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Issues of Race, Ethnicity, and Culture in Caregiving Research

A 20-Year Review (1980–2000)

^a Department of Human Development and Family Studies, University of North Carolina at Greensboro

Correspondence: Peggye Dilworth-Anderson, PhD, Elizabeth Rosenthal Excellence Professor, Department of Human Development and Family Studies, University of North Carolina, P.O. Box 26170, Greensboro, NC 27402-6170. E-mail: p_dilwor{at}uncg.edu.

Decision Editor: Laurence G. Branch, PhD

	Abstract

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Purpose: The goals of this review are to synthesize what is known about caregiving among diverse groups and to identify gaps in knowledge to guide future research on caregiving. The review focuses on conceptual and theoretical approaches, sampling strategies, measurement techniques, and similarities and differences found among groups and across studies. Design and Methods: A narrative approach was used to review 59 articles published between 1980 and 2000, with particular attention to race, ethnicity, and/or culture. Primary sources of relevant articles included electronic databases, other review articles, and reference lists. Results: Caregiving experiences and outcomes varied across racial and ethnic groups. However, the use of nontheoretical approaches, nonprobability samples, and inconsistent measures among studies has limited understanding of caregiving among diverse populations. Implications: It is important that conceptualization and theorizing broaden with increasing numbers of studies that include diverse groups. Future caregiving research needs to give more attention to such issues as acculturation, assimilation, and cultural values, beliefs, and norms, while also improving theoretical and methodological rigor.

Key Words: Diverse groups • Caregiving • Literature review • Research issues

The U.S. population is rapidly aging as a result of various factors including improvements in nutrition, medical care, and technology (which increase longevity), as well as increases in wealth and education and the shift to a postindustrial society (which decrease fertility rate; Olshansky, Carnes, and Cassel 1993). According to census data (U.S. Bureau of the Census 2000), from 1930 to 1990 the U.S. elderly population increased from 5% to 13% of the total U.S. population. With continued population aging, those older than 65 are projected to increase to 20% of the total U.S. population by the year 2050 (U.S. Bureau of the Census 2000). The percentage of racial and ethnic minority elders will increase at a much higher rate than that of non-Hispanic White elders over the next 50 years. From 2000 to 2050, projections indicate that the White elderly population will double, and the African American elderly population will quadruple. During this same period, the Hispanic elderly population will increase to 7 times, the Asian/Pacific Islander elderly population will increase to 6.5 times, and the elderly American Indian population will increase to 3.5 times their current numbers (U.S. Bureau of the Census 2000).

With relatively greater numbers of elders in the population, a more in-depth understanding of how best to care for those who are dependent, especially in racially and ethnically diverse groups, is needed. In addition to the projected increase of minority elders in the future, findings have shown that the prevalence of severe functional limitations among minority elderly people is higher than found among their White counterparts (U.S. Department of Health and Human Services 1991). The rate of institutionalization for minority elders is lower than for older Whites. And finally, some research has suggested that minorities underuse formal services to assist with caregiving, especially among African Americans and Native Americans (Caserta, Lund, Wright, and Redburn 1987; Logan and Spitze 1994), as compared with their White counterparts.

Given the aforementioned information, it is important to review what is known about different racial and ethnic groups and how this knowledge can inform and direct future caregiving research in diverse populations. Therefore, the major goals of this review article were to synthesize what is known about caregiving among diverse groups and identify gaps in knowledge. We identified these gaps by taking stock of a body of knowledge through an in-depth analysis of the literature and through an epistemological journey that illustrates what is known and how what is known about caregiving was acquired. For this purpose, we identify major content areas addressed by the reviewed articles. We also identify conceptual and theoretical approaches, describe sampling strategies, discuss measurement techniques, and report major findings on the similarities and differences among groups and across studies. Finally, based on findings from this review, we provide suggestions for conducting future caregiving research.

	Methods

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Approach and Search Strategy
The approach used in this review is similar to that used by other researchers (Aranda and Knight 1997; Yee and Schulz 2000) who reviewed the caregiving literature using a narrative as opposed to a meta-analytic approach. A narrative approach was used because, as Yee and Schulz 2000 stated, it allows for use of a range of articles that have used different methodologies to study the same problem. Use of different methodologies across studies hinders employing meta-analysis. Two earlier review articles (Connell and Gibson 1997; Schulz, O'Brien, Bookwala, and Fleissner 1995) were helpful in directing how best to present such a vast amount of information. Furthermore, most of the articles included in the review by Connell and Gibson were also included in this review, because it too was a review of caregiving research of various ethnic groups. This review, however, moves beyond Connell and Gibson's by including studies of caregivers of elders who were dependent for a variety of reasons (not limited to dementia), by including articles that examined single racial or ethnic minority groups without a comparison group, and by covering a greater time span.

All articles included in this review were published in English within the past 20 years (1980–2000) in refereed professional journals. Articles were included on the basis of their focus on informal caregiving of dependent elderly people with particular attention to race, ethnicity, or culture. Comparisons among racial and ethnic groups and descriptive reports of single minority groups were examined. The majority of the studies included in this review had an aspect of race, ethnicity, or culture in the title or the abstract, which was a key to their inclusion in the review. Studies were included only if race, ethnicity, or culture were used in the conceptualization of the investigation on caregiving. Caregiving research that used race only as a control variable was excluded (e.g., Bass, Noelker, and Rechlin 1996; Cicirelli, Coward, and Dwyer 1992). Articles that dealt only with the caregiving of institutionalized elderly people were also excluded (e.g., Wallace, Levy-Storms, Kingston, and Andersen 1998). In addition, articles were excluded if only the care recipients reported their views about receiving care (e.g., Bass and Noelker 1987; Burton et al. 1995; R. C. Gibson 1982; Miner 1995; Norgard and Rogers 1997). The care recipient's viewpoint is important to understanding the totality of the caregiving process, but is beyond the scope of this review.

To find articles meeting the above criteria, we searched the following databases: Family Studies Database, Medline, HealthStar, PsycINFO, Infotrac, and ERIC. Search terms included African American, Black, White, Latino, Latina, Mexican, Hispanic, Puerto Rican, Cuban, Japanese, Chinese, Korean, Native American, Indian, American Indian, Asian, elderly, aged, caregiving, minority, race, ethnicity, culture, ethnic minorities, cultural differences, and racial differences. To supplement the search, we used reference lists from articles already chosen for inclusion in this review. The search process yielded a total of 59 articles that are included in this review. Because of the inclusion/exclusion criteria and the specific search strategy used, some relevant articles may have been omitted.

Strategies for Organizing Information
Several steps were used in organizing this review. The first step involved summarizing the studies by constructing a table containing the theory, sampling strategies, measures, and salient findings for each study selected for inclusion. The second step was to determine which topical domains of focus were most common in the study of race, ethnicity, and culture among caregivers. Topical domains were defined as common areas of research that comprise a broad framework for organizing this research. For example, a domain on negative effects could include depression, burden, and distress. At least 10 articles focusing on a common area of research composed a domain. Each of us examined the articles and made an independent determination of the domain in which each article should be placed. Then comparisons were made and consensus was reached regarding any differences. Using these guidelines, we identified four domains of research: (a) social support of the caregiver and care recipient (formal and informal); (b) the negative effects of caregiving on the primary caregiver; (c) coping with the stress of caregiving, both on the individual and the kin network level, and (d) cultural effects on caregiving (e.g., meaning, filial responsibility, and/or cultural–historical perspective). Many of the studies included in this review fit under more than one of these domains, which illustrates that different topics of caregiving research are interrelated and are studied simultaneously by researchers, as indicated in Table 1 . For example, an article looking at depression among caregivers as an outcome may also examine the effects of informal support. Thus, this article would be included in both negative effects and social support domains. Allowing such overlap helps maximize our ability to discuss multiple domains despite the limited overall number of studies that address issues of race, ethnicity, and culture in the caregiving literature. Therefore, of the 59 articles that were reviewed, 32 were included in social support, 29 in negative effects, 13 in coping, and 20 in cultural effects.

	Domains of Research

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Sampling
Comparisons of ethnic groups were made in the majority of studies (23 of the 32), and the remaining studies used a single minority group. Among the comparative studies, 14 compared a White sample with an African American, Cuban American, Hispanic, or Mexican American sample. Two studies compared an African American sample with a Hispanic sample (Cox and Monk 1990, Cox and Monk 1996); one compared White, African American, and Hispanic caregivers (Kosloski et al. 1999); one compared three groups of Asian Americans (Chinese, Japanese, and Korean; Ishii-Kuntz 1997); one compared African American, Chinese American, Irish American, and Latino caregivers (Levkoff et al. 1999); and one compared Korean, Korean American, and White American caregivers (Youn et al. 1999). Two studies compared German, Irish, English, and African American caregivers (Thornton et al. 1993; White-Means and Thornton 1990). Another study compared African American, Chinese American, Latino, and European American caregivers (Ho et al. 2000). The studies examining only one group included samples of African American caregivers (Dilworth-Anderson, Williams, and Cooper 1999a, Dilworth-Anderson, Williams, and Cooper 1999b; Sterritt and Pokorny 1998; White-Means and Thornton 1996), Hispanic caregivers (Cox and Monk 1993), Puerto Rican caregivers (Delgado and Tennstedt 1997a, Delgado and Tennstedt 1997b), Cuban American caregivers (Harwood et al. 2000), and American Indian caregivers (Hennessy and John 1996).

The majority of the study samples (27 out of 32) examining social support used a convenience and purposive sampling design. Participants were recruited from senior centers, case management agencies, local health care providers, health clinics, support groups, and churches. Three studies used regional probability samples (Dilworth-Anderson et al. 1999a, Dilworth-Anderson et al. 1999b; Wallsten 2000), and two studies used a national probability sample (Thornton et al. 1993; White-Means and Thornton 1990). The size of samples varied, from studies containing only 9 caregivers (Sterritt and Pokorny 1998) to studies containing as many as 1,486 caregivers (Kosloski et al. 1999). There were 11 studies with fairly large samples (greater than 100) that researchers may find more useful for population comparisons between groups (Cox 1999; Delgado and Tennstedt 1997a, Delgado and Tennstedt 1997b; Dilworth-Anderson et al. 1999a, Dilworth-Anderson et al. 1999b; Kosloski et al. 1999; Lawton et al. 1992; Phillips, de Ardon, Komnenich, Killeen, and Rusinak 2000; Stommel, Given, and Given 1998; Thornton et al. 1993; White-Means and Thornton 1996). When samples are small and nonrandomly drawn, it is difficult to make inferences about the characteristics of the population. Thus, issues of external validity are of great concern for future researchers using small, purposive samples of diverse groups. However, small samples may be the result of selecting ethnic groups that are challenging to obtain. Therefore, it is important to give some credibility to findings that provide researchers with preliminary results that could be used in future comparisons between ethnic groups that may be hard to recruit.

Measures
Different types of measurement scales were used to assess social support. The majority of researchers (25 out of 32) developed their own scales, using multiple items to assess social support through Likert-scale responses. Many of these studies failed to capture the multidimensional nature of social support. In particular, asking caregivers to list the number of informal helpers or to give the frequency of using informal supports or formal support services (e.g., Cox 1993; Ho et al. 2000) does not capture the complexity of a caregiver's support system. Some researchers chose to measure social support through established instruments and measures. Of the 32 articles in this domain, 7 used established instruments such as the Social Support Questionnaire (Dilworth-Anderson et al. 1999a; Haley et al. 1995, Haley et al. 1996), Awareness and Utilization of Community-Based Services (Mintzer et al. 1992), the Perceived Emotional Support Scale (Pearlin, Mullan, Semple, and Skaff 1990), the Arizona Social Support Interview schedule (Phillips et al. 2000), and the shortened version of the Social Network Interview (Wallsten 2000). Using an established measure, such as the Social Support Questionnaire, allows researchers not only to determine the number of potential helpers but also to determine caregivers' satisfaction with the level of social support received.

Findings
The articles reviewed on social support focused on two primary areas: informal and formal support. Fifteen out of 32 articles examined informal support, 5 articles examined formal support, and 12 examined both informal and formal support among caregivers. The majority of findings suggested that minority caregivers have a more diverse group of extended helpers than do non-Hispanic Whites. Despite the widely held view that minority caregivers receive more social support from their families and friends than do non-Hispanic White caregivers, the articles reviewed in this domain did not support this view. Although minority caregivers used formal services at various levels, they expressed a greater need for formal support services than non-Hispanic White caregivers.

Informal Support
Four studies reported that informal social support was more diverse for African American caregivers than for White caregivers (Cox 1993; Lawton et al. 1992; Smerglia, Deimling, and Barresi 1988; Wood and Parham 1990). For example, Smerglia and associates reported that African American caregivers were more likely than White caregivers to report a friend or a neighbor as a very important helper. Lawton and colleagues 1992 found that White caregivers were likely to be caring for a spouse, whereas African American caregivers were often caring for a sibling, other relative, or friend. Thornton et al. 1993 conducted a study with White ethnic (German, Irish, and English American) and African American caregivers. They found that White ethnic caregivers were more likely to use only immediate family members in their networks than African American caregivers. Levkoff and colleagues 1999 also included Irish Americans in a qualitative study and found that although these caregivers sought social support from religious organizations, many reported being dissatisfied with the support they received. Wood and Parham 1990, who examined only female caregivers, found that African Americans, unlike Whites, were likely to include God as part of their informal support system. Similarly, in a qualitative study examining only African American caregivers (Sterritt and Pokorny 1998), participants ranked God or religion as their first source of informal support followed by family, friends, and neighbors. The formal healthcare system was used last by caregivers.

Aside from the diverse caregiver–care recipient relationships (e.g., adult–child, friend) found among minority caregivers as compared with White caregivers, Hinrichsen and Ramirez 1992 found that White caregivers received more support services from their family members than African American caregivers. Wallsten 2000 and Haley and colleagues 1995, however, found that African American and White caregivers had similar numbers of informal caregivers in their social support networks. The results from these studies also showed that African American caregivers had more persons in their networks than their noncaregiving counterparts. Haley and colleagues reported that both African American and White caregivers expressed lower levels of satisfaction with the quality of their social support, decreased visitation with others, and lower levels of social activity than their noncaregiving counterparts. Through the use of noncaregiving controls, the findings reported by both Wallsten and Haley and colleagues provide needed evidence on how the caregiving experience varies between racial groups and how these groups vary from their noncaregiving counterparts.

In regards to specific caregiving tasks, Stommel and colleagues 1998 reported that African American caregivers shared caring responsibilities with other helpers more often than White caregivers. However, when they controlled for other potential confounds (e.g., caregiver age, number of functional impairments of the care recipient) they found that African American and White caregivers shared caring responsibilities with others at similar levels, but African American caregivers were more likely than White caregivers to be the sole provider of care. This finding illustrates the importance of controlling for factors that could potentially affect the pattern of social support. The researcher is then able to explain the observed differences attributed to the caregiver's situation. Future research also needs to test for potential interaction effects of race, socioeconomic status, and health.

Findings on social support networks among other ethnic and racial groups are similar to those found for African Americans. Like African Americans, Asian Americans' informal networks consist of both family and friends (Ishii-Kuntz 1997) but are not necessarily larger than the caregiver networks of other racial and ethnic groups. For example, Youn and colleagues 1999 study of Korean, Korean American, and White American caregivers shows that Korean American caregivers, primarily daughter caregivers, reported having more social support than Korean caregivers but less social support than White caregivers. Phillips and colleagues 2000 found that Mexican American caregivers had smaller social networks than non-Hispanic White caregivers. Harwood and colleagues 2000 examined Cuban American caregivers and found that the caregivers' perceived amount of emotional support (from family and friends) and age were predictive of their level of satisfaction with their social support network. This finding supports the idea that if the caregiver perceives social support is available, positive outcomes are experienced. Comparing African American and White caregivers, Cox 1999 found that White caregivers tended to be more dissatisfied with their overall support than African American caregivers, although both groups reported similar amounts of informal support.

The role gender plays in examining social support to dependent elders is another area that is explored in this domain. In particular, informal caregiving has focused primarly on women as the primary and sometimes the only caregiver. Delgado and Tennstedt 1997b, however, examined both sons and daughters in their research on Puerto Rican caregivers. Their qualitative findings illustrate that sons often provided financial management and transportation, whereas daughter caregivers provided more personal care (e.g., bathing, dressing). In addition, Delgado and Tennstedt discovered that Puerto Rican sons provided similar amounts of informal care as the daughters, although daughters were more likely to have someone to turn to for assistance or emotional support than sons. Generalizability of these findings is limited due to specific characteristics of the sample (e.g., coresidence of caregiver and care recipient, caregiver unemployment and marital status). Haley and colleagues 1995 examined African American and White caregivers and their noncaregiver counterparts and also found that male caregivers were likely to have fewer social supports in the household than female caregivers. Among noncaregivers, however, women were found to have fewer social supports within the household than men. In general, Haley and colleagues reported that women received more visits from relatives and friends than did men. Future studies examining the effect of gender on caregiving experiences are needed to further validate these findings and better understand the cultural importance of gender in providing social support to elders and their caregivers in racial and ethnic groups.

Caregivers increased their level of informal social support on the basis of the level of elder dependency. For instance, Delgado and Tennstedt 1997a found that, among Puerto Rican caregivers, as the number of elders' disabilities increased, the number of hours of informal care increased for caregivers. Ishii-Kuntz 1997 also found that Chinese, Japanese, and Korean American parent–adult child pairs provided more care when the elder needed assistance. These studies illustrate the importance of acknowledging how care recipients' health affects caregiving support networks, which in turn affect how caregivers and care recipients use their informal helpers. Further, recent research has shown that the amount of informal social support is related to the use of formal services (Auslander and Litwin 1990; Bass and Noelker 1987; Williams and Dilworth-Anderson 2002). As a result, to understand the unique social support circumstances of different racial and ethnic caregivers, researchers need to more critically examine the characteristics of both elders and their primary caregivers, the multiple helpers in support networks, and the use of formal services by care recipients and caregivers.

Formal Service Use
Findings have shown that African American and Hispanic caregivers are similar in how often they used informal and formal support to assist with caregiving to elders with dementia (Cox and Monk 1996). Both of these groups used more informal as opposed to formal support services (Cox and Monk 1990). Three other studies reported that minority caregivers expressed a greater need for formal social support services than non-Hispanic White caregivers (Cox 1993, Cox 1999; Hinrichsen and Ramirez 1992). Between Chinese American and Puerto Rican caregivers, Levkoff and colleagues 1999 found that language and cultural barriers led caregivers to use ethnic-oriented organizations for support. In addition, Miller and Guo 2000 found that White caregivers were more likely to use formal support resources than African American caregivers. However, in a qualitative study, Levkoff et al. 1999 discovered that African American caregivers used mainstream formal services but expressed dissatisfaction with the support due to cultural misunderstandings. Such dissatisfaction points to the need to develop more appropriate, culturally relevant formal support services for use by different ethnic groups.

Delgado and Tennstedt 1997a examined Puerto Rican caregivers and found that only 16% of their sample used formal care services. The two most frequently used services were home health aide and homemaker services. Deimling and Smerglia 1992 descriptively illustrated that when caregivers and elders were in the process of making care-related decisions, both African American and White caregivers rarely used formal service providers. Ho and colleagues 2000 examined Latino, African American, Chinese American, and European American caregivers and found that Latino caregivers had more medical service needs than European American caregivers. However, these researchers did not find any significant differences in overall formal service needs across the four groups. Hinrichsen and Ramirez 1992 also found no differences in service needs between African American and White caregivers. However, in regard to unmet needs, Ho and colleagues 2000 found differences across ethnic groups. African Americans had fewer unmet medical needs, whereas Chinese American and European American caregivers had more unmet mental health needs. Finally, Latino caregivers had more unmet social service needs. The findings reported by Ho and colleagues are limited, however, because of the small sample used in the study (see Table 1 ). Additional studies comparing Latino, African American, Chinese American, and European American caregivers and their formal service use are needed to validate the findings.

Receiving formal social support was considered beneficial to caregivers as their caregiving role became more challenging. White-Means and Thornton 1996 found that African American caregivers' depression levels were significantly lower if they received formal support. It was noted that not all caregivers came into the study with the same resources. In particular, some caregivers were already receiving some formal support, possibly due to the care recipients' level of dependency, and other caregivers were not. Therefore, depression levels reported may not be totally due to the caregiving experience. As a result, comparing depression levels of caregivers who already receive formal support to those of caregivers who do not could be misleading. Dilworth-Anderson et al. 1999a found that African American caregivers who were not distressed had higher levels of satisfaction with their social support system. Further, Dilworth-Anderson et al. 1999b reported that care recipients' use of formal support services predicted their informal caregiving structure. In particular, as the number of formal services used by the care recipient increased, care was more likely to be provided in the largest caregiving structure that included three types of caregivers (i.e., primary, secondary, and tertiary) than in smaller structures that included one or two types of caregivers. Most caregivers in this study were providing care in a collectivist rather than an individualistic caregiving structure (collectivist involves two or more caregivers, whereas individualistic involves only one caregiver). Qualitative findings have shown that American Indian informal caregivers also shared a collectivist value orientation to giving care to their dependent elders (Hennessy and John 1996).

Minority caregivers reported a desire or need for varying types of formal support services despite similar usage and lower burden scores as compared with White caregivers. For example, Mintzer and colleagues 1992 found that Cuban American adult daughter caregivers reported a need for more support services that included caregiving training, family support groups, case management, and respite care. They also reported that awareness and use of formal services did not differ between Cuban American and White non-Hispanic adult daughter caregivers. Cox 1999 examined White and African American caregivers over time and found that a high percentage of both groups reported planning to use information and referral services and/or support groups, but a year later most had not followed through on using these services. Cox found that caregivers who used information and referral services did not report a change in level of burden, whereas caregivers who did not use the service reported an increase in burden. Care recipients' higher levels of cognitive impairment and lower levels of functional impairment were associated with greater likelihood of caregivers using information and referral services. In addition, higher levels of care recipient cognitive impairment and lower levels of caregiver burden were associated with increased likelihood of attending a support group. Hinrichsen and Ramirez 1992 found that despite reporting lower levels of burden, African American caregivers expressed a greater need for formal support services than White caregivers. Finally, Cox and Monk 1993 found that there was a strong negative relationship between the use of professional help and depression among Hispanic caregivers.

In summary, 18 of the articles reviewed in this domain were primarily atheoretical, using empirical generalizations, whereas the other 14 articles had a theoretical focus. Researchers using theoretical models most often used stress and coping–stress process models. More culturally relevant and theory-driven research would provide a useful guide on how to examine the findings across studies, especially when comparing different ethnic groups. There were several racial group comparisons conducted. However, 11 studies used the common comparison of African American and White caregivers. Because of the small number of studies that compared other ethnic groups, generalizations about these groups are limited. Comparisons between African American and White caregivers should not be considered the standard; thus, more research should identify and study other racial and ethnic groups to expand the findings reviewed in this domain in addition to making within-group comparisons. Overall, studies in this domain illustrate that ethnic minority caregivers have more diverse informal networks than their White counterparts and, in general, minority caregivers use informal services similarly and formal services less than nonminority caregivers.

Domain 2: Negative Effects
Theory
This domain includes articles that address depression, burden, role strain, psychological distress, and relationship strain. More than half of the articles (15 out of 29) identified in this domain were atheoretical, relying heavily on empirical generalizations (see Table 1 ). Of the remaining 14, 12 articles used conceptual models and 2 used conceptual frameworks. The conceptual models used were stress and coping–stress process models (Cox and Monk 1996; Farran, Miller, Kaufman, and Davis 1997; Fredman, Daly, and Lazur 1995; Haley et al. 1996; Ho et al. 2000; Knight, Silverstein, McCallum, and Fox 2000; Miller, Campbell, Farran, Kaufman, and Davis 1995; Wood and Parham 1990; Youn et al. 1999), Andersen and Newman 1973 behavioral model of health services use (Cox 1999), a "structural model of caregiving dynamics" (Lawton et al. 1992, p. 161), and a "conceptual model of race, caregiving context, and outcomes" (Young and Kahana 1995, p. 226). Mui 1992 used a conceptual framework taken from role theory, and Dilworth-Anderson et al. 1999a used a conceptual framework combining a contextual approach and stress process theory (see Table 1 ). In this domain, the use of theory has been important in guiding hypothesis testing and the methods through which they have been tested. Two of these theoretical approaches (Dilworth-Anderson et al. 1999a; Young and Kahana 1995) provided some specificity with regard to race and culture, whereas the remaining approaches in this domain did not explicitly conceptualize race, ethnicity, or culture. However, stress and coping–stress process models can be made culturally relevant (see discussion of this in the Future Direction section). The studies based on empirical generalizations lacked theoretical guidance and were mostly exploratory in nature. The value of these studies must be recognized, but the findings should be viewed with some caution without more theoretically based hypothesis testing.

Sampling
Various groups were studied in the articles investigating negative effects of caregiving. Eighteen of the articles compared African American and White caregivers (see Table 1 ). Five articles compared Hispanic caregivers to one other group of caregivers; 2 of these compared Hispanic and African American caregivers (Cox and Monk 1990, Cox and Monk 1996), and 3 compared Hispanic caregivers and non-Hispanic White caregivers (Harwood et al. 1998; Mintzer et al. 1992; Phillips et al. 2000). One article compared three groups of caregivers—Korean American, Korean, and European American (Youn et al. 1999), and 1 article examined four groups—Latino, European American, African American, and Chinese American caregivers (Ho et al. 2000). The remaining 6 articles examined only one ethnic group. Three articles examined only African American caregivers (Dilworth-Anderson et al. 1999a; Fox, Hinton, and Levkoff 1999; White-Means and Thornton 1996); 2 examined only Hispanic caregivers (Cox and Monk 1993; Harwood et al. 2000), and 1 examined American Indian caregivers (Hennessy and John 1996).

Only a few (3 out of 29) articles on negative effects used random samples. Two used national probability samples (Fredman et al. 1995; Mui 1992), whereas Dilworth-Anderson and colleagues 1999a used the Established Populations for the Epidemiological Study of the Elderly in North Carolina to recruit caregivers. The remaining 26 articles used purposive and convenience samples. These samples, much like those examining social support, were recruited largely from community organizations, social service agencies, medical facilities, and advertisements in newspapers and on radio stations. The use of purposive and convenience samples limits generalizability, accuracy of statistical findings, and comparability across studies. It is very difficult to determine the populations represented by these samples.

Measures
The majority of the studies in the negative effects domain used established measures and scales to assess the level of negative outcomes experienced by caregivers, but the same measures were not used across studies. The most commonly used measure of depression was the Center for Epidemiological Studies–Depression scale (CES–D; Radloff 1977), which was used in 15 studies (Cox 1999; Cox and Monk 1990, Cox and Monk 1993; Farran et al. 1997; Haley et al. 1995, Haley et al. 1996; Harwood et al. 1998; Ho et al. 2000; Knight and McCallum 1998; Knight et al. 2000; Lawton et al. 1992; Miller et al. 1995; Mintzer et al. 1992; White, Townsend, and Stephens 2000; Youn et al. 1999). Several scales were used to measure burden among caregivers. These included several versions of Zarit and colleagues 1980, Zarit and colleagues 1986(1988) Burden Interview (Cox 1999; Cox and Monk 1990, Cox and Monk 1993, Cox and Monk 1996; Hinrichsen and Ramirez 1992; Knight et al. 2000; Youn et al. 1999; Young and Kahana 1995), the Family Burden Instrument (Morycz, Malloy, Bozich, and Martz 1987), the Caregiver Burden Scale (Harwood et al. 2000), and the Relatives' Stress Scale (Wood and Parham 1990). Other researchers developed instruments for burden using various combinations of items. The Global Severity Index of the Brief Symptom Inventory (Derogatis and Spencer 1982) was used in three studies (Dilworth-Anderson et al. 1999a; Haley et al. 1995; Knight et al. 2000) to address general psychological distress, and various measures were used to assess strain (i.e., Relationship Strain [Cox 1993]; Personal Strain and Role Strain Personal Strain and Role Strain [Cox and Monk 1996; Caregiver Global Role Strain Caregiver Global Role Strain [Miller et al. 1995; Global Role Strain Global Role Strain [Mui 1992). The use of established measures provides more confidence in the validity and reliability of findings. Furthermore, studies that use the same measures can be more easily compared with one another, allowing for more in-depth examination of sample-specific findings across studies.

Findings
Depression and burden were the two main areas of focus in studying the negative effects of caregiving. Eight articles measured caregiver depression, 10 articles measured caregiver burden, and 7 additional articles measured both depression and burden. Other areas of negative effects that were examined included four studies examining role strain (Cox and Monk 1996; Farran et al. 1997; Miller et al. 1995; Mui 1992) and three examining more generalized psychological or emotional distress (Dilworth-Anderson et al. 1999a; Farran et al. 1997; Wykle and Segall 1991). One study focused on relationship strain (Cox 1993), and one examined satisfaction as well as burden (Phillips et al. 2000). Overall, some findings have shown that depression and burden were higher among White caregivers than among African American caregivers, whereas others found no difference. Depression was similar between White caregivers and Hispanic caregivers, and burden was similar between Hispanic caregivers and African American caregivers.

Depression
A total of 14 studies examined depression among caregivers. Most of the studies comparing two or more groups began with some simple bivariate results examining mean differences in depression scores. Most of these comparisons did not involve controlling for other factors (e.g., socioeconomic status or sex). However, some studies went on to control for other factors when conducting regression analysis or path analysis. Six studies compared White and African American caregivers and reported no difference in depression between the two groups (Cox 1993, Cox 1999; Knight and McCallum 1998; Knight et al. 2000; White et al. 2000; Young and Kahana 1995). The other 4 studies comparing these two groups found that White caregivers were significantly more depressed than African American caregivers (Farran et al. 1997; Haley et al. 1995, Haley et al. 1996; Lawton et al. 1992; Miller et al. 1995) and comparison groups of White and African American noncaregivers (Haley et al. 1995).

Several potential reasons can be noted for the inconsistency in mean differences in depression between African American and White caregivers. First, sample sizes varied across these studies. With the exception of two studies by Cox 1993, Cox 1999, the studies that found no difference in depression had smaller numbers of African American caregivers (56 or fewer) compared with the studies that found a difference (70 or more). Sample size is important because of its relationship to effect size and power in statistical analyses. Second, two of the studies that found no difference between African American and White caregivers (Cox 1993; Young and Kahana 1995) used scales other than the CES–D. Cox 1993 used "three items assessing the extent of nervousness, irritability, and feelings of sadness" (p. 35) to measure depression. Young and Kahana 1995 used the depression subscale of the Symptom Checklist (Derogatis, Lipman, and Covi 1973). Third, the samples used in these studies differed not only in geographical location in the United States, but also in recruitment methods. The two studies by Knight and colleagues (Knight and McCallum 1998; Knight et al. 2000) used samples that were recruited exclusively from formal service providers, which included an older adult counseling center. The samples used in the two Cox 1993, Cox 1999 studies were recruited exclusively from among those who had contacted a branch of the Alzheimer's Association. The caregivers in these samples may represent a more clinical population than those in the studies that found a difference in depression between African American and White caregivers, whose referral sources included community organizations and self-referral through responses to advertisements. Finally, the study by Young and Kahana 1995 examined primary caregivers of patients recently discharged from a hospitalization following myocardial infarction, whereas the other nine studies examined caregivers of elders with dementia.

The remaining studies examining depression among caregivers could not be compared to the same extent as those comparing White and African American caregivers because there were not multiple studies examining the same groups. Cox and Monk 1990 found that Hispanic caregivers had higher levels of depression than African American caregivers. Mintzer et al. 1992 found no difference in depression levels between Cuban American Hispanic and non-Hispanic White caregivers using a very small sample, whereas Harwood et al. 1998, using a much larger sample, found that a significantly higher proportion of White Hispanic (mostly Cuban American) caregivers was clinically depressed when compared with White non-Hispanic caregivers. White-Means and Thornton 1996, examining only African American caregivers, found that depression levels were significantly lower for caregivers receiving formal support than for those not receiving formal support (mean level of depression was not reported). Youn et al. 1999 reported that there was no significant difference in depression scores between Korean American and White American caregivers.

Findings from multivariate analyses conducted in several studies examining depression are particularly important to note because of their conceptual and methodological sophistication. Knight and McCallum 1998 performed a unique study that included an "objective" assessment of caregiver psychophysiological stress. Despite finding no mean difference in depression between African American and White caregivers, Knight and McCallum did find other differences. They found that African American caregivers who reported high levels of depression and high positive reappraisal had the least change in heart rate when telling a story about their most stressful time caregiving. For White caregivers, the opposite was found. That is, White caregivers who reported high levels of depression and high positive reappraisal had the greatest changes in heart rate while telling of their most stressful time. Thus, the relationships among depression, positive reappraisal, and heart rate reactivity were found to operate differently for African American and White caregivers. Knight and McCallum pointed to cultural differences that may relate to positive reappraisal increasing stress among Whites while decreasing stress among African Americans. Haley et al. 1996 found that the relationship between race and depression was mediated by caregivers' appraisals of stress and coping. Furthermore, they found that stressfulness appraisals were affected by race directly and indirectly, through self-efficacy appraisals. Finally, Lawton and colleagues 1992 reported that for African American caregivers, greater burden was directly associated with greater depression. They also reported that burden mediated the relationships between depression and caregiver physical health, amount of time spent caregiving, and caregiving satisfaction for African American caregivers. All of these relationships were found for White caregivers. In addition, there was a direct relationship between caregiver physical health and depression, and burden mediated the relationship between impaired persons' symptoms and depression among White caregivers. Lawton and colleagues used path analysis to examine their proposed conceptual model separately for each group and found no significant difference in model fit between the two groups, despite differences in the significance of some paths between groups. Testing models separately for each group is recommended when using different racial or ethnic groups in a study.

Burden
Among the 18 studies examining burden, 9 compared African American caregivers and White caregivers. Five studies found that White caregivers reported significantly higher burden than African American caregivers (Fredman et al. 1995; Hinrichsen and Ramirez 1992; Knight et al. 2000; Lawton et al. 1992; Macera et al. 1992). The remaining 4 studies found no difference in burden scores between African American and White caregivers (Cox 1999; Morycz et al. 1987; Wood and Parham 1990; Young and Kahana 1995). However, when Morycz and colleagues looked exclusively at caregivers of relatives with dementia in their sample, they found that White caregivers reported significantly higher levels of burden than African American caregivers. Thus, these researchers concluded that dementia caregiving could create differential risk for burden between African American and White caregivers.

Fox and colleagues 1999 directly challenged these findings regarding African Americans' experiencing lower levels of burden when compared with White caregivers. These researchers conducted a qualitative study in which African American caregivers provided in-depth discussions of their caregiving experiences. The challenge issued by Fox and colleagues was directed toward the limited ability of existing studies to address the complexities of cultural analyses of caregiving burden. They stressed the importance of integrating personal and family histories and larger sociopolitical factors into such analyses. Contrary to many reports of low levels of stress and burden among African American caregivers, Fox and colleagues found that "these caregiver accounts speak of deep frustration and trauma. They are stories full of burden and loss, emptiness and alienation. These aspects of African American caregivers' experience have not been adequately captured in comparative social gerontology on caregiver burden" (p. 520).

The other seven articles examining burden (Cox and Monk 1990, Cox and Monk 1993; Harwood et al. 2000; Hennessy and John 1996; Phillips et al. 2000; White-Means and Thornton 1996; Youn et al. 1999) did not compare White and African American caregivers but studied single racial or ethnic minority groups or compared other groups. Cox and Monk 1993 investigated burden among Hispanic caregivers and reported moderate burden scores. Among these caregivers, as burden scores increased the likelihood of seeking professional help with caregiving also increased. Harwood et al. 2000 studied a sample of Cuban American caregivers and found that increased perceived emotional support was a significant predictor of increased caregiver satisfaction and decreased caregiver burden when other factors were controlled. Phillips et al. 2000 did not report mean differences in global burden scores between White American and Mexican American caregivers. Instead, they reported mean differences in burden subscale scores; Mexican American caregivers were found to have lower mean scores on the Social Restriction and the Relationship Change subscales than White American caregivers. Hennessy and John 1996, in a study of American Indian caregivers, found that feelings of burden were associated with anxiety about medical conditions, problems with difficult psychosocial aspects of care, strains on family relations, and negative effects on personal health and well-being. White-Means and Thornton 1996 examined burden among African American caregivers and found that the mean burden score for the sample indicated relatively low burden, but as caregivers' level of perceived physical or emotional burden increased, their sense of general well-being decreased. White-Means and Thornton also found that greater burden lowered life satisfaction and increased physical depreciation. Comparing a sample of African American and Hispanic caregivers, Cox and Monk 1990 found no significant difference in burden scores. Finally, Youn et al. 1999 found that Korean and Korean American caregivers did not differ from one another in burden scores, but both groups had significantly higher burden scores than White American caregivers.

Role Strain
Four studies in the negative effects domain examined role strain (Cox and Monk 1996; Farran et al. 1997; Miller et al. 1995; Mui 1992). Cox and Monk 1996 found that Hispanic caregivers reported significantly higher role strain and personal strain than African American caregivers. Older age and higher frequency of phone contact with those in the support network were related to lower role strain for Hispanic and African American caregivers. In addition, lower care recipient activities of daily living (ADL) deficits, higher frequency of face-to-face and phone contact with those in the support network, and lower caregiver income were related to lower personal strain for both groups. Farran et al. 1997 examined role strain among African American and White caregivers and found that the best predictors of caregiver role strain were being White, having greater behavioral problem distress, greater task distress, and higher levels of spouse physical activities of daily living (PADL). These predictors were the same for depression, with the addition of having poorer physical health. Farran and colleagues 1997 reported significantly lower levels of both provisional and ultimate meaning for White caregivers as compared with African American caregivers. They also found that higher levels of provisional meaning had an independent effect on lower levels of depression and lower levels of role strain for both groups of caregivers, whereas ultimate meaning did not have a significant effect. Miller et al. 1995 found that White caregivers reported higher levels of role strain than African American caregivers. They also used a measure of caregiving mastery (the caregiver's perception of his or her competence in caregiving) and found that it was a significant predictor of role strain (as mastery decreased, role strain increased).

Mui 1992 examined role strain, role demand, and role conflict among a sample of African American and White female caregivers of dependent elderly parents. She found that White caregivers reported significantly higher mean role strain scores than African American caregivers, and African American caregivers reported significantly higher role demand than White caregivers. She also found that caregivers' perceptions of being in poorer physical health and their perception of unavailability of respite support predicted role strain among African American caregivers but not among White caregivers. On the other hand, a poor parent–daughter relationship predicted role strain among White caregivers but not among African American caregivers.

Relationship Strain
Relationship strain was a topic of focus in only one article (Cox 1993), which reported that levels of relationship strain did not differ significantly between African American and White caregivers. However, both groups of caregivers reported rather high levels of relationship strain. Relationship strain was captured by Cox through a composite measure including the "caregiver's feelings of being pressured, angry, depressed, manipulated, strained, resentful, depended upon, and the feeling that the relationship had a negative effect on other family members" (p. 35).

Psychological Distress
Three articles focused on global outcomes of psychological distress in assessing negative effects of caregiving (Dilworth-Anderson et al. 1999a; Farran et al. 1997; Wykle and Segall 1991). Dilworth-Anderson et al. 1999a found that 20% of African American caregivers in their sample experienced high levels of psychological distress. Among these caregivers, those who were distressed reported being less satisfied with the social support they received, reported greater role strain, rated their general health lower, and reported less mastery of caregiving than those who were not distressed. Farran and colleagues 1997 found that African American caregivers reported significantly lower levels of emotional distress than White caregivers. Furthermore, African American caregivers appraised their caregiving situation more favorably than White caregivers and reported lower levels of psychological distress outcomes. In contrast, Wykle and Segall 1991 found that African American caregivers were significantly more likely than White caregivers to be distressed (determined by a greater proportion of African American caregivers answering "yes" to two of the seven items from the Langner Psychological Distress Scale; Langner 1962). In this situation, the study by Farran and associates may warrant more confidence owing to its larger sample size and comparisons based on caregivers' scores on an entire burden scale as compared with the smaller sample and incomplete scale comparisons in the Wykle and Segall study.

In summary, articles in this domain were often guided by empirical generalizations; however, when guided by theory, stress and coping–stress process models were typically used. Inconsistent operationalization of constructs, however, makes comparisons across studies inconclusive. For example, Haley et al. 1996 reported that African American caregivers had less depression (CES–D) than White caregivers, whereas Cox 1993 reported no difference in depression (three-item measure) between African American and White caregivers. These results are in direct contrast to one another, but in this example, the contradiction may have more to do with the different measures used than with differences in samples or true differences in depression. It is important that more work be done to develop and test measures that are sensitive to various ways in which caregiving may have negative effects on different ethnic groups of caregivers (as noted by Fox et al. 1999).

Findings in this domain regarding the relationships among numerous variables (including race and ethnicity) and negative outcomes for caregivers cannot be directly compared due to vast differences in theory use, construct measurement, and statistical techniques across studies. When reviewing the literature, researchers are left making comparisons of findings across studies that do not move beyond the bivariate level. For example, numerous studies can be compared at the bivariate level (e.g., mean depression scores for different ethnic groups of caregivers), but few can be directly compared at the multivariate level (e.g., predictors or antecedents of depression for different ethnic groups of caregivers) because of the inconsistent application of theory, use of samples that diverge widely across studies, inconsistent use of measures, and use of varied data analytic techniques. This limitation in comparability has seldom been acknowledged in the extant caregiving literature. Thus, more emphasis is needed on attempts at replication of previous studies using new samples of caregivers. This can allow for comparisons across studies and added confidence (if findings can be replicated) in both generalizability and the robustness of particular models. Further, the use of noncaregiving controls (as seen in Haley et al. 1995) is recommended to allow for the assessment of whether outcomes such as depression are actually associated with caregiving.

Domain 3: Coping
Theory
We identified 13 articles that focused on types of coping strategies used by caregivers. Unlike those in the previous domains, most of the studies (10 out of 13) included in the coping domain were theoretically based. Stress and coping–stress process models were used as the only theoretical approach in 6 of the articles (Gonzalez 1997; Haley et al. 1996; Knight and McCallum 1998; Knight et al. 2000; Strong 1984; Wood and Parham 1990). Farran et al. 1997 combined an existentialist theoretical framework with stress process theory. Picot, Debanne, Namazi, and Wykle 1997 used an eclectic theoretical approach that incorporated assumptions and concepts from stress process theory, Reed's transcendence paradigm, and choice and social exchange theory. Picot 1995a used choice and social exchange theory, and Picot 1995b combined stress and coping with choice and social exchange theory (see Table 1 ). All of the theoretically based articles in this domain used stress and coping–stress process models either alone or in combination with other theories. This is a departure from the wider variety of theoretical approaches seen in the other three domains. However, the use of stress and coping–stress process models in the articles in this domain was not accompanied by rigorous attempts to make the theoretical underpinnings more culturally relevant.

Sampling
The majority (9 out of 13) of the samples used in the coping domain compared African American and White caregivers' strategies and effectiveness in dealing with the challenges of caregiving. Of the remaining 4 studies, 3 examined only African American caregivers (Picot 1995a, Picot 1995b; Segall and Wykle 1988–1989) and 1 compared American Indian and White caregivers (Strong 1984). Due to the samples used in the studies in this domain (i.e., 12 out of 13 including African American caregivers and 9 of these comparing with White caregivers), not much can be said about coping among minority groups other than African American. The majority of these studies (12 out of 13), as was the case in the previous two domains, used purposive, convenience samples. The 1 remaining study (Picot et al. 1997) used a random-digit dialing process in order to obtain a random sample from a large metropolitan area in the midwestern United States.

Measures
A variety of measures were used in the coping domain, and each relates specifically to the research problem or questions under investigation. Thus, no one measure was identified as more reliable or appropriate than any other in assessing coping among caregivers. Several studies used established measures or inventories of general coping strategies (Gonzalez 1997; Haley et al. 1996; Hinrichsen and Ramirez 1992; Knight and McCallum 1998; Knight et al. 2000; Picot 1995b; Segall and Wykle 1988–1989; Wood and Parham 1990). In addition, researchers used measures of coping strategies specific to caregiving (Farran et al. 1997; Hinrichsen and Ramirez 1992; Strong 1984). Two articles (Segall and Wykle 1988–1989; Wykle and Segall 1991) used an open-ended question to allow caregivers to report one "special way" they dealt with caregiving difficulties. Strong 1984 also used open-ended questions to assess coping strategies and compared these responses to responses on close-ended questionnaire items. Spirituality and religiosity were assessed as coping strategies by asking caregivers to report the frequency with which they attended religious services, listened to or watched religious broadcasts, read religious materials, and prayed (Haley et al. 1996; Picot et al. 1997). In other studies, spiritual or religious coping strategies were expressed in response to open-ended questions regarding coping and social support among African American caregivers (Segall and Wykle 1988–1989; Wood and Parham 1990; Wykle and Segall 1991). Another coping strategy, social support, was measured using established scales of informal support, formal support, or both (Haley et al. 1996; Hinrichsen and Ramirez 1992). Caregiving appraisals were generally assessed by asking caregivers to rate the degree to which they found various caregiving tasks troubling or stressful (Haley et al. 1996; Hinrichsen and Ramirez 1992; Knight et al. 2000; Wood and Parham 1990). In addition, Knight and McCallum 1998 assessed positive reappraisal through the use of seven items from the revised Ways of Coping Questionnaire (Folkman and Lazarus 1988).

Findings
The studies in this domain addressed coping among caregivers of dependent elders in a variety of ways. For the purposes of this review, four major areas of focus in the coping domain were identified. These include use of established coping strategies inventories, and the examination of spirituality and religiosity, social support, and caregiving appraisals as coping resources. The following section addresses findings in each of these areas separately.

Coping Strategies
As discussed in the Measures section, several studies in this domain used established coping strategies inventories, which assessed caregivers' general approaches to handling problems. Strong 1984 found that American Indian caregivers were more likely than White caregivers to use stress management strategies, especially the passive forbearance strategy. Knight et al. 2000 conducted a study that was well developed theoretically and demonstrated methodological rigor. They found that African American caregivers reported using more emotion-focused coping (a latent construct including an Escape-Avoidance Coping subscale on which African American caregivers also scored higher) than White caregivers. Haley and colleagues 1996 also conducted a theoretically and methodologically rigorous study and found that African American caregivers reported higher levels of avoidance coping and lower levels of approach coping than did White caregivers. These levels of coping were associated with greater negative effects (increased depression and decreased life satisfaction). Thus, the relationship between greater negative effects and caregiver race was mediated by coping strategies. In contrast, Hinrichsen and Ramirez 1992 found no significant differences in the use of different coping strategies between African American and White caregivers. Using a sample of African American caregivers, Picot 1995b found that quality of social support predicted confrontive coping, appraisals of perceived rewards predicted palliative coping, and appraisals of perceived costs predicted emotive coping.

In a study comparing urban and rural African American and White caregivers, Wood and Parham 1990 found that urban African American caregivers used more behavioral coping strategies than rural African American caregivers. Also, urban African American and White caregivers used more cognitive coping strategies than rural African American and White caregivers. Finally, Farran and colleagues 1997 used an existentialist framework to guide their study. This theoretical framework shaped the research questions that were asked, the conceptual model that was proposed, the specific measures that were used, and the interpretation of results, providing a fine example of the application of theory at every level of the research process. They found that provisional and ultimate meaning (positive psychological resources that may be used for coping) were higher for African American caregivers than for White caregivers, and the effects of provisional and ultimate meaning on negative outcomes were the same for African American and White caregivers. Thus, if finding meaning does operate as a coping strategy, it has similar results for both groups of caregivers.

Spirituality and Religiosity
Findings show that African American caregivers cope with difficulties of caregiving with prayer, faith in God, and religion (Picot 1995b; Picot et al. 1997; Segall and Wykle 1988–1989; Wood and Parham 1990; Wykle and Segall 1991). Furthermore, differences were found between African American and White caregivers' use of spirituality and religiosity as a way of coping with the demands of caregiving. Wood and Parham 1990 reported that African American caregivers, unlike White caregivers, reported God to be a part of their informal support to the same extent as family, friends, and neighbors. Wykle and Segall 1991 used an open-ended question that asked caregivers to identify one special way they dealt with caregiving. Eighty percent of the African American caregivers reported that prayer, faith, or religion was their special way of coping, whereas none of the White caregivers answered in that way. Picot 1995b found that a palliative coping strategy of prayer and divine trust was used more often than any other coping strategy for African American caregivers. The second most common strategy reported by these caregivers was maintaining control over the situation. Picot and colleagues 1997 found that African American caregivers reported higher religiosity than White caregivers, and religiosity influenced perceived caregiver rewards for both groups. Both Picot studies (Picot 1995b; Picot et al. 1997) provide examples of how to conceptualize constructs with the integration of cultural information. Her examinations of religiosity and spirituality among caregivers incorporated cultural constructions of beliefs and practices among White and African American caregivers, which in turn strengthened the interpretations of findings. Finally, Haley et al. 1996 found no difference between African American and White caregivers on items regarding spirituality and religiosity.

Social Support
In the following articles, social support was explicitly conceptualized as a coping resource. For example, Wood and Parham 1990 posited that "use of social support may be appropriately considered as a coping strategy" (p. 326), and Picot 1995b wrote, "Social support was conceptualized as a coping resource" (p. 150). In general, White caregivers were found to report using formal social support as a way of coping with caregiving more often than African American caregivers (Wood and Parham 1990; Wykle and Segall 1991). However, Hinrichsen and Ramirez 1992 found no difference in professional help seeking between African American and White caregivers. Picot 1995b found that African American caregivers reported God to be their most helpful source of support, even with respect to help with physical care. Haley et al. 1996 found no difference between African American and White caregivers' use of or satisfaction with informal support as a way of coping with the demands of caregiving, but they found that White caregivers were more likely than African American caregivers to report seeking guidance and support as a form of behavioral coping (one of eight domains in the Coping Responses Inventory; Moos 1988). Although the studies mentioned earlier provide a first step, much more conceptual work is needed to understand how social support is used as a coping resource or strategy among diverse groups of caregivers. In particular, information is needed on the cultural interplay between social support and other coping resources or strategies to clarify the part social support plays in the process of coping among caregivers.

Caregiving Appraisals
Findings have shown that African American caregivers tend to use more positive reappraisal than White caregivers when dealing with the difficulty of caring for a dependent elder (Farran et al. 1997; Haley et al. 1996; Knight and McCallum 1998; Knight et al. 2000; Wood and Parham 1990). Haley and colleagues 1996 found that caregivers' appraisals and other coping responses mediated the effects of race on well-being. They also found that African American caregivers appraised self-care problems, as well as memory and behavior problems, as less stressful than did White caregivers. Likewise, Knight and McCallum 1998 found that African American caregivers used positive reappraisal more often than White caregivers, and positive reappraisal was effective in reducing stress for African American caregivers but not for White caregivers. However, Hinrichsen and Ramirez 1992 found that African American and White caregivers were similar on indices of appraisal. Finally, Picot 1995a assessed African American caregivers' appraisal of rewards of caregiving and found that lower education and older age were associated with greater rewards. These findings point to potential cultural factors that may affect one's view of caregiving as problematic or not. However, more attention to the mechanisms and pathways through which culture shapes appraisals is needed.

In summary, the studies in this domain are mostly theoretical, using stress and coping–stress process models. However, factors in the models were operationalized differently across studies, making it difficult to compare results. Most of these studies used purposive, convenience samples of only African American and White caregivers, which seriously limits the generalizability of findings. More diverse samples and random samples are needed in order to generalize stress process findings to caregivers in diverse groups. In addition, more in-depth conceptualization and testing of coping instruments among diverse groups of caregivers are necessary. The findings in this domain point to the efficacy of using spirituality–religiosity measures and stress appraisal measures in studies comparing African American and White caregivers. Authors of these studies pointed to cultural characteristics of African American caregivers and White caregivers to explain differences. For example, Knight and McCallum 1998 wrote,

Ethnic differences were interpreted as providing support for the view that African American cultural values support a view of caregiving as a valued part of family life, whereas white cultural values tend to see the familial obligation of caregiving as disruptive of individual life goals. (p. 220)

Domain 4: Cultural Effects
Theory
The vast majority (14 out of 20) of the articles in this domain were atheoretical, relying instead on empirical generalizations to guide the research. Three articles, however, reported using conceptual models. These models included the structural model of caregiving dynamics (Lawton et al. 1992), the stress and coping model (Strong 1984), and the cultural pluralism model (Thornton et al. 1993). Although different models were used in each of these studies, they equally provided adequate conceptual guidance needed for the purposes of each investigation. Three studies used conceptual frameworks: Dilworth-Anderson and associates 1999a used a contextual approach informed by a stress and coping model; Fox et al. 1999 and Ortiz, Simmons, and Hinton 1999 used a medical anthropological approach. The conceptual framework in Dilworth-Anderson and colleagues 1999a provided more direct theoretical guidance than the approach used by Fox and colleagues and Ortiz and associates. For example, Dilworth-Anderson and colleagues outlined five specific components of their contextual approach, gave examples of variables reflecting each context, and used measures in their research that were representative of each context of their approach. Finally, Hicks and Lam 1999 used grounded theory in order to develop inductively the social process of decision-making model (see Table 1 ). A benefit of using grounded theory in this study is that it provided the needed theoretical building blocks for examining Chinese Americans in future studies.

Sampling
The majority of the studies (17 out of 20) used nonprobability samples. However, 1 study used a national probability sample (Thornton et al. 1993), and 2 other studies used a regional probability sample (Dilworth-Anderson et al. 1999a, Dilworth-Anderson et al. 1999b). These probability samples, unlike some of the small community-based samples discussed later, allow for greater generalizability of findings. A variety of cultural groups, using comparative and noncomparative samples, were investigated to understand cultural effects on caregiving. We did not find that one sampling strategy was more useful than the other in assessing these studies. Instead, we found that the research questions asked and the hypotheses tested best determined the adequacy of the samples used. Therefore, all of the studies discussed used samples that reflected the research questions asked and hypotheses that were tested.

Eleven of the articles examined only one ethnic or racial group: Hicks and Lam 1999 studied Chinese Americans, whereas Clark and Huttlinger 1998, Cox and Monk 1993, and Henderson and Gutierrez-Mayka 1992 investigated Hispanic caregivers. An Asian American sample was investigated by Ishii-Kuntz 1997. Hennessy and John 1996 studied an American Indian sample. Five studies used samples of only African American caregivers (Dilworth-Anderson et al. 1999a, Dilworth-Anderson et al. 1999b; Fox et al. 1999; McAuley 1998; Nkongo and Archbold 1995). Three articles compared African American caregivers to another group: Cox and Monk 1990 compared African American and Hispanic caregivers, whereas 2 articles compared African American and White caregivers (Lawton et al. 1992; Miller and Kaufman 1996). Three articles included multiple racial and ethnic groups: Levkoff and colleagues 1999 and Hinton and Levkoff 1999 studied African American, Chinese American, Irish American, and Puerto Rican American caregivers; Thornton et al. 1993 studied three White ethnic groups (German, Irish, and English American) and a group of African Americans. The remaining 3 articles assessed various groups of caregivers. Ortiz et al. 1999 studied Latino and Irish American caregivers; Youn et al. 1999 compared Korean, Korean American, and White caregivers; and Strong 1984 compared American Indian and White caregivers.

Measures
Three studies (Cox and Monk 1993; Dilworth-Anderson et al. 1999a, Dilworth-Anderson et al. 1999b) used structured (quantitative) measures of culture, which provided methodological rigor and guidance for assessing culture. In other articles, cultural effects (e.g., values, norms, and beliefs) were assessed qualitatively through open-ended questions (e.g., Miller and Kaufman 1996), focus groups (e.g., Hennessy and John 1996), and ethnographic interviews (e.g., Henderson and Gutierrez-Mayka 1992) that allowed researchers to assess what respondents identified as aspects of their culture that influenced their caregiving to older family members. The remainder of the articles in this domain inferred cultural differences by using race and ethnicity as a proxy for cultural values, beliefs, and norms. Inferring culture from a variable such as race, as noted in some sociological literature, is very problematic given that race is a socially constructed category that provides only a limited view of one's life based on race identification (Hayward, Crimmins, Miles, and Yang 2000; Kington and Smith 1997). Thus, much caution should be taken when using caregiving research that lacks a clear conceptualization and measure of culture.

Findings
Findings on cultural effects were primarily reported on cultural values, norms, perceptions, and meanings. These results show that culture affects caregiving experiences. Findings on values and norms provide evidence that individuals and groups use explicit rules and guidelines that influence who provides care to elders as well as interactions between caregivers, family members, and social institutions. Results reported on perceptions about and meanings assigned to disease by cultural groups show the link between their values and norms and their perceptions and meanings used to understand and interpret caregiving experiences.

Cultural Values and Norms. Most researchers found that cultural groups have values about reciprocity (giving back), filial obligation, and a sense of responsibility for providing care to older family members. For example, Cox and Monk 1993 and Clark and Huttlinger 1998 found that cultural values and norms governed familial relationships and the care of the elderly people among Hispanics, where the extended family was expected to provide care to older relatives. Youn et al. 1999 found that Korean families unlike White families, have specific beliefs about familial roles, wherein daughters-in-law are expected to serve as primary caregivers to older family members. Findings reported by Hennessy and John 1996 and Strong 1984 have shown that American Indians strongly value giving back to those who have provided for them in the past. Further, Ishii-Kuntz 1997 found that reports of strong filial obligation were related to increased frequency of emotional aid to parents for both Korean Americans and Chinese Americans. Although all of these studies on values and norms provided useful information on the different groups under investigation, more discussion is needed on defining and measuring values and norms in caregiving research.

Cultural Perceptions and Meanings
Cultural perceptions about illness and disease that shape the meanings groups assign to a dependent person with an illness were investigated by several research groups (Fox et al. 1999; Henderson and Gutierrez-Mayka 1992; Hinton and Levkoff 1999; Ortiz et al. 1999). Some researchers (e.g., Henderson and Gutierrez-Mayka 1992; Nkongo and Archbold 1995) have suggested that culturally based illness meanings assigned to different diseases are a part of a larger belief system (values and norms) that helps define caregivers and their responses to an ill relative. For example, Henderson and Gutierrez-Mayka 1992 found that Hispanics viewed elders with dementia as being "crazy" or having "bad blood," a stigma that may be shared by the entire family. Such cultural meanings among caregivers created barriers to seeking assistance outside the family system (Henderson and Gutierrez-Mayka 1992). The study by Fox and colleagues 1999 of African American caregivers shows a need to look beyond "just" contrasting groups in interpreting diseases such as Alzheimer's disease, and to examine how macrostructural factors (sociopolitical and historical) shape different groups' perceptions of and meanings they assign to an illness, which can influence caregiving experiences and outcomes. This study by Fox and colleagues 1999, when compared with the studies noted previously, provided more conceptual and methodological direction on how to address issues of culture in caregiving research as it pertains to meanings and perceptions of illness and disease. Of particular interest is the anthropological approach they used that allowed for using grounded theory in data collection and interpretation. This enabled them to use the words or voices of the participants in their study to give meaning to their experiences. Thus, these researchers were less likely than others to make conceptual and interpretive leaps about illness meanings and perceptions without the voices of the participants in their study.

In summary, the majority of studies in the cultural effects domain were atheoretical. Little attention was given to defining culture from a sociohistorical perspective, through which issues of acculturation and assimilation would be considered, such as voluntary or involuntary immigrant status of minority groups in American society (Ogbu 1993). Culture was most often measured implicitly or inferred by researchers; however, a few studies used structured instruments (Cox and Monk 1993; Dilworth-Anderson et al. 1999a, Dilworth-Anderson et al. 1999b) or inductively measured culture through qualitative approaches (e.g., Fox et al. 1999). As expected, samples in this domain of research included various racial, ethnic, or cultural groups. Researchers typically used convenience samples. Only three studies used a probability sampling design. Findings primarily focused on two areas of research: (a) cultural values and norms and (b) perceptions and meanings.

	Summary and Direction for Future Research

TOP Abstract Methods Domains of Research Summary and Direction for... Appendix References

 
During the 20-year span that this review covers, researchers have primarily focused on four areas or domains of research when studying caregiving among racial and ethnic minority groups: social support, negative effects, coping, and cultural influences. Almost half (28 out of 59) of the studies in this review used an identifiable theoretical approach. The remaining studies relied primarily on empirical generalizations to guide studies that were largely exploratory in nature. The studies that were guided by explicit theoretical approaches consisted mostly of conceptual models, which were used as analytic tools to illustrate relationships among variables. The conceptual models and frameworks used by researchers provided a vocabulary of defined terms for other researchers to use that show how major concepts are related to one another in light of a particular research problem or question. Stress and coping–stress process models were the most common conceptual models used in these studies. The remainder of the studies used a wide variety of approaches such as the structural model of caregiving dynamics, choice and social exchange theory, and the hierarchical compensatory model, to name a few. The other studies, guided by empirical generalizations, provided less direction for researchers with no definite expectations about what an observation should look like. However, empirical generalizations are useful, in that the data collected may lead to the development of new theoretical foundations more appropriate for a particular research problem among specific groups.

Nonprobability sampling designs were used in the vast majority (51 out of 59) of the articles. A few studies used national or regional probability samples. Only 1 study (Strong 1984) in the coping domain had a sample including caregivers who were not White or African American. The measures used among the studies in this review followed along lines similar to those of theory use and sampling; that is, there is little consistency across studies. However, patterns can be seen within domains. For example, the majority of the articles in the social support domain used measures that had not been previously established to assess both informal and formal support. In the negative effects domain, two instruments were used in several studies—the CES–D and versions of Zarit and colleagues 1980(1988) Burden Inventory. However, no established measure was used in common across studies in the coping domain. In the cultural effects domain, open-ended questions and ethnographic interviews were often used to assess cultural aspects of caregiving. A few studies used quantitative measures to assess different cultural or ethnic differences. Most often, culture was inferred through racial and ethnic group categorization; that is, race and ethnicity were used as a proxy for culture. In addition, although some established measures were used in each domain, most of them have not been tested for cultural relevance or sensitivity across groups.

Although findings reported in this review varied on the basis of which domain of research was discussed, a connection can be made in summarizing the major findings reported in each domain. The majority of research reported that caregivers to older ethnic minorities use more informal than formal support in their caregiving and that close and distant family members as well as the extended family provide the majority of this support. This finding supports those reported in the cultural effects domain, which show that cultural values and norms direct feelings of obligation and reciprocity in providing care to older ethnic minorities. In addition, some researchers reported that social support could be used by caregivers to reduce negative effects associated with caregiving (e.g., depression, burden, or strain).

Formal services were rarely used by caregivers to older ethnic minorities, which is not fully explained by the research reported in this review. A few suggestions can be gleaned from what is reported in the literature, such as (a) caregivers may avoid seeking help because of feelings of shame, (b) obligation may preclude help seeking outside the family, or (c) formal services may not be perceived as culturally sensitive or relevant. For minority caregivers, findings have also shown that providing support was viewed as part of their cultural socialization. Other research has suggested that caregivers may even appraise, reframe, and interpret the situation of dependency such that outside support is not an option for them. In some instances, findings have shown that certain groups may interpret symptoms of diseases such as dementia as normal (Hinton and Levkoff 1999). Thus, the illness is not addressed through formal support and interventions outside the family. Minority caregivers were also less likely to use formal services as a coping strategy compared with their White counterparts.

Other findings reported in the negative effects and coping domains show the link between these two domains. Several studies in the negative effects domain found that African American caregivers were less depressed and/or burdened in their role as compared with Whites, whereas others found no differences between the two groups. Possible reasons for discrepancies include sample size, recruitment strategies, geographic region, and the use of different measures across studies. Studies in the coping domain linked higher levels of spirituality and religiosity (more common among African American caregivers) with lower depression and burden. Further, the use of different coping strategies and appraisals of the situation by African American caregivers led to different levels of depression and burden when compared with White caregivers. The cultural role domain can be linked here as well, because findings on cultural values, norms, expectations, and feelings of obligation and reciprocity have shown that these factors may encourage a positive appraisal of caregiving experiences for caregivers of older ethnic minorities. Most important, some researchers found that although diverse groups have similar belief systems, the context in which these systems are experienced is an important factor to consider in interpreting findings.

Given the findings reported in this review, where do we go from here? Although the four domains of research (social support, negative effects, coping, and cultural influences) identified in this review provide valuable information on caregiving among diverse populations, they also highlight gaps in our knowledge base. There are other areas of knowledge (e.g., physical health effects and positive outcomes of caregiving) that did not constitute domains in our review of the caregiving literature but warrant further attention. Some researchers (Ferraro and Farmer 1996; Ferraro, Farmer, and Wybraniec 1997) have noted that understanding the physical health effects of caregiving is of major concern for ethnic minority caregivers because of long-term health risks they often bring to the caregiving situation. Regarding positive outcomes of caregiving, Picot and colleagues 1997 and Picot 1995a, Picot 1995b have highlighted the need to assess both the costs and the rewards caregivers experience in their role as caregivers to dependent elders. Additional support for this research focus is shown in findings reported by Farran et al. 1997. They found that caregivers who assigned positive meanings to their roles fared better in terms of depression and role strain. Furthermore, Lawton et al. 1992 found that African American caregivers, as compared with their White counterparts, expressed the feeling that caregiving was less intrusive in their lives. We propose that such positive experiences and effects of caregiving will be viewed as an important research topic when researchers better conceptualize and theoretically frame caregiving beyond a strictly burdensome or negative experience as highlighted by the negative effects domain.

We also strongly suggest, as Antonucci and Cantor 1994 proposed, that future research on family support and caregiving for minority older people should include conceptual frameworks and theoretical perspectives that are culturally relevant. Cultural relevance speaks to frameworks or perspectives, such as life course, symbolic interaction, social constructivism, and the use of anthropological approaches, that allow for capturing the cultural–historical background (values, beliefs, identities, and meanings assigned to experiences) and sociopolitical conditions (economic status and access to goods and services) of diverse groups. These frameworks and perspectives also allow for defining and giving meaning to certain concepts (e.g., burden and coping) from a cultural frame of reference.

As they are the most commonly used conceptual models among the studies in this review, it is important to discuss how stress and coping–stress process models can be made more culturally relevant. First, because of differences in the levels and effects of independent variables in stress process models across ethnic groups, it would be more productive to model the stress process separately for each group included in a multiple regression study. When caregivers are combined in the same regression model, race or ethnicity is used as an independent variable with its significance primarily hinging on racial or ethnic differences in levels of the dependent variable. Further, in such regression analyses, race or ethnicity serves as a control influencing the significance of other variables. In these cases, significance of other independent variables is difficult to interpret in relation to race or ethnicity. A similar case can be made for modeling ethnic groups separately when conducting path analysis or structural equation modeling. Overall model fit for the entire sample, particularly when the number of caregivers differs between ethnic groups, fails to determine whether the same model fits each group separately. When one group is larger than the other, the lack of fit for the smaller group may be washed out by the larger group's good fit. These techniques, when compared with multiple regression, certainly allow greater interpretation of the influence of race or ethnicity on other constructs in the model, but assessing overall fit remains problematic. It is important to note that use of path analysis and structural equation modeling requires much larger sample sizes than multiple regression in order to place confidence in the results. Second, constructs that measure an aspect of culture (e.g., the Cultural Justifications for Caregiving scale; Dilworth-Anderson 1995) should be included in stress process models. Measures of constructs attempting to assess culture that will be valid and reliable across groups are extremely difficult to create. Nevertheless, more work is needed in this area. Third, the use of qualitative data to inform findings from quantitative stress process models can be invaluable when examining cultural similarities and differences across groups. When qualitative data are placed within a broader theoretical framework such as symbolic interactionism (within which stress process models also fit), explicit connections can be made between the qualitative and the quantitative findings (Gibson 2001). This also can be a first step toward the development of measures of cultural constructs mentioned earlier.

Immigration and migration issues are also important when theorizing about diverse populations. Ogbu 1993 suggested that the entrance of diverse groups into a society shapes their cultural development and experiences. Thus, voluntary immigrants versus those groups who enter into a society involuntarily (slaves) or groups who are part of the society but exist as a "conquested people" (Native Americans) have different social, economic, and political positions in a society. It is suggested here that when we as researchers use race as a proxy for understanding the issues noted earlier, the underlying meaning of racial and ethnic diversity is not fully conceptualized in our research. It is also evident that there is a need to separate the diversity within such populations as Hispanics and Asians because of their different histories and cultural backgrounds. These different histories reflect differences in norms, values, and cultural rules that help define a people, thus influencing how they care for dependent family members. There is also a need to disaggregate samples of White caregivers to identify distinct cultural and ethnic identities among them. For example, Greek, Irish, and Italian Americans have similar but also distinct cultural backgrounds that may influence a family's approach to caregiving for its dependent elder members.

Sampling is also an important topic of concern for studying caregiving to minority elders. Sampling issues for this discussion include examining existing approaches on who should be included in a caregiving study among ethnic minority groups. For example, this review suggests multiple caregivers may need to be included in caregiving research because ethnic minority families usually give care in an extended family system where it is likely that multiple caregivers, and not just a primary caregiver, play central roles in providing care to dependent elders. The use of a comparative approach, where a noncaregiving sample is used in the research, is also notably lacking in the caregiving literature. For example, the use of noncaregivers as controls allows for determining whether or not the outcomes of interest (e.g., depression or social support) are associated with caregiving. Further, the discussion on comparative samples includes assessing when and how to compare one ethnic group to another. As mentioned in each of the domains of literature reviewed, some studies include a single group and other studies compare White samples with at least one ethnic group. We suggest that more in-depth research is needed on single ethnic groups that provide knowledge on how best to compare different ethnic groups. As previously mentioned, we recommend that different models are needed for each racial and ethnic group to determine how relationships among variables are shaped by race, ethnicity, and culture. There is also a need for more studies that examine gender effects among caregivers. Although some studies included men in their samples, the numbers of male caregivers were often insufficient to test for gender effects.

When using measures in caregiving research that includes diverse samples, more attention needs to be paid to the cultural relevance and sensitivity of instruments. In other words, do the questions reflect the lives and experiences of the group under investigation? And do the questions capture the cultural nuances, often the unspoken words and meanings of a group, to know that the appropriate question has been asked? Only a few researchers in this review addressed such issues by providing information on how they validated the use of certain instruments for each racial and ethnic group in their research (Cox and Monk 1993; Picot 1995a, Picot 1995b). Because little, if any, information was provided by researchers on cultural relevance of measures throughout most of their discussion on measurement, caution should be taken when deciding what instruments or measures work best for diverse populations of caregivers. Presently, there is a need to evaluate if and how existing instruments used in caregiving research address issues of cultural relevance. Reliability of instruments across groups is also a concern. Researchers often fail to report reliability coefficients by ethnic group in addition to the overall sample. We further suggest that new instruments and measures are needed that incorporate the cultural values, norms, and beliefs of racial and ethnic minorities.

Given the diversity among the groups discussed in this review, we believe that no one method is best or most appropriate for studying caregiving among ethnic minorities and other ethnic groups. We propose that multimethod approaches (e.g., quantitative and qualitative interviews, observations, and focus groups) be used to provide different types and levels of information (Dilworth-Anderson and Burton 1999; Myers 1996) about the caregiving experiences and outcomes of diverse populations. These different methods are helpful in the development of instruments and refinement of those already being used. Multimethod approaches can also help fill the gaps in our understanding inherent in the use of single-method approaches (e.g., close-ended surveys). For example, ethnographic interviews and information from focus groups can be used to help identify issues, develop questions for surveys, develop scales, and interpret findings.

Several analytic issues are also important to future research on caregiving among diverse populations. We propose that instead of using race as a proxy for understanding ethnic and cultural differences in caregiving, future research should include, as LaVeist 1994 suggested, variables that allow for understanding the sociocultural characteristics (e.g., socioeconomic status, discrimination, and economic exploitation) of racial and ethnic minorities (Hayward et al. 2000; Stack and Burton 1993). This will, in turn, provide more explanatory power regarding outcome measures. When interpreting findings from studies that include diverse samples, attention needs to be given to within- as well as between-group differences and similarities. For example, Lawton et al. 1992 found that African American caregivers with less education reported more caregiving intrusion than those who had more education, whereas the opposite was true for White caregivers. In addition, they found that African American caregivers with higher incomes also reported more burden. However, White caregivers who reported higher incomes reported less burden. Furthermore, significantly different scores on an instrument measuring depression do not necessarily indicate cultural difference between two racial or ethnic groups. Likewise, similarities in scores do not indicate a lack of cultural difference between two racial or ethnic groups. There are several reasons for this; first, using race or ethnicity as a proxy for culture ignores cultural differences (e.g., various levels of acculturation) within racial and ethnic categories. Therefore, specific measures of culture are necessary to assess differences between groups living in a multicultural society. Second, the processes through which levels of depression are affected often represent differential cultural influences across groups. Third, findings of statistically significant mean differences are contingent on sample sizes, variance of measures, and the use of various controls (e.g., socioeconomic status). Finally, the experience of depression is shaped by culture (Kleinman, Eisenberg, and Good 1978). Thus, similar levels of depressive symptomatology between racial and ethnic groups may be experienced quite differently as a result of differences in cultural context. Accurate interpretation of such findings will require integrating cultural constructs into our conceptual frameworks and theoretical perspectives. When this integration takes place, we move from a static and limited view of culture as race toward a more dynamic view of culture as it shapes and is shaped by racially and ethnically diverse groups of caregivers.

A related analytic issue deals with the use of control variables, particularly socioeconomic status, in caregiving research using ethnic minority samples. For example, the status of current caregiving research includes controlling for socioeconomic status without disentangling the relationship between race or ethnicity and socioeconomic status. Future studies need to capture the multiple pathways and circumstances of caregivers' lives to better understand particular outcomes of caregiving. These pathways include duration of experiencing discrimination, poverty, and lack of access to health care, all of which may be highly related to race and socioeconomic status. Some researchers have suggested that until we can disentangle these relationships, through the use of longitudinal research, we must exercise caution in our interpretation of findings when controlling for such factors as socioeconomic status or income (Kington and Smith 1997; Williams 1996, Williams 1997).

Overall, we believe that this review offers information on where we have been, where we are, and where we could go when conducting future research on caregiving to an increasingly diverse older population. Thus, we can build on the strengths of existing studies reviewed in this article and improve on what we have identified as limitations in our knowledge base. Most important, we can approach our research with a more sensitive eye for inclusiveness that captures the rich diversity among older care recipients and their caregivers as our society continues to change demographically and culturally.

The Forum

Book Reviews

Practice Concepts

	Acknowledgments

 
Work on this article was supported by funds from National Institute on Aging Grant RO1 AG12268-01-04. An earlier version of this article was presented at the symposium "A Spectrum of Aging and Health" at Case Western Reserve University, Cleveland, OH, October 23, 1998. We would like to thank Carol Farran and Bob Knight for their critical comments on an earlier version of this article.

Received for publication April 24, 2001. Accepted for publication November 1, 2001.

	Appendix

TOP Abstract Methods Domains of Research Summary and Direction for... Appendix References

 
Notes

1. A conceptual model is an analytic guide for examining specific relationships (Doherty, Boss, LaRossa, Schumm, and Steinmetz 1993).
   
2. A conceptual framework is a set of assumptions and ideas about the fundamental features of the social world. It serves as a guide to selecting areas of focus and modes of inquiry (Doherty et al. 1993).
   
3. Empirical generalizations provide a summary of research findings that are linked to other research findings and to some more general ideas about the research topic. These generalizations are then used to guide the methodology of the study for which they are being used (Doherty et al. 1993).
   

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