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a Center for Mental Health Services Research, School of Social Work, University of Pittsburgh, Pittsburgh, PA
b Department of Psychiatry and University Center for Social and Urban Research, University of Pittsburgh, PA
Correspondence: Jennifer L. Yee, PhD, Center for Mental Health Services Research, School of Social Work, 2217A Cathedral of Learning, University of Pittsburgh, Pittsburgh, PA 15260.
Decision Editor: Vernon L. Greene, PhD
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Abstract |
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 TOP Abstract Gender Differences in General...Factors in the Caregiving...Summary and Directions for...Implications for Interventions...References |
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Key Words: Gender • Caregiving • Psychiatric morbidity • Depression • Stress • Caregiving activities
Research on the morbidity effects of caregiving has firmly established the negative impact of providing care on the psychological well-being of caregivers. As noted in two review articles (Schulz, O'Brien, Bookwala, and Fleissner 1995
; Schulz, Visintainer, and Williamson 1990), this literature strongly indicates that, compared with population norms and noncaregiving controls, caregivers report higher levels of depressive symptoms, clinical depression, and anxiety. However, systematic analysis of the role of individual differences, such as gender, in explaining the psychological well-being of caregivers has been limited.
Although the relationship between gender and caregiving is reported in many studies, little effort has been made to systematically review and synthesize the findings from these studies. To date, the only review of this literature is Miller and Cafasso 1992 meta-analysis, which included 14 studies and examined gender differences only with regard to caregiver burden as the outcome measure. A strong case can be made that it is equally if not more important to examine gender differences on indicators of psychiatric morbidity (George and Gwyther 1986; Schulz et al. 1995). Mental health outcomes provide a stronger basis for making policy recommendations, and they facilitate comparisons across many different types of populations, including noncaregivers.
Our goal in this article is to update and further synthesize the empirical research on caregiver gender and psychiatric morbidity. First, we review the results of existing studies on gender differences in psychiatric morbidity, with the aim of answering the question: Is there greater psychiatric morbidity among female caregivers than male caregivers? Next, we examine whether there is excess psychiatric morbidity among female caregivers that is attributable to caregiving. We then evaluate factors in the caregiving situation that may contribute to excess morbidity among female caregivers by using a basic stress process model as an organizing framework. Subsequently, we discuss directions for future research and implications for interventions and public policy.
This review includes 30 empirical research reports published from 1985 through 1998. Articles were selected for inclusion on the basis of the following criteria: (a) gender was a main focus of investigation; (b) empirical results were reported on gender differences in caregivers' psychiatric morbidity and/or factors in the caregiving experience that may account for gender differences in psychiatric morbidity (e.g., caregiver burden, role strain, caregiving tasks performed, or formal/informal support received); and (c) the focus was on caregivers of frail elders, physically ill adults, and/or demented adults. We excluded studies on caregivers of those with other mental illnesses (e.g., schizophrenia) and caregivers of physically ill children. Articles were identified through the PsychLit, Medline, and Current Contents databases and through citations from other published articles.
We adopted a narrative rather than a meta-analytic approach when conducting this review for two reasons. First, the studies included in this review differed drastically in terms of methodology, and thus quantitative comparisons would be difficult to make. Second, a narrative approach was used to maximize the number of articles included in this review, as some studies do not provide the information needed to conduct a meta-analysis.
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Gender Differences in General Psychiatric Symptomatology, Depression, Life Satisfaction, and Anxiety |
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TOPAbstractGender Differences in General...Factors in the Caregiving...Summary and Directions for...Implications for Interventions...References |
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; Fitting, Rabins, Lucas, and Eastham 1986; Lutzsky and Knight 1994; Parks and Pilisuk 1991; Pruchno and Resch 1989; Rose-Rego, Strauss, and Smyth 1998; Schulz and Williamson 1991; Tennstedt, Cafferata, and Sullivan 1992; Williamson and Schulz 1990). In addition, three studies (Collins and Jones 1997; Lutzsky and Knight 1994; Young and Kahana 1989) reported gender differences in general psychiatric symptomatology.
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), Lutzsky and Knight 1994, Pruchno and Resch 1989, and Rose-Rego and colleagues 1998 found that wife caregivers reported higher levels of depressive symptoms than husband caregivers. In addition, using samples of caregivers that included adult children and spouses, Schulz and Williamson 1991, Tennstedt and colleagues 1992, and Williamson and Schulz 1990 reported that women had higher CES-D scores than men. Furthermore, on examining the men's and women's means for all studies that used the CES-D, the means for women are very close to or above the cutoff score of 16 for being considered at risk for clinical depression, whereas the mean values for men in almost all instances fall below the 16 cutoff score. Thus, it appears that women caregivers are especially at risk for clinical depression. With respect to other measures of depression, Fitting and colleagues 1986, who used the Minnesota Multiphasic Personality Inventory Depression subscale and the Wiggins Depression Inventory, found that wife caregivers reported higher depression scores than husband caregivers. Parks and Pilisuk 1991 reported no gender differences in depression among adult children, and Beach and colleagues in press found no overall gender differences among spousal caregivers.
Three investigators who used general measures of psychiatric symptomatology found that women had higher levels of psychiatric symptoms. Using the General Health Questionnaires (GHQ), Collins and Jones 1997 found that a higher percentage of women caregivers than men caregivers reached the cutoff of 12 for psychiatric "caseness." Similarly, Young and Kahana 1989 reported that women had higher levels of distress (Symptoms Checklist scores) than men. Using the General Symptom Index (GSI), Lutzsky and Knight 1994 showed that wives reported greater psychiatric symptomatology than husbands.
Although depression is the most commonly studied psychiatric problem in the caregiving literature, Fitting and colleagues 1986 and Parks and Pilisuk 1991 also found gender differences in anxiety. Both Parks and Pilisuk and Fitting and colleagues found that women had higher anxiety scores than men. In addition, Fitting and colleagues showed that women reported more paranoia than men, and several investigators mentioned that women caregivers reported lower life satisfaction than men caregivers (Chang and White-Means 1991; Collins and Jones 1997; Rose-Rego et al. 1998).
Most studies that report gender differences in psychiatric morbidity are cross-sectional. As a result, the differential effects of caregiving on men's and women's psychiatric symptomatology over time is not clear. In a longitudinal study conducted on gender differences in depression among dementia caregivers, Schulz and Williamson 1991 found that at Time 1, consistent with other studies, women reported more depressive symptoms than men. However, over a 2-year period, women's depression scores remained high and stable, whereas men's depression scores increased and became essentially equivalent to women's scores. In another longitudinal study that included caregivers and noncaregivers, Beach and colleagues in press found that gender did not predict changes in Diagnostic Interview Schedule depression or anxiety. However, they did report that caregiving involvement had differential effects on changes in men's and women's mental health depending on whether they were in high- or low-quality marriages. Specifically, for women in good marriages, the more help they provided, the more improved their mental health. For women in poor quality marriages or men in either high- or low-quality marriages, increased caregiving demands were associated with decreased mental health.
Comparison of Caregiver Depression Scores With Age-Matched Noncaregiving Community Samples
Although many studies show that women caregivers report higher levels of depression than men caregivers, it is possible that these differences reflect a general tendency for women to report higher depression levels than men (Blazer 1993; George 1989, George 1994) rather than the differential impact of caregiving on men and women. Thus, it is important to answer this question: "Is there excess depression among women attributable to caregiving?" To address this question, we compared depression scores of caregivers with scores of age-matched noncaregiving community samples.
In studies that included middle-aged and elderly community samples of men and women, Berkman and colleagues 1986 reported that the women's CES-D mean was 8.82 and the men's CES-D mean was 6.72, whereas Murrell, Himmelfarb, and Wright 1983 reported a women's CES-D mean and a men's CES-D mean of 9.5 and 9.2, respectively. In a more recent study, Lewinsohn, Seeley, Roberts, and Allen 1997 reported a women's CES-D mean of 8.67 and a men's CES-D mean of 7.87. In contrast, in studies reviewed here, women caregivers' CES-D means, which ranged from 13.98 to 18.87, tend to be more elevated when compared with these community samples than men caregivers' CES-D means, which ranged from 6.91 to 14.40.
Similar results were found when we examined the percentages of women and men who were at risk for clinical depression (e.g., had scores 
16 on the CES-D). In two studies that examined depression among older community-residing adults, O'Hara, Kohout, and Wallace 1985 reported that 7.34% of men and 10.01% of women were at risk for clinical depression, whereas Kennedy and colleagues 1989 found that 11.14% of men and 19.91% of women were at risk for clinical depression. Using data from the Duke Establishment of a Population for Epidemiologic Studies of the Elderly (EPESE), Blazer, Burchett, Service, and George 1991 reported that 6.4% of men and 10.7% of women were at risk for clinical depression. More recently, in a study that included middle-aged and elderly community-residing adults, Lewinsohn and colleagues 1997 reported that 11.90% of men and 15.04% of women were at risk for clinical depression. Using a population-based sample of men and women caregivers, Tennstedt and colleagues 1992 reported that 26.4% of men caregivers and 40.7% of women caregivers were at risk for clinical depression. When compared with the percentages of men and women at risk for clinical depression in community samples, Tennstedt and colleagues' results suggest that although both men and women are affected by caregiving, the percentage of women caregivers at risk for clinical depression is more elevated than that of men caregivers. We can also estimate the percentage of women caregivers at risk for clinical depression in studies reviewed here by examining the mean CES-D scores for women. The fact that, in most studies, women caregivers' CES-D means are above 16 suggests that approximately 50% of women caregivers are at risk for clinical depression.
To summarize, the results of most studies indicate that women caregivers tended to report higher levels of depression, anxiety, and general psychiatric symptomatology and lower levels of life satisfaction than men caregivers. In addition, it appears that the excess psychiatric morbidity among women caregivers is in part attributable to the caregiving experience, as evidenced by the larger difference between depression scores of women caregivers and comparable noncaregiving female community samples when compared with the difference in depression scores of men caregivers and comparable noncaregiving male community samples. However, most studies examining gender differences in psychiatric morbidity were conducted on spousal caregivers of Alzheimer's patients. Thus, additional research is needed to further clarify the nature of gender differences in psychiatric symptomatology among adult child caregivers and those caring for physically disabled recipients. In addition, in most of these studies bivariate rather than multivariate analytic strategies were used. To more clearly establish the prevalence of women caregivers' psychiatric morbidity, more multivariate studies are needed that control for factors associated with psychiatric morbidity (e.g., socioeconomic status, and the caregiver's physical health).
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Factors in the Caregiving Situation That May Place Women at Greater Risk for Psychiatric Morbidity |
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TOPAbstractGender Differences in General...Factors in the Caregiving...Summary and Directions for...Implications for Interventions...References |
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; Pearlin, Mullan, Semple, and Skaff 1990; Pruchno, Peters, and Burant 1995). Cohen, Kessler, and Gordon 1995 developed a particularly useful stress process model, which Schulz and his associates (Martire and Schulz in press; Schulz and Salthouse 1999) recently adapted to the caregiving situation. Fig. 1 shows an adaptation of the Cohen and colleagues model for the purposes of this review and a summary of gender differences observed at each stage of the stress process. Similar to other stress process models, the Cohen and colleagues model includes primary stressors/objective demands (e.g., recipient's disability), appraisals/subjective reactions (e.g., perceptions of burden or strain), and the effects of these variables on mental health. This model represents an improvement over other stress process models because it incorporates features from biological, environmental, and psychological perspectives of stress and coping. Previous models focused primarily on psychological and/or environmental factors associated with stressful events. In addition, unlike other stress process models, the Cohen and colleagues model includes physiological, affective, behavioral, and cognitive responses to stress. This model also explicitly focuses on morbidity effects as an endpoint of the stress process.
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model, people are confronted with challenging life events or environmental demands. Applied to the caregiving situation, these demands are driven by the level of patient disability and the consequent caregiving tasks required to maintain patient functioning in the community. In the next stage of this model, people then evaluate whether they have the resources to cope with these demands and if these demands pose a potential threat. If people believe that their coping resources are not sufficient to meet the challenges posed by environmental demands, they perceive themselves to be stressed. In the caregiving literature, perceived stress has generally been conceptualized as caregiver burden, caregiver strain, or role strain. In the next stage of this model, people can respond to this perceived stress by engaging in behaviors that increase or decrease their risk for mental health symptomatology. Behavioral responses to stress in the caregiving situation include seeking formal or informal support, taking care of one's health needs (e.g., getting enough rest or exercise), and relinquishing caregiving responsibilities. In the following sections of this article, we use this model as a general framework for assessing gender differences at each stage of the caregiving process (caregiving demands, perceived stress, and behavioral responses). Our goal is to better understand the source of the differential psychiatric morbidity observed among men and women and ultimately to make policy recommendations consistent with this analysis.
Caregiving Demands: Types and Amounts of Care Provided
Several researchers have argued that women caregivers may be at greater risk for negative mental health effects because they provide more caregiving assistance in general and are more likely to help with more hands-on, day-to-day caregiving activities, such as meal preparation, cleaning, cooking, and personal care (Horowitz 1985; Miller and Cafasso 1992; Montgomery 1992; Stoller 1990). Many studies 
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included in this review used some measure of the amount and/or types of assistance that men and women caregivers provided to care recipients. Columns 3 and 4 of Table 1 identify the types of care provided and associated gender differences in care provision, when available. Gender differences in the performance of caregiving tasks are discussed in terms of general indicators of caregiving task performance, household-related tasks, personal care tasks, and care management and transportation tasks.
General indicators of caregiving task involvement.
Most studies that examined gender differences in time spent on caregiving reported that women spend more time on caregiving tasks than men (Allen 1994; Horowitz 1985; Montgomery and Kamo 1989; Neal, Ingersoll-Dayton, and Starrels 1997). Two exceptions to this general conclusion are the findings of Fredriksen 1996 and Chang and White-Means 1991, who reported no gender differences in the amount of time spent providing care. In a study examining gender differences between husband and wife and between son and daughter caregivers, Dwyer and Seccombe 1991 reported that husbands spent the most extra hours providing care and that wives reported spending the least amount of extra hours on providing care. However, Dwyer and Seccombe's sample was asked about extra hours of care provided rather than hours spent providing help. Thus, wives may have underreported the hours that they spent on caregiving because they perceived that time they spent helping their husbands was part of their duties as wives rather than extra time spent on caregiving.
In general, inconsistent findings were obtained concerning gender differences in the number of different caregiving tasks performed. Dwyer and Coward 1991 and Neal and colleagues 1997 reported that women performed more caregiving tasks than men. In contrast, Barusch and Spaid 1989 results showed that men assisted with marginally more tasks than women. Pruchno and Resch 1989 and Schulz and Williamson 1991 reported no gender differences in the number of different caregiving tasks that men and women performed. In sum, most studies demonstrated that women spent more time on caregiving than men; however, inconsistent results were found in terms of the number of caregiving tasks performed.
Housework-related caregiving tasks.
Using general measures of household task performance (e.g., meal preparation, laundry, and housework). Collins and Jones 1997, Fredriksen 1996, and Ingersoll-Dayton, Starrels, and Dowler 1996 found that more women caregivers reported helping with such tasks than men caregivers. Researchers also reported that women were more likely than men to perform specific household tasks, especially meal preparation, laundry, and housework. Dwyer and Coward 1991, Horowitz 1985, and Neal and colleagues 1997 reported that women were more likely than men to assist with meal preparation and housework. In addition, Stoller 1990 found that women were more likely to assist care recipients with preparing meals and laundry than were men. In contrast, Tennstedt, Crawford, and McKinlay 1993 found no gender differences in household caregiving tasks performed.
Most of these studies included primarily adult child caregivers; thus, there is strong evidence to support daughters' greater levels of assistance with housework-related tasks when compared with those of sons. However, the pattern for spousal caregivers is less conclusive. Collins and Jones 1997 found that wives were more likely to provide help with household tasks than were husbands. In a study that included husband, wife, and daughter caregivers, Young and Kahana 1989 reported that wives were more likely to provide assistance with cooking and laundry than any other group. However, Barusch and Spaid 1989 found no significant differences between husbands and wives in terms of housework-related caregiving tasks.
Two studies have been conducted that included both adult child and spousal caregivers. Chang and White-Means 1991 reported that wives and daughters were more likely to help with meal preparation than were husbands and sons. In contrast, Dwyer and Seccombe 1991 reported different findings for adult child and spousal caregivers. These researchers found that daughters were more likely than sons to spend extra time assisting with laundry and meals, whereas husbands were more likely than wives to report spending extra time helping with laundry and housework. However, because participants in the Dwyer and Seccombe study were asked about extra time spent providing help, wives may have underreported the care that they provided because they viewed their assistance with household chores for an impaired husband as part of their role as wife rather than extra time spent caregiving. In sum, adult daughters caring for parents with physical ailments or dementia-related conditions are more likely to perform housework-related caregiving tasks than adult sons. However, the results are less conclusive for spousal caregivers.
Personal care tasks.
The results of several studies reviewed also provide evidence supporting women's greater involvement in hands-on personal care tasks (e.g., assistance with toileting, bathing, eating). Chang and White-Means 1991, Collins and Jones 1997, Dwyer and Coward 1991, Finley 1989, Horowitz 1985, and Kramer and Kipnis 1995 demonstrated that women were more likely to assist with personal care tasks than were men. Similarly, Dwyer and Seccombe 1991 reported that daughters and wives were more likely than husbands and sons to spend extra time helping with bathing. Consistent with these researchers, Montgomery and Kamo 1989 and Tennstedt and colleagues 1993 reported that men spent less time on personal care tasks than did women. Contrary to these findings, a smaller subset of studies (Allen 1994; Fredriksen 1996; Neal, et al. 1997; Stoller 1990; Young and Kahana 1989) reported no significant gender differences in the provision of personal care tasks. In addition, Barusch and Spaid 1989 reported that husbands were more likely to perform personal care tasks than were wives. Overall, women's greater performance of personal care tasks can be observed in studies that include adult child and spousal caregivers and caregivers of recipients with physical disabilities and dementia-related conditions.
Care management, shopping, and transportation tasks.
Some researchers (Horowitz 1985) have argued that women are more likely to perform day-to-day caregiving tasks, such as housework and personal care, whereas men are more likely to help with intermittent tasks, such as care management and transportation tasks. The results of this review generally do not support men's greater performance of intermittent tasks. Most studies found no differences between men and women caregivers in terms of care management tasks (Chang and White-Means 1991; Finley 1989; Fredriksen 1996; Horowitz 1985; Kramer and Kipnis 1995; Neal et al. 1997; Stoller 1990; Tennstedt et al. 1993). In terms of shopping and transportation, most studies showed that women were more likely than men to perform these tasks (Dwyer and Coward 1991; Horowitz 1985; Montgomery and Kamo 1989; Neal et al. 1997). In summary, results of the reviewed studies indicate that women tend to be exposed to greater caregiving demands than men, especially in terms of time spent on caregiving, and the performance of hands-on, day-to-day caregiving activities, such as household chores and personal care. The results also suggest that gender differences in the performance of household tasks may depend on the type of relationship between the caregiver and the care recipient.
Perceived Stress
Caregiver strain, caregiver stress, and caregiver burden.
Seventeen of the studies in this review (Barusch and Spaid 1989; Chang and White-Means 1991; Collins and Jones 1997; Fitting, Rabins, Lucas, and Eastham 1986; Fredriksen 1996; Horowitz 1985; Kramer and Kipnis 1995; Lutzsky and Knight 1994; Miller 1990; Montgomery and Kamo 1989; Mui 1995; Neal et al. 1997; Parks and Pilisuk 1991; Pruchno and Resch 1989; Williamson and Schulz 1990; Young and Kahana 1989; Zarit, Todd, and Zarit 1986) used measures of caregiver strain, stress, or burden (see Table 1 ). The vast majority of these studies reported that women experienced higher levels of burden than men.
Barusch and Spaid 1989, Collins and Jones 1997, Fredriksen 1996, Kramer and Kipnis 1995, Lutzsky and Knight 1994, Parks and Pilisuk 1991, Williamson and Schulz 1990, and Young and Kahana 1989 found that women caregivers reported higher amounts of caregiver burden than men caregivers. In addition, Horowitz 1985 reported that a greater proportion of daughters mentioned that their emotional state had changed for the worse and that their plans for the future were negatively affected by caregiving. In addition, Neal and colleagues 1997 found that after control variables (e.g., caregiver's and elderly recipient's sociodemographics, number of hours worked, number of problem behaviors in the care recipient) were introduced, gender was a significant predictor: Women experienced greater chronic elder care stress than men. In a study of husband and wife caregivers, Miller 1990 found that women had higher levels of health strain and time stain than men caregivers. In addition, Chang and White-Means 1991 found that women reported increased emotional and physical strain than did men. Although Fitting and colleagues 1986 reported no overall gender differences in burden, they did find that younger wives and older husbands reported increased burden as the care recipient's level of impairment increased. In contrast to most studies, Montgomery and Kamo 1989 and Mui 1995 reported no gender differences in caregiver burden.
Almost all studies examining burden or strain as an outcome measure reported that women had higher levels of burden or strain than men. However, similar to depression, the differential effects of caregiving on men's and women's perceptions of stress over time is unclear. In the only longitudinal study addressing this issue, Zarit, Todd, and Zarit 1986 found that, at Time 1, wives reported greater burden levels than husbands. At the 2-year follow-up, there were no significant gender differences in caregiver burden. Specifically, the husbands' burden means remained relatively constant, whereas the wives' means significantly declined. Note, however, that the Time 2 sample included caregivers of spouses who lived at home and those that placed their spouses in care facilities between Time 1 and Time 2. The means of wives who placed their husbands dropped much more substantially from Time 1 to Time 2 than the means of women caring for a spouse who still resided in the home. Thus, the decrease in women's burden levels may be due in part to the inclusion of caregivers who placed their spouses. To summarize, in the vast majority of reviewed studies, women experienced higher burden levels than men. Women's higher levels of caregiver burden were found among different samples, including adult child and spousal caregivers as well as caregivers of recipients suffering from dementia-related and physical conditions. In addition, women reported increased burden in studies that used both bivariate and multivariate analytic strategies.
Role conflict or strain.
Nine of the studies reviewed (Chang and White-Means 1991; Fredriksen 1996; Ingersoll-Dayton et al. 1996; Kramer and Kipnis 1995; Miller 1990; Miller and Montgomery 1990; Mui 1995; Neal et al. 1997; Young and Kahana 1989) discussed gender differences concerning the impact of caregiving duties on other role obligations, such as work and social life. Montgomery 1992 maintained that women, especially those that are employed, are more likely than men to experience role strain because they are more likely to fully assume the role as primary caregiver to an impaired relative. In contrast, men, especially sons, are more likely to become secondary caregivers, providing intermittent care on an as-needed basis (Montgomery 1992; Stoller 1990).
Consistent with the reasoning that women are more likely to experience role strain as a result of caregiving, Kramer and Kipnis 1995 noted that women were more likely than men to report being distracted at work and having to use sick leave to fulfill their caregiving obligations. Furthermore, Neal and colleagues 1997 showed that gender (women more than men) was a significant predictor of reduced work effectiveness and difficulty combining work and family. Similarly, Mui 1995 showed that women reported greater work role strain than men. Fredriksen 1996 reported that women were more likely than men to give up their jobs entirely for caregiving, although she reported no gender differences in interference of caregiving with work. In contrast to these studies, Horowitz 1985 found no gender differences in work role strain.
Four studies that used general measures of role strain reported gender differences. Fredriksen 1996, Ingersoll-Dayton and colleagues 1996, and Young and Kahana 1989 reported greater role strain for women than for men. Furthermore, Chang and White-Means 1991 demonstrated that a higher percentage of women than men reported serious time limitations as a result of caregiving.
In terms of interference of caregiving with social life, Miller and Montgomery 1990 reported that women were more likely to experience social limitations due to caregiving than men. In addition, Chang and White-Means 1991 and Horowitz 1985 found that a higher proportion of women reported interference of caregiving with family and leisure time than did men. In contrast to these investigators, Mui 1995 reported no gender differences in interference of caregiving with social life. To summarize, most studies that examined gender differences in role strain showed that women reported more interference of caregiving with work and social life. Women's higher levels of role strain and role conflict were observed in samples that included caregivers of physically ill individuals and of those with dementia-related conditions. In addition, women reported greater role strain than men in bivariate as well as multivariate studies. Most of these studies focused on adult child caregivers, probably because interference with work and family is more likely to occur for these caregivers. However, Miller and Montgomery 1990 and Young and Kahana 1989 reported that wives and daughters experienced increased role conflict when compared with husbands and sons.
Behavioral Responses to Caregiving Stress
Assuming and relinquishing the caregiving role.
Before there is even an opportunity to experience the demands and stresses of caregiving, there are important gender differences in terms of who assumes primary responsibility for caregiving. Because caregiving is more consistent with women's identities as carers and nurturers, women are more likely to feel responsible for assuming caregiving duties (Walker 1992). In addition, because caregiving is more consistent with women's socialization experiences, women expect and are expected to assume primary caregiving responsibilities (Montgomery 1992). Supporting this view, data from national surveys have shown that women are more likely to become caregivers than men. These national surveys estimate that approximately 70–75% of all caregivers are women (National Alliance for Caregiving and the American Association of Retired Persons 1997; Stephens and Christianson 1986; Stone, Cafferata, and Sangl 1987). Therefore, men are less likely to be exposed to the demands of caregiving. In addition, men may report fewer mental health symptoms than women caregivers because they are more likely to feel that they have chosen to assume the caregiving role.
With regard to the decision to relinquish caregiving duties, which can be viewed as a behavioral response to caregiving stress, Stoller 1990 maintained that men are more likely to drop out of the caregiving role as the recipient's need for assistance intensifies. Supporting this argument, she found evidence indicating a shift toward more women caregivers as the functional capacity of elderly recipients declined. In addition, Stoller reported that women's greater performance of personal care tasks and household-related tasks were especially pronounced when the elderly recipients required regular assistance. Furthermore, there is some evidence suggesting that men may be less tolerant of the memory and behavior problems that are characteristic of recipients suffering from dementia (Moritz, Kasl, and Ostfeld 1992; Moritz, Stanislav, & Berkman, 1989; Mui 1995). This lower degree of tolerance for problem behaviors may lead men to relinquish the caregiving role sooner than women. To summarize, men are less likely to assume caregiving responsibilities and thus are less likely to be exposed to the demands of caregiving. In addition, once men are in the caregiving role, there is evidence that they are more likely to relinquish caregiving responsibilities as the recipient becomes increasingly disabled.
Obtaining informal and formal support.
Women may be at greater risk for psychiatric symptomatology because they are less likely to obtain assistance with caregiving. Stoller and her associates (Stoller 1990, Stoller 1992; Stoller and Cutler 1992) argued that because men are less comfortable with the caregiving role, they are more inclined to seek and receive outside assistance for caregiving from formal and informal sources. Furthermore, they contended that because assuming the caregiving role is generally not expected of men, others are more likely to notice the care that men are providing and to assist them with caregiving to a greater degree than they would for women. Eleven investigators examined gender differences with respect to formal and/or informal support that caregivers received (see Table 1 ).
In terms of informal caregiving task support, several studies reported that men had more informal support than women from friends and family with caregiving tasks (Allen 1994; Ingersoll-Dayton et al. 1996; Pruchno and Resch 1989; Stoller and Cutler 1992). In contrast, two studies (Collins and Jones 1997; Horowitz 1985) reported no gender differences in informal supports. Although Horowitz did not find overall differences in family support between sons and daughters, she did report that sons had more support from their spouses than did daughters.
A few studies examined whether men and women caregivers differed with regard to the number of formal services or supports that they used. Barusch and Spaid 1989 and Horowitz 1985 found no gender differences in the overall number of formal services that caregivers used. Contrary to these investigators, Stoller and Cutler 1992 found that husband caregivers reported receiving more formal support than wife caregivers. With regard to specific services, Barusch and Spaid 1989 and Tennstedt and colleagues 1993 reported that men were more likely to get home-delivered meals than were women. In summary, results of studies that included samples of adult child caregivers as well as spousal caregivers showed that men received more assistance with caregiving than women. However, inconclusive evidence was found concerning gender differences in formal support for caregiving.
Health behaviors.
In a recent study that included a sample of caregivers and noncaregivers, Burton, Newsom, Schulz, Hirsch, and German 1997 reported that women were less likely to engage in several preventative health behaviors than men. These researchers found that women were more likely to report not having enough time for rest and exercise, not being able to rest when sick, not being able to find time for doctors' appointments, and forgetting to take medications. Because women engage in fewer preventative health behaviors, they may be at greater risk for physical as well as psychiatric morbidity.
Moderators
Variables such as personality characteristics, attitudes, and beliefs can act as moderators at any stage of the stress process (Cohen et al. 1995). Evidence is emerging that men and women differ on some important moderators than can influence their susceptibility to psychiatric morbidity. One such moderator is coping resources, which Pearlin and Schooler 1978 define as personality characteristics (e.g., self-mastery) that people can draw upon to help them deal with stress. Men and women may also differ in their preference for coping strategies. With regard to coping resources, Rose-Rego and colleagues 1998 found that women caregivers reported lower mastery levels than men. In addition, Parks and Pilisuk 1991 reported that low mastery was correlated with depression among women but not among men. Neuroticism is a negative personality trait that indicates an individual's susceptibility to psychological distress, the propensity to use ineffective coping strategies, and an inability to control impulses (Costa and McCrae 1985; Watson and Clark 1984). Lutzsky and Knight 1994 found that women's higher levels of depression and psychiatric symptomatology could be explained in part by their higher neuroticism scores and greater use of escape–avoidance coping. Barusch and Spaid 1989 reported that women used a greater diversity of coping strategies than men and that the strategies women used were more effective than those reported by men in coping with psychological problems. Compared with women, men reported that the strategies they used were more effective in coping with interpersonal problems, financial problems, and health-related problems. Hooker, Frazier, and Monahan 1994 found no gender differences among Alzheimer's caregivers in the use of problem-focused, emotion-focused, or social support coping.
Gender differences in coping preferences have not been consistently found in the coping literature (Miller and Kirsch 1987), and this may be due in part to differences in the types of life events examined. Wethington, McLeod, and Kessler 1987 found that women perceive life events involving members of their social network as more stressful than do men. In addition, these researchers argued that women are socialized to use less effective coping strategies than men when dealing with stress. Thoits 1991 suggested that women use more diverse coping strategies than men when coping with stressful events because the strategies that they initially use are not effective. Similarly, Pearlin and Schooler 1978 reported that women use less effective coping responses, such as selective ignoring, particularly when dealing with marital and family problems. Therefore, women may use less effective coping modes to manage the stresses of caregiving, which often involve family problems and negative life events that occur to a member of one's social network. Admittedly, these ideas are speculative and more research is needed to clarify the role that coping plays in women caregivers' higher levels of psychiatric morbidity. To summarize, a few studies suggest that women may be at greater risk for psychiatric morbidity than men because they appear to be at a disadvantage in terms of important moderators of the stress process, such as coping resources and responses.
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Summary and Directions for Future Research |
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Although there is evidence to support gender differences at each stage of the caregiving stress process that place women caregivers at a greater risk for psychiatric morbidity than men, little has been done to directly test the relative importance of these factors in explaining differences in psychiatric morbidity among men and women caregivers. Studies are needed that systematically control for known correlates of psychiatric morbidity (socioeconomic status, and the caregiver's health) and explore gender-specific models. More research is also needed that examines whether gender differences vary with respect to the type of relationship between the caregiver and care recipient, and the nature of the recipient's illness (e.g., physical disability or dementia).
The vast majority of studies included in this review focused on the negative effects of providing care. However, some theorists posit that there are also positive effects associated with caregiving (e.g., Kramer 1997; Martire and Schulz in press). For example, Beach and colleagues in press findings suggest that there may be gender differences in the positive effects of caregiving that favor women. Specifically, these researchers found that among women in high-quality relationships, helping a disabled spouse was related to reduced anxiety and depression. Thus, a fruitful area for future research concerns further establishing the nature of gender differences in the positive effects of caregiving.
Finally, our analysis focused on psychiatric outcomes because the empirical literature targets primarily these types of outcomes. However, a strong argument can be made that it is just as important to examine gender differences in physical health outcomes (Schulz et al. 1997). Future research should focus on differential behavioral health and biological consequences of caregiving among men and women.
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Implications for Interventions and Social Policy |
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TOPAbstractGender Differences in General...Factors in the Caregiving...Summary and Directions for...Implications for Interventions...References |
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). Support groups that enable caregivers to learn new ways of responding to the challenges of caregiving, and educational programs that emphasize the importance of taking preventative health measures, would help women engage in behaviors that reduce the risk of physical and psychiatric morbidity. In addition, women caregivers could benefit from skills training that teaches them to develop a greater sense of mastery so that they have greater coping resources to draw on during stressful caregiving situations.
Men can also benefit from intervention programs. Stoller 1990 maintained that men tend to relinquish the caregiving role sooner than women, especially if the caregiving role involves day-to-day housework or personal care activities. Therefore, caregiving men may benefit from skills training that teaches them how to perform caregiving tasks that they may have little experience with, such as cooking and cleaning. In addition, the above-mentioned intervention programs would benefit care recipients by improving the quality of care that they receive and by decreasing the likelihood of institutionalization.
However, practitioners need to proceed with caution when designing interventions and treatment programs for men and women caregivers. First, practitioners need to consider the individual needs and circumstances of caregivers, such as the caregiver's relationship to the recipient (Toseland and Rossiter 1989) and the caregiver's needs and desires for services (Hooyman and Gonyea 1995). In addition, Gwyther 1992 contended that it is important for clinicians to adapt delivery methods for treatment programs that are gender sensitive. She argued that the language used by service providers is especially crucial when designing gender-sensitive treatment programs for caregivers. Women are more likely to respond to labels such as "support groups," whereas men are more likely to respond when the program is labeled "informational seminar" or "forum." Furthermore, Gwyther pointed out that clinicians need to consider that men and women have different needs for services. She noted that men caring for an Alzheimer's patient are more inclined to ask about available task-oriented formal assistance, such as meal services and housekeeping, whereas women are more likely to ask for emotional support in dealing with behavioral, functional, or personality changes in the patient.
The results of this review also have broader policy implications. Several demographic trends point to an increased need for caregivers, coupled with a decreased availability of individuals to provide care. Thus, more women, as well as men, will be called on to provide care in the future. Zedlewski and McBride 1992 projected that the number of elderly people living in the community with disabilities in activities of daily living will more than double to 9.7 million by the year 2030. In addition, more older adults will be childless and parents with children will have fewer children available to provide care (Zedlewski and McBride 1992). The U.S. Bureau of the Census 1995 projected that the parent–support person ratio (the number of adults 85 and over per 100 persons age 50 to 64) is expected to almost triple from 10 to 29 between 1993 and 2050. In addition, because of the relatively high divorce rates among the baby-boomer generation, there may be fewer spouses available to provide care (Dwyer and Coward 1992). Finally, the increased participation of women in the labor force may further deplete the pool of available caregivers.
Unless broad gender- and family-responsive policies and programs are adopted to address the needs of both patients and caregivers, more women will be placed at risk for psychiatric morbidity and emotional, financial, and physical strain. A number of macro-policy recommendations have been proposed to address these future needs (Foster and Brizius 1993). First, we should continue to reduce the severity of conditions that require care (e.g., by developing programs to reduce workplace injuries and injuries in the home) and continue research aimed at preventing or curing Alzheimer's disease and other conditions that compromise the functional ability of older persons. Second, we should increase the options available to caregivers, such as encouraging employers to develop a more family-responsive workplace that allows families to meet caregiving needs more easily and effectively, or developing different means of financing caregiving to improve the range of choices available to caregivers and patients.
At an even broader level, researchers such as Foster and Brizius 1993 and Hooyman and Gonyea 1995 argued that inequities in the provision of care will continue unless we develop policies that redress gender inequities in our current economic and social systems. When a couple has to decide which one of them will quit a job or reduce hours to allow time for caregiving responsibilities, the woman's job is often the first to go because it is usually the lowest paid. To encourage a more equal sharing of caregiving responsibilities among men and women, these researchers advocate policies that ameliorate gender inequities in pay and career advancement. The rising population of elderly persons, combined with the decreased availability of women to provide care and increasing divorce rates, will necessitate that more men provide care in the future. Thus, these authors have also advocated policies that enable and encourage men to take on caregiving responsibilities, such as employer-subsidized elder care and more flexible work hours. Our analysis of the literature on gender differences in caregiving do not allow us to advocate any one of these many policy recommendations that could be implemented to redress gender inequities in psychiatric morbidity. However, the magnitude of the gender differences are large enough that multiple approaches will be required.
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Acknowledgments |
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Received for publication March 23, 1999. Accepted for publication September 27, 1999.
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References |
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TOPAbstractGender Differences in General...Factors in the Caregiving...Summary and Directions for...Implications for Interventions...References |
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