=35)
M(S.D.)
t
CES-D 17.32(10.47) 18.58(10.62) .49
Zarit Burden Inventory 39.62(15.43) 45.77 (15.85) 1.60*
Familism 30.17 (8.88) 24.80 (8.93) -2.52*
Positive Reappraisal 11.67 (2.97) 11.83 (2.91) .82
Religious Coping 14.32 (2.95) 11.02 (4.55) -3.56**
*p< .05, **p< .001
35
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Social Support
A separate general linear model was run with the social support
variables as dependent, and age of the caregiver, caregiver income, and
relationship to the caregiver as the covariates. In this instance, the between
subject effects were significant F(1,18) = 7.50. Among the White caregiving
group, age showed an impact on conflict with the instrumental main helper,
income with positive instrumental support from the main helper, and
relationship to the care recipient with size of the support network. Among
African Americans, age showed an impact on positive instrumental support
from the main helper, income on size of the support network, and relationship
to the caregiver on conflict with the instrumental main helper. The within
subjects analysis showed age effects for both ethnic groups, F(7,12) = 5.03.
Past studies involving older African Americans have suggested that
this group possesses a more diverse support network than older Whites.
The data gathered from this sample made distinctions between proximal
relatives, distal relatives, non-relations within the support network, and
professionals. No participants listed professionals as a part of their support
network, so a 2x3 Pearson % 2was run. The overall social support networks of
the two groups did not significantly differ in their diversity, % 2 (2, N = 70) =
2.02, £ = .36. African American caregivers reported significantly fewer
individuals on their social support lists, t (68) = 3.40, £ = .001, more positive
emotional support from the main helper, t (68) = -3.39, and more emotional
36
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conflict from the main helperj (68) = -2.58. Size of affective network and size
of instrumental network did not differ. Respondents could include the same
people on both lists if they received assistance in both affective and
instrumental areas. Many respondents also listed people in the overall
network that they failed to list on either the affective or instrumental lists.
Thus, the means for the affective and instrumental lists do not add up to the
overall network size mean in either case. Whites reported an overall network
size of 7.31 (4.98), an affective network size of 4.26 (3.54), and an
instrumental network size of 1.60 (1.44). African Americans reported an
overall network size of 4.18 (1.88), and affective network size of 3.42 (2.03),
and an instrumental network size of 1.68 (1.45). Contrary to the hypothesis,
African Americans failed to report more diversity within their networks than
Whites in this sample. Both groups reported significantly diverse networks.
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Table 3
Summary Table of Social Support Means
Comparison of African American and White Caregivers
Measure
African Americans
(n=35)
M(S.D.)
Whites
(n=35)
M(S.D.)
t
Positive Emotional
Support
32.96(19.72) 16.23(19.24) -3.39**
Positive Instrumental
Support
37.13(17.88) 44.04(14.59) -1.51
Negative Emotional
Support
7.96 (6.33) 4.02 (5.82) -2.58*
Negative Instrumental
Support
6.78 (2.74) 7.36 (3.38) .64
Social Support
Network Size
4.18(1.88) 7.31 (4.96) 3.40**
Number in Network
Emotional Support
3.42 (2.03) 4.26 (3.54) 1.15
Number in Network
Instrumental Support
1.68(1.45) 1.60(1.44) -.21
*p< .05, **p< .001
Cardiovascular Measures
A summary of the cardiovascular measure group means is presented
in table 4. No significant groups differences were found. Tables 5 and 6
provide ranges, means, and n’s for the cardiovascular measures, while table
7 presents a comparison of the difference scores between the groups. No
significant differences were recorded among the difference scores.
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Table 4 Summary Table of Cardiovascular Measure Means
Comparison of African American and White Caregivers
African Americans Whites
Measure N Mean (S.D.) N Mean (S.D.) t
Baseline Heart Rate 18 75.93(11.76) 18 79.29(12.82) .82
Heart Rate Mental Task 19 77.32(11.71) 17 81.50(12.40) 1.03
Heart Rate Story Task 18 77.09(12.47) 17 78.94(14.11) .42
Baseline Systolic BP 31 134.88(19.19) 33 129.80(17.25) -1.12
Systolic BP Mental Task 30 140.33 (21.53) 34 136.77(17.91) -.72
Systolic BP Story Task 30 142.37 (21.19) 32 138.01 (20.40) -.85
Baseline Diastolic BP 30 73.98(10.63) 33 72.49 (9.60) -.58
Diastolic BP Mental Task 27 77.11 (10.13)) 33 76.93 (9.16) -.07
Diastolic BP Story Task 28 77.99(10.71) 30 76.95 (9.76) -.40
Table 5 Summary Table of Cardiovascular Measures
Descriptive Statistics for African Americans
Measure N Range Minimum Maximum Mean
Baseline Heart Rate 19 47.75 53.50 101.25 75.93
Heart Rate Mental Task 19 47.00 55.75 102.75 77.32
Heart Rate Story Task 19 47.75 58.00 105.75 77.09
Baseline Systolic BP 32 80.00 99.25 179.25 134.88
Systolic BP Mental Task 31 87.25 101.25 188.50 140.33
Systolic BP Story Task 32 87.00 100.50 187.50 142.37
Baseline Diastolic BP 30 46.50 47.25 93.75 73.98
Diastolic BP Mental Task 28 41.25 52.50 93.75 77.11
Diastolic BP Story Task 31 40.25 58.75 99.00 77.99
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Table 6 Summary Table of Cardiovascular Measures
Descriptive Statistics for Whites
Measure N Range Minimum Maximum Mean
Baseline Heart Rate 18 57.00 50.00 107.00 79.29
Heart Rate Mental Task 17 47.75 64.75 112.50 81.50
Heart Rate Story Task 18 62.50 43.00 105.50 78.94
Baseline Systolic BP 34 67.50 106.25 173.75 129.80
Systolic BP Mental Task 35 81.50 103.00 184.50 136.77
Systolic BP Story Task 34 79.75 106.75 186.50 138.01
Baseline Diastolic BP 33 35.75 57.50 93.25 72.49
Diastolic BP Mental Task 34 44.00 63.50 107.50 76.93
Diastolic BP Story Task 31 44.00 57.75 101.75 76.95
Table 7 Summary Table of Cardiovascular Measures
Difference Scores
African Americans Whites
Measure N Mean (S.D.) N Mean (S.D.) t
Heart Rate Mental Task 19 1.39 (6.01) 17 .48 (6.23) -.44
Heart Rate Story Task 18 2.01 (6.27) 17 .39 (6.02) -.77
Systolic BP Mental Task 30 6.41 (10.40) 34 7.41 (11.71) .36
Systolic BP Story Task 30 5.71 (9.55) 32 7.82(10.49) .82
Diastolic BP Mental Task 27 2.37 (5.98) 33 4.40 (6.72) 1.22
Diastolic BP Story Task 28 3.56 (6.56) 30 3.75 (5.95) .13
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Correlational Analyses
In order to assess the association between the study variables, a
correlation matrix of all the variables was created for each group (see Tables
8 and 9). Due to the number of correlations, a test-wise alpha of .01 was
used in order to restrict the experiment -wise alpha, and reduce the number
of significant relationships generated by chance. The dichotomous variable
of relationship to the caregiver is included in these matrices. It was coded 0
for spouses and 1 for children in the data set.
Correlational Analyses for African American Caregivers
African American caregivers showed a number of strong correlations
among the CVR variables. Baseline heart rate was strongly correlated with
heart rate during the mental and story tasks, and each task also correlated
strongly with the other (.82 to .89).
The systolic measures showed similar strong correlations with systolic
blood pressure during each task, as did each task with the other (.83 to .92).
The three diastolic measures showed strong intercorrelations, as well,
ranging from .75 to .82.
Among the support measures, positive emotional support was
correlated with negative emotional support (.61).
Under care recipient factors, care recipient behavior problems showed
one correlation. Behavior problems were correlated with care recipient
depression (.58).
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Finally, burden showed a moderate correlation with CES-D, at .55.
Correlational Analyses for White Caregivers
Among the White caregiver demographic variables, age showed the
most correlations. Age was moderately positively correlated with systolic
blood pressure during the mental task (.55), and negatively correlated with
relationship to care recipient (-.67).
As with the African American caregivers, the CVR measures showed
strong intercorrelations. Baseline heart rate was strongly correlated with
heart rate during the task conditions (.86 and .88), and moderately to strongly
correlated with all three diastolic measures (.56 to .73). Similarly, heart rate
during the mental task was strongly correlated with heart rate during the story
task (.89), as well as with all three diastolic measures (.47 to .70).
The systolic measures were strongly intercorrelated (.75 to .82).
Other than the aforementioned relationships with the other CVR
measures, the diastolic blood pressure measures only showed correlations
among themselves (.74 to .80).
Among the social support variables, positive emotional support
showed a strong correlation with negative emotional support (.75), while the
remaining support variables showed no correlations with any other variables.
Among the coping variables, positive reappraisal was moderately
correlated with religious coping (.58)
Lastly, burden was moderately correlated with CES-D (.56)
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Table 8 Pearson Correlation Matrix for
African American Caregivers
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
1 Careqiver Aqe 1
2 Annual Income .11 1
3 Rel to Care Recipient -.37 -.18 1
4 Baseline Heart Rate .09 -.03 .01 1
5 Heart Rate-M Task .14 -.15 .33 .86 1
6 Heart Rate-S Task .07 -.29 .26 .82 .89 1
7 Baseline Systolic BP .21 -.09 -.14 -.01 .09 .11 1
8 Systolic BP-M Task .13 -.02 -.18 .02 .09 .18 .83 1
9 Systolic BP-S Task .11 -.07 -.27 -.13 -.08 .02 .83 .92 1
10 Baseline Diastolic BP -.39 -.14 .29 .28 .36 .37 .41 .30 .18 1
11 Diastolic BP-M Task -.30 -.30 .17 .14 .29 .37 .52 .55 .45 .82 1
12 Diastolic BP-S Task -.34 -.23 .25 .03 .04 .19 .46 .33 .35 .77 .75 1
13 Familism .26 -.01 -.17 -.02 -.19 -.09 .42 .36 .37 -.02 .19 .21 1
14 Pos Emotion Support -.26 -.14 .24 -.52 -.31 -.49 -.10 -.26 -.21 .12 -.03 .16 -.22 1
15 Pos Instru Support .44 -.26 -.04 .57 .62 .32 -.14 -.27 -.27 -.31 -.38 -.19 -.21 .48 1
16 Neq Emotion Support -.32 -.19 .22 -.37 -.25 -.37 -.19 -.29 -.18 .08 -.04 .08 -.12 .61 .17 1
17 Neq Instru Support -.06 -.41 -.39 .30 -.01 -.02 .29 .33 .36 .41 .46 .33 .11 -.32 -.06 -.07 1
18 Social Support Size -.30 .44 .03 .22 .36 .12 -.05 -.11 -.17 .14 .05 -.02 -.18 .37 .21 .25 -.11 1
19 Care Rec Mem Prob .05 .01 .07 -.15 -.31 -.35 -.01 .00 -.11 .00 -.09 -.03 .00 .11 .18 .09 -.27 -.33 1
20 Care Rec Behav Prob -.13 -.42 .31 -.16 .00 -.07 -.04 -.17 -.16 .17 .18 .09 .06 .19 -.02 .37 -.14 -.24 .12 1
21 Care Rec Depression -.26 -.15 .43 -.09 .11 -.03 -.35 -.43 -.39 -.03 -.07 .01 -.35 .34 .29 .47 -.42 .02 .16 .58 1
22 Positive Reappraisal -.26 -.01 .25 .28 .37 .23 -.06 -.05 -.14 .23 .32 .29 -.12 .25 .13 .43 .00 .41 -.01 .14 .08 1
23 Reliqious Copinq -.06 -.29 -.19 .04 .05 -.04 .01 -.06 -.09 -.28 -.10 -.19 .00 .18 .49 .34 .31 .13 .00 .34 .28 .26 1
24 Burden -.01 .16 .23 .00 .07 .00 .08 .00 -.03 .10 .01 .13 .02 .21 .01 .20 -.11 .27 .06 .31 .20 .24 .35 1
25 CES-D Depression -.14 -.05 .28 -.12 .11 .08 .02 -.06 -.04 .17 .01 .20 -.02 .18 -.23 .42 -.17 .07 -.12 .44 .30 .03 .13 .55 1
N = 35 except for the cardiovascular variables (N = 9-20), and the social support variables (N = 9-28). Data was lost on these variables due to difficulties with
equipment in the first case and improper coding in the second case. Relationship to the care recipient, a dichotomous variable, is coded 0 for spouses and 1 for
children.
oo
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Table 9 Pearson Correlation Matrix
for White Caregivers
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
1 Careqiver Aqe 1
2 Annual Income .16 1
3 Rel to Care Recipient -.67 -.46 1
4 Baseline Heart Rate -.15 -.06 .04 1
5 Heart Rate-M Task -.06 -.02 -.19 .86 1
6 Heart Rate-S Task -.23 -.16 .08 .88 .89 1
7 Baseline Systolic BP .52 .14 -.34 .37 .22 .14 1
8 Systolic BP-M Task .55 .15 -.48 .28 .18 .05 .78 1
9 Systolic BP-S Task .52 .00 -.35 .20 .19 .06 .82 .75 1
10 Baseline Diastolic BP -.03 .10 -.05 .46 .47 .19 .41 .18 .19 1
11 Diastolic BP-M Task -.19 .12 -.10 .73 .70 .56 .50 .25 .27 .74 1
12 Diastolic BP-S Task -.06 .12 -.09 .59 .51 .39 .44 .20 .42 .81 .80 1
13 Familism .27 -.06 .00 .06 -.20 .13 .03 -.10 .09 .04 .18 .25 1
14 Pos Emotion Support .02 .08 .06 .29 .29 .24 -.06 -.14 -.16 .11 -.01 .14 .21 1
15 Pos Instru Support -.25 .02 -.01 -.32 -.11 -.33 .03 -.07 .05 .05 .03 .09 -.15 -.11 1
16 Neq Emotion Support -.17 .00 .19 .03 .02 .10 -.16 -.20 -.11 -.08 -.08 .20 .21 .75 .08 1
17 Neq Instru Support -.53 -.36 .31 .00 .10 .20 -.42 -.40 -.34 .05 .07 .11 -.05 -.24 .37 .08 1
18 Social Support Size -.05 .06 -.26 -.28 .10 .00 -.14 .00 -.02 -.03 -.09 .01 -.09 -.24 .24 -.01 .14 1
19 Care Rec Mem Prob -.01 .13 .10 -.28 -.19 -.21 .18 .22 .21 -.10 .05 -.10 -.03 -.30 .19 -.17 .12 -.03 1
20 Care Rec Behav Prob -.26 -.02 .18 .04 -.15 .08 -.13 -.11 -.03 -.08 .07 .11 .19 -.16 .00 .08 .24 -.37 .21 1
21 Care Rec Depression -.11 -.31 .15 .18 .09 .32 -.06 -.03 -.04 -.30 -.06 -.19 -.06 -.32 .11 -.19 .20 -.34 .18 .48 1
22 Positive Reappraisal .02 -.01 .13 .12 .05 .14 .13 -.11 .09 -.08 .09 .02 .17 .00 .01 .07 .02 -.07 -.20 .01 .09 1
23 Reliqious Coping .12 .09 -.21 .25 .09 .20 .17 -.11 .13 .06 .14 .21 .38 .15 -.14 .10 -.11 -.13 -.40 .28 .11 .58 1
24 Burden -.22 -.17 .17 .30 .09 .39 -.02 .04 .03 -.09 .21 .08 .03 -.30 -.15 -.09 .14 -.33 .16 .52 .27 .20 .37 1
25 CES-D Depression -.29 -.28 .42 .04 -.10 .07 -.08 -.08 -.08 -.24 -.08 -.10 -.02 -.20 -.07 -.12 .06 -.33 .26 .40 .39 .19 .35 .56 1
N = 35 except for the cardiovascular variables (N = 9-20), and the social support variables (N = 9-28). Data was lost on these variables due to difficulties with
equipment in the first case and improper coding in the second case. Relationship to the care recipient, a dichotomous variable, is coded 0 for spouses and 1 for
children.
4^
■ fc .
DISCUSSION
Introduction
Variables associated with the Sociocultural Stress and Coping Model,
as implemented in this study, illuminated a number of areas for discussion
vital to ethnicity and caregiving research. This discussion centers on the
study hypotheses, which were as follows:
1) African American caregivers will score significantly lower on measures
of burden (appraisal of caregiving as stressful).
2) African Americans caregivers will score significantly higher on
measures of familism.
3) African American caregivers will utilize “positive interpretation” coping
strategies including positive reappraisal and religious coping
techniques significantly more than White caregivers.
4) African American caregivers will report a more diverse network of
support, including more peripheral relatives and fictive kin.
5) African American caregivers will show significantly greater
cardiovascular reactivity than will White caregivers.
Mirroring the hypothesis questions, this discussion begins with an
examination of the sample groups’ differences in burden. Next, the role of
familism within each equation is discussed, followed by a section on coping
responses. The role of CVR in the model and aspects of social support and
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are subsequently discussed. The discussion concludes with a summary, a
section on the limitations of this study, and potential research avenues
suggested by these findings.
Differences in Burden
The hypothesis that African American caregivers would report lower
rates of burden than White caregivers was supported in this sample. Based
on earlier research in the field, ethnic differences in burden were expected.
The literature has consistently stated that African Americans report lower
rates of burden than White caregivers, a disparity replicated here. Burden
remains the key piece to achieving a greater understanding about the African
American caregiving process, particularly in relation to depressed mood.
Accordingly, researchers must continue to seek out cultural mechanisms that
will show relationships to burden. One potential cultural mechanism could be
cultural expectations. It may be that White caregivers hold certain
expectations for their future with or without the care recipient. White
spouses may expect a pleasant shared retirement with more time for
recreation or travel, while White caregiving children may expect their parents
to be self sufficient and require little caregiving. As it becomes clear that
these expectations will not be met, the burden of caregiving may be
exacerbated. In other words, the dashed expectations may add
incrementally to the emotional and physical tolls exacted by caregiving, and
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thus may increase burden for these caregivers. African American caregivers
on the other hand, may hold different expectations about their future with the
care recipient. For example, African American caregivers are more likely to
have been raised in a family system where caregiving for family members of
all ages is an expected duty (Taylor, et al., 1997). This expectation may
serve to lessen the comparative burden for African American caregivers.
Another culturally based explanation of differences in burden might be
found by examining health related schemas. Landrine and Klonoff (1992)
suggest that many White Americans tend to view illness as a person-
centered, temporally bounded, and discontinuous event, whereas many
African Americans view illness as a long term, fluid, and continuous
manifestation of changing relationships within the family, the community, or
nature. Dementia is a progressive and long-term illness. Viewing it as such
may assist African American caregivers in psychologically adjusting to the
difficulties inherent in caregiving, leading them to experience less burden in
the caregiving role.
Familism
This relationship between caregiving and familial duty is explored with
the familism measure. Familism was introduced as an attempt to uncover a
cultural mechanism that differentiated the groups and contributed to lower
rates of burden. As hypothesized, African American caregivers reported
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higher levels of familism than Whites. This result is similar to earlier attempts
to use traditional family values (Lawton et al., 1992) and mastery (Miller et
al., 1995) as cultural variables within the stress and coping framework in
ethnicity and caregiving.
Traditional caregiving ideology, mastery, and presently, familism have
all been examined thus far, but have either failed to display an association to
burden or failed to test for such associations. Other areas to explore
suggested by the findings of this study include family history of caregiving,
caregiving expectations, meaning in the caregiving role, and religiosity
(specifically collaborative coping with God). A family history of multi-
generational caregiving may make caregiving more of a normative, expected,
and accepted role for African American caregivers, thus lessening burden.
Similarly, finding meaning in the caregiving role could also serve to lessen
burden by both increasing one’s sense of accomplishment and in upholding
familial tradition. In order to effectively investigate these issues, qualitative
studies are needed with African Americans and other diverse groups of
caregivers. Family caregiving history, meaning in the caregiving role, and
religiosity are all rich, layered and complex areas of research. Accordingly,
each lend themselves to in-depth, qualitative study.
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Coping Styles and Ethnicity
Religious Coping
Just as levels of familism differed by ethnicity in this sample, so did
coping. In the original hypothesis it was suggested that religious coping and
positive reappraisal, the ‘positive interpretation’ coping strategies, would be
employed more often by African American caregivers than by their White
counterparts. As hypothesized, African Americans utilized more religious
coping than Whites, though levels of positive reappraisal were
indistinguishable between the groups. In other studies, older African
American women report higher levels of religiosity than older African
American men and older Whites (both men and women), as well as more
comfort from prayer and more perceived rewards from caregiving (Chatters,
et al., 1992; Picot, et al., 1997). Thus, it is not surprising that the African
Americans in this all female sample reported significantly higher rates of
religious coping.
Many dementia related behavior problems are confusing, frustrating,
and misunderstood by caregivers as intentional. Aspects of religious coping
are an attempt to make sense out of a disease that often causes loved one’s
to engage in perplexing behaviors. When behaviors appear beyond one’s
understanding and patience becomes limited, the reliance on faith can
provide the comfort and the strength many caregivers need to continue in the
caregiving role. A closer examination of religious coping, may also shed
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greater light on the unfolding of burden in African American caregiving
samples.
CVR and Social Support Data Inclusion
Despite incomplete data, the decision was made to use both the CVR and
social support information provided by the participants. As noted in the
methods section, complete data was not reported for heart rate and some of
the social support variables. The heart rate/blood pressure monitors had
difficulty in recording heart rate, but were able to record systolic and diastolic
blood pressure with consistency. This resulted in complete heart rate data for
19 African Americans and 18 White caregivers. Blood pressure data was
successfully acquired in at least 31 African Americans and 32 Whites. The
decision was made to use what heart rate data was recorded along with
more complete systolic and diastolic blood pressure data for several reasons.
First, CVR was one of two major focuses of the study, and incomplete data
still sheds useful light on this understudied area. Second, the usable data
was considered enough to show potentially significant relationships. In the
case of the social support variables, all participants were asked if they had a
main helper. Those who did not, were not given the positive and negative
support questions about their main helper. This greatly decreased the
number of responses recorded concerning positive and negative support, as
those with no main helper were dropped from the analysis. The number of
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recorded participant responses varied from 9 to 28 in the social support data.
The decision to use this data was made for similar reasons. In an
understudied area of research, even incomplete data is of great use.
Cardiovascular Reactivity Measures
The inclusion of CVR measures in this study proved an important
means of confirming or contradicting self reported information such as
depressed mood. The use of such measures is important for a number of
reasons. First, the vast literature examining dementia caregiving contains a
limited number of studies with physiological outcome measures. Second,
only one other study has looked at African American caregivers and
physiological stress (Knight & McCallum, 1998). That study found ethnic
differences in the relationship between coping style and CVR, with African
American caregivers showing an inverse relationship between positive
reappraisal coping and CVR and White caregivers showing a positive
relationship between the two. In other words, positive reappraisal appeared
to yield a positive physiological response for African Americans and a
negative physiological response for Whites.
The results of this study fail to shed much light on potential differences
between the ethnic groups in CVR. The two groups tested could not be
differentiated based on the data yielded. As will be discussed in the
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limitations section, the small sample size makes it difficult to draw
conclusions from this data set.
Social Support
Early ethnicity and caregiving studies suggested that social support
differed between African Americans and Whites, with African Americans
either having larger support networks, or receiving more positive support
from those within the network. The hypothesis pertaining to social support in
this study suggested that the network among African Americans would be
more diverse than that of Whites, containing more peripheral relatives and
fictive kin. None of these suggestions were supported by the data from this
sample. White caregivers reported larger support networks, and the groups
did not significantly differ in diversity of network composition. African
Americans did report more positive and negative emotional support than
Whites, however. These results contradict the findings of Haley and his
colleagues (1995), who found no evidence of ethnic differences in perceived
social support or satisfaction from that support. Haley et al. also found more
diversity in the support networks of African American caregivers. The results
of this study showed diversity in the network composition of both ethnic
groups, suggesting that Whites in the sample may have shown more
variation than was found in previous studies. On the other hand, the study’s
restriction to those 50 years of age and older likely decreased the overall
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diversity in African American networks. Regardless, both ethnic groups, in
the absence of immediate family members, likely used more distant family
members and non-relations as useful substitutions in the support network.
This compensation has been associated with African American support
networks in the past (Chatters, Taylor, & Jackson, 1985), but these results
lend evidence for its use among Whites as well. The use of more distant
and non-relations in the support network is positive for both groups, as it
widens the circle from which caregivers can potentially receive assistance. It
is crucial for all caregivers to receive the assistance they need in order to
best continue their function in the caregiving role.
Summary
In this sample, variables associated with the Sociocultural Stress and
Coping Model differentiated the groups in terms of burden, familism, and
religious coping. However, the sample data did not suggest differences in the
use of positive reappraisal or in the diversity of the social support network.
Taken as a whole, the aforementioned findings lend more evidence to the
possibility of ethnic differences in caregiving. Specifically, these results
suggest ethnic differences in the nature of the stress response to caregiving,
with African Americans possibly relying upon familism and religious coping to
keep their caregiving burden lowered.
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Limitations
There are several important limitations to this study, many of which
characterize dementia caregiving and ethnicity research to this point. These
limitations include small sample size, single gender sample, participant
recruitment methods, the use of a cross sectional study design, and
limitations regarding the measures employed.
Small Sample Size/Single Gender Sample
This was a small convenience sample of 35 African American and 35
White, female caregivers. With samples of this size, it is important to
emphasize that the results of the study may not generalize to larger
populations of African American and White caregivers. Studies have also
reported gender differences in caregiver depression (Lutzsky & Knight,
1994), so these results should not be generalized to male caregivers. This
sample was taken entirely from Southern California, predominantly from Los
Angeles County. The Southern California region is distinct in a variety of
ways, and African American caregivers living there may be different from
African Americans living in other parts of the country. The same may be
true for White caregivers. The small sample size also limited the statistical
strength of the analysis. Accordingly, what may appear to be non-significant
differences should not be viewed as ethnic similarities.
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Participant Recruitment
As is common, the White participants were recruited through a
research center and service settings. The African American participants
were also recruited through a research center and service settings, as well
as through church sponsored health fairs, and newspaper and radio
advertisements targeted toward the African American community. This type
of recruitment has been shown to yield help seeking caregivers. Thus the
results may not generalize to caregivers who do not actively seek assistance.
Additionally, the complementary recruitment techniques for African
Americans, though necessary, may have yielded a more religious sample,
further limiting generalizability.
Cross Sectional Study Design
Further limitations are manifest in the study design. This was a cross
sectional study in which directionality of covariate relationships cannot be
inferred. As dementia is a progressive disease, the caregiving role unfolds
over time. Thus, longitudinal studies are better able to shed light on the
intricate stress and coping process into which all caregivers enter. It is also
possible that variables placed earlier in the model are influenced by those
appearing later in the regression equation.
Measurement Tools
The inclusion criteria and the choice of measurement tools also limited
the scope of the results. The inclusion criteria for this study required only
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that care recipients display memory problems, not that they be diagnosed
with Alzheimer’s disease or other dementia. While this criterion was
intended to increase the number of African Americans eligible for the study, it
also served to lessen the generalizibility of the overall results. Without
evidence of similar care recipient diagnoses, the study cannot rule out that
differences within the sample were in fact related to diagnosis.
Finally, with no measures to examine positive aspects of caregiving,
these results show only a partial picture. Caregiver well being, perceived
rewards from caregiving, meaning in the caregiving role, and stress related
growth are all measures that may further illuminate ethnic differences in
caregiving.
Ideas for Future Research
It is clear that a great deal of future research is needed to answer
several of the questions put forth in this study, and to shed more light on
some of its findings. As the overall number of dementia caregiving and
ethnicity studies remains quite small, an increase in the number of theory
driven studies examining the effects of cultural variables would add
immeasurably to the existing works.
Physiological Measures
Additionally, this work represents only the second study examining
physiological responses to caregiving, ethnicity, and dementia. More studies
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are needed to replicate the findings from the first study and to expand the
type of physiological measures employed. Both previous works examine
CVR. The handful of caregiving studies looking at physiological responses to
caregiving in Whites have used cardiovascular, immunilogical and metabolic
measures. Specifically, studies investigating heart rate reactivity, white
blood cell activity, cortisol change, and glucose activity are needed to
determine if psychological reports correlate with physiological measures in
caregiving populations. Though the findings in this study fail to shed light on
potential ethnic differences in CVR, this remains an area worthy of
investigation.
Longitudinal Studies
Finally, this area of research is replete with cross sectional studies,
but short on longitudinal studies. Future research should move into
longitudinally designed studies for several reasons. First, longitudinal data
can make clear the direction of the causal flow between the variables in the
regression equations. The relationship between faith-oriented coping and
burden, as well as disengaged coping and burden for African Americans
would become clear under such a design. Second, physiological data could
be recorded longitudinally to shed light on several realms. Some
physiological measures are capable of recording stress levels while
caregivers are in the act of caregiving. The ability to measure their
responses at specific times and over time would add to the literature
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examining both the short and long term physiological effects of caregiving.
This study design could also look at physiological states after in-home
caregiving is completed.
In summary, the area of ethnicity and dementia caregiving research
would be well served to move into more qualitative studies to examine family
histories of caregiving, individual and familial caregiving expectations,
meaning in the caregiving role, and collaborative versus deferred religious
coping techniques. The use of longitudinal designs is likewise crucial to the
advancement of this field so that the directionality of relationships and the
effects of caregiving over time as viewed through the sociocultural stress and
coping model may be revealed. Finally, the expansion of physiological
studies is necessary to place the entire process in a heretofore little
examined framework. Physiological studies may be particularly relevant to
this area of research as this study found dissonance between psychological
and physiological responses in African Americans.
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Asset Metadata

Creator McCallum, Todd Jason (author)

Core Title Dementia caregiving and ethnicity: African American caregivers and the sociocultural stress and coping model

School Graduate School

Degree Doctor of Philosophy

Degree Program Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Black studies,Gerontology,OAI-PMH Harvest,Psychology, clinical

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Knight, Bob G. (committee chair), Gatz, Margaret (committee member), John, Richard S. (committee member), Silverstein, Merril (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-541438

Unique identifier UC11339283

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Legacy Identifier 3094358.pdf

Dmrecord 541438

Document Type Dissertation

Rights McCallum, Todd Jason

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

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