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Correspondence: Address correspondence to Berit Ingersoll-Dayton, School of Social Work, The University of Michigan, 1080 South University, Ann Arbor, MI 48109. E-mail: bid{at}umich.edu
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Abstract |
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 TOP Abstract Gender Differences in Caregiver...Theoretical FrameworkMethodsResultsDiscussionReferences |
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Key Words: Spousal caregiving • Gender differences • Caregiver stress
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Gender Differences in Caregiver Stress |
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TOPAbstractGender Differences in Caregiver...Theoretical FrameworkMethodsResultsDiscussionReferences |
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A second theory proposes that gender differences in caregiver distress are related to psychological changes that occur in later life (Gutmann, 1994). According to this perspective, late-life role changes (e.g., retiring, or having one's children leave home) result in shifting psychological needs that differ for aging men and women. Specifically, men want to be more nurturant toward others whereas women desire more opportunities for productivity and assertiveness. These shifting psychological needs can, in turn, affect the way in which husbands and wives react to spousal caregiving. That is, husband caregivers may enjoy their new role as care providers to their wives. For example, Motenko (1988) noted that the daily tasks associated with caring for wives gave husbands a feeling of self-efficacy, mastery, and fulfillment. In contrast, wife caregivers who have a history of nurturing their family may yearn for freedom from caregiving. For these older wives, caring for a dependent husband can result in feelings of constraint and resentment (Fitting, Rabins, Lucas, & Eastham, 1986).
Existing research on distress among spousal caregivers often focuses on gender differences in reaction to the problematic characteristics of the care recipient. The following section summarizes such findings in relation to care-recipient problem behaviors and augments this approach by exploring another care-recipient behavior (i.e., helping behavior) that may enhance or offset caregiver distress.
Problem Behaviors of Care Recipients
Care recipients' problematic behaviors have been studied extensively and are consistently found to be influential predictors of caregiver distress (Pinquart & Sorensen, 2003; Schulz, O'Brien, Bookwala, & Fleissner, 1995). Such problems (e.g., falling down, making excessive demands, or asking repetitive questions) are typically associated with either physical illness or cognitive impairment (Bookwala & Schulz, 2000). Early research on the incidence of problem behaviors among care-recipient spouses indicated that husband caregivers reported more problematic behaviors among their spouses than did wife caregivers (Barusch & Spaid, 1989). However, a more recent study (Bookwala & Schulz, 2000) discovered a different pattern of results. These researchers found that, in contrast to husband caregivers, wife caregivers reported a higher incidence of problem behaviors among their care-receiving spouses.
In addition to gender differences in the incidence of problem behaviors, the effect of such behaviors may also vary by caregivers' gender. For example, Bookwala and Schulz (2000) reported that, although a multigroup analysis found no significant gender differences in the size of the path coefficients linking problem behaviors and depression, models run separately for husband and wife caregivers resulted in a different pattern of findings. Specifically, the problem behaviors of care-recipient spouses were not significantly related to depression for caregiving husbands but were related to depression for caregiving wives. In addition, in a study that focused on only female caregivers, husbands' problem behaviors were significant predictors of their wives' maladaptation to caregiving (Seltzer & Li, 1996). That is, wife caregivers whose husbands exhibited problem behaviors were likely to feel distant from their husbands and burdened by caregiving.
Taken together, these recent studies suggest that gender differences in distress among spousal caregivers may be partially attributable to the problematic behaviors of care recipients. In comparison with their male counterparts, caregiving wives contend with more problematic behavior from their spouses, and these behaviors have a stronger impact on their depressive symptoms (Bookwala & Schulz, 2000).
Helping Behaviors of Care Recipients
A second care-recipient characteristic—the help they provide to their caregivers—may also explain gender differences in spousal caregiver distress. In comparison with care-recipient problem behaviors, care-recipient helpfulness has been virtually ignored in the caregiving literature (Walker, Pratt, & Eddy, 1995). One exception is a study by Miller (1990), who found that both caregiving husbands and wives received considerable help from the spouses for whom they were caring. She reported that care recipients provided their caregiving spouses with several forms of support, which included helping with chores, providing companionship, and making them feel useful. Another exception is a study conducted by Vinokur and Vinokur-Kaplan (1990) on the emotional and instrumental support exchanged between wives with breast cancer and their husbands. These researchers found that the wives, even though they had breast cancer, provided support to their husbands.
Drawing from the literature on social support, one can see that there is ample evidence that supportive exchanges contribute toward the well-being of older people (Antonucci, 2001; Antonucci & Akiyama, 1995). When applied to the caregiving situation, the help provided to caregivers by their care recipients may have positive consequences. However, help given to caregivers from care recipients can have negative effects as well. For example, in a study of older care recipients and their adult-child caregivers, some forms of help from care recipients were associated with increased caregiver stress (Ingersoll-Dayton, Neal, & Hammer, 2001). Apparently, help from care recipients made some caregivers feel guilty, frustrated, and inadequate. As suggested by Rook (1990), social support can have detrimental as well as beneficial consequences.
Although minimal research has been conducted on help exchanged between care recipient and caregiver spouses, it seems plausible that the amount of help provided by care recipients would differ according to gender. That is, care-recipient wives might be expected to provide more help to their husband caregivers than vice versa. Miller's (1990) examination of spousal caregiving lends some empirical support to our speculations about gender differences in care-recipient helpfulness. She found that caregiving husbands were more likely than caregiving wives to obtain help with household chores from their care-recipient spouses.
Furthermore, as suggested by gender-role socialization theory (Gilligan, 1993), women learn at an early age to care for others. Therefore, even when disabled, care-recipient wives could be expected to assist their caregiving husbands in ways that would significantly reduce their caregiver stress. In contrast, care-recipient husbands generally lack such early socialization to helping others; therefore, their attempts to be helpful to their caregiving wives in later life are expected to be less effective in reducing their wives' caregiver stress.
Problem Behaviors and Helping Behaviors of Care Recipients
The same care recipients who exhibit problematic behaviors may also attempt to provide help to their caregiving spouses. Such help may be a mixed blessing for caregivers (Ingersoll-Dayton et al., 2001). On the one hand, help from care recipients can offset the stressful effects of problem behaviors. That is, caregivers whose spouses have problem behaviors may be less distressed if their spouses also provide help. On the other hand, the help provided by spouses with problem behaviors may actually make caregiving more difficult and thereby exacerbate caregiver distress.
Although few researchers have addressed this issue, an early study by Motenko (1989) provides some possible clues about the interaction between care-recipient problem behaviors and helpfulness. She found that when husbands with dementia tried to be helpful, their wives experienced more frustration with household chores. Motenko suggested that the wives' frustration was a function of the inadequacy of their husbands' help. Instead of reducing the wives' caregiving burden, help from their husbands made the completion of household chores even more difficult. Her research lends support to the notion that, for wife caregivers, help from husbands with problem behaviors may exacerbate their caregiver distress.
We found no comparable research focused on care-recipient help to husband caregivers, but we speculate that the interaction between care-recipient helpfulness and problem behaviors may have a different effect for them. On the basis of early gender-role socialization theory (Gilligan, 1993), we would expect that women have extensive experience with nurturing and helping others. Therefore, the assistance care-recipient wives provide to their caregiving husbands may be quite beneficial and result not only in directly reducing their husbands' stress but also in diminishing the effects of their problematic behaviors on their husbands' caregiving stress.
In sum, the present study examines the relationship between two care-recipient characteristics and caregiving stress. One of these characteristics, problem behaviors, has been extensively studied (Pinquart & Sorensen, 2003; Schulz et al., 1995), whereas the other characteristic, helping behaviors, has been generally overlooked (Walker et al., 1995). By examining the separate and interacting influence of these two care-recipient characteristics, we add to the existing literature that attempts to understand gender differences in spousal caregiving distress.
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Theoretical Framework |
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TOPAbstractGender Differences in Caregiver...Theoretical FrameworkMethodsResultsDiscussionReferences |
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This study tests five hypotheses related to gender differences in spousal caregiving. The first three hypotheses replicate previous findings; the last two are unique to this study.
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Methods |
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Our data were from the NLTCS community survey conducted in 1999 that included primary caregivers of care recipients living in noninstitutionalized community settings. Our subsample consisted of wives (n = 253) and husbands (n = 188) who were providing primary care to their spouses (for more details on the NLTCS sampling procedures, see Barrett & Lynch, 1999, and Center for Demographic Studies, 2002). Unlike many of the previous studies of gender differences in caregiving that focused on specialized samples of care recipients with dementia (Pruchno & Resch, 1989; Zarit, Todd, & Zarit, 1986) or specific health problems (Young & Kahana, 1989), the present sample included care recipients with a wide range of functional and cognitive abilities.
Measures
The outcome variable in this model, caregiver stress, was an index of four items: "exhausted when you go to bed at night," "more things to do than you can handle," "lack time for yourself," and "feel you work hard as a caregiver but never seem to make any progress." We measured the items by using a 4-point Likert scale that ranged from 1 = not at all to 4 = completely. We summed the items to create an index (
=.86) ranging from 4 through 16, with a higher score indicating greater caregiver stress.
The key variables of interest were caregiver gender, care-recipient problem behaviors, and care-recipient helping behaviors. We measured gender of the caregiver dichotomously (1 = wife and 2 = husband). We identified problem behaviors by asking caregivers to determine how frequently during the previous week they had addressed each of 10 care-recipient behaviors (1 = problem behavior was not addressed; 4 = problem behavior was addressed during 5 or more days). These problem behaviors were as follows: keeping the caregiver up at night, repeating questions, dressing the wrong way, hiding belongings, clinging to the caregiver, being irritable or angry, swearing, threatening others, exhibiting inappropriate sexual behavior, and destroying property. We created a problem behavior index ( =.71) by summing the ratings across the 10 problem behaviors with a range of 10 through 40; a high score represented a greater frequency of problem behaviors.
We measured helping behaviors by asking caregivers whether or not their care recipients had been helpful to them in three different areas. The first area was keeping the caregiver company; the second was helping with household chores; and the third was buying things for the caregiver or giving him or her money. We measured each of these helping behaviors dichotomously (0 = helping behavior was not performed; 1 = helping behavior was performed). Because minimal research has been conducted on the helping behaviors of care recipients (Walker et al., 1995), we examined these individual items separately and did not combine them into a scale.
We included four control variables found to be related to caregiver stress (Barusch & Spaid, 1989; Neal, Chapman, Ingersoll-Dayton, & Emlen, 1992; Schulz et al., 1995; Thompson, Futterman, Gallagher-Thompson, Rose, & Lovett, 1993) in the analyses. Caregiver's age was a continuous variable measured in years. Financial hardship reflected the caregiver's response to a question concerning the degree to which it was a financial hardship to care for the recipient (1 = no hardship; 5 = a great deal of hardship). Care recipients' functional dependency was based on a scale developed by the Duke University Center for Demographic Studies (Manton, Corder, & Stallard, 1993). Response categories ranged from 1 (does not need assistance with any ADL or IADL) to 5 (needs assistance with five or six ADLs). Hours of caregiving was the average number of hours caregivers spent helping the care recipient in a typical week.
Analysis Strategy
We conducted a series of analyses to test the hypotheses addressed in this study. We evaluated gender differences among spouse caregivers in the incidence of care-recipient problem behaviors and helping behaviors by using t tests. We examined the effects of problem behaviors and helping behaviors on stress for husbands and wives in two ways. First, we ran bivariate correlations separately for husbands and wives. Second, we conducted hierarchical multiple regression analyses for the entire sample to examine two-way and three-way interaction effects related to gender. We entered the control variables and the key main effects (i.e., gender, problem behaviors, and each of the three care-recipient problem behaviors) into the first step of the regression. In the second step, we added the three two-way multiplicative terms between the key variables to the first model so that a significant coefficient indicated an interaction effect. As suggested by Aiken and West (1991), we centered the problem-behavior index around its respective mean when we were assessing for interaction effects. Finally, to test for a possible three-way interaction effect, we added the multiplicative terms for the three key variables to a third model that included the main and two-way interaction terms. When these models resulted in a significant interaction coefficient, we conducted separate subgroup analyses for caregiving husbands and wives to determine gender differences in the effects of the key variables on caregiver stress.
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Results |
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TOPAbstractGender Differences in Caregiver...Theoretical FrameworkMethodsResultsDiscussionReferences |
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.001).
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.001). Specifically, three kinds of problem behaviors were significantly more prevalent for caregiving wives than caregiving husbands: repeated questions (M = 1.76 and M = 1.48, respectively; p .01), clinging to the caregiver (M = 1.42 and M = 1.13, respectively; p .001), and swearing (M = 1.25 and M = 1.10, respectively; p .01).
The second hypothesis focused on the impact of care-recipient problem behaviors on caregiver stress. The bivariate correlations in Table 2 revealed a significant relationship between frequency of problematic behaviors and stress for both caregiving husbands (r =.43, p .001) and caregiving wives (r =.39, p .001). However, when these relationships were examined within a multivariate context (see Table 3), there was no interaction effect for Gender x Problem behaviors for any of the three helping behaviors, indicating that the relationship between frequency of problem behaviors and stress was not significantly different for caregiving wives and caregiving husbands.
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.001). However, there were no significant differences between wife and husband caregivers in their receipt of either companionship or gifts from their care-receiving spouses.
The fourth hypothesis focused on gender differences in the impact of care-recipient helpfulness on caregiver stress. Table 2 provides the bivariate relationship between the three kinds of helpfulness and caregiver stress for wives as compared with husbands. These correlations indicated that help from a care-receiving spouse was significantly related to reduced caregiver stress for both caregiving husbands and wives. Caregiving husbands and wives experienced a reduction in stress when they received companionship (r = –.21, p .01 and r = –.13, p .05, respectively), help with household chores (r = –.41, p .001 and r = –.25, p .001, respectively), and gifts (r = –.23, p .01 and r = –.15, p .05, respectively). When examined within a multivariate context (Table 3), the interaction betweenfrom care recipients gender and help from the care recipient was significant for one kind of help: receiving gifts (B = 1.18, p .05). To determine the nature of this interaction effect, in Table 5 we provide separate data on the relationship between receiving gifts and caregiver stress for wife caregivers as compared with husband caregivers. These findings indicated that there was no significant relationship between receiving gifts and caregiver stress for caregiving wives; however, for caregiving husbands, receiving gifts was significantly associated with reduced caregiver stress (B = –.86, p .05).
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.05) and was significant at the trend level for receiving gifts and problem behaviors (B =.33, p =.07).
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Discussion |
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TOPAbstractGender Differences in Caregiver...Theoretical FrameworkMethodsResultsDiscussionReferences |
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Three of our hypotheses concerning gender differences among spouse caregivers were supported by the data. First, we found that wife caregivers reported more frequent problem behaviors among their care-receiving spouses than did husband caregivers. Second, we discovered that wife caregivers received less help from their care-recipient husbands; and third, care-recipient help had a greater reduction on the distress of husband caregivers than wife caregivers. These findings help explain the advantage experienced by caregiving husbands who generally report less depression (Yee & Schulz, 2000) and burden (Barusch & Spaid, 1989; Pruchno & Resch, 1989) than do caregiving wives.
Two of our hypotheses were not supported by the data. One of these hypotheses was that husband caregivers would be less distressed by the problem behaviors of their care-receiving spouses than would wife caregivers. Contrary to previous studies (Barusch & Spaid, 1989; Bookwala & Schulz, 2000), we found no gender differences in the extent to which problem behaviors were associated with caregiver stress. Our findings may be related to our study sample, which was selected on the basis of functional impairment. In contrast, most of the previous research on gender differences in caregiving spouses has focused on samples in which the care recipient is cognitively impaired. Perhaps problem behaviors have a differential effect on husband and wife caregivers when the care recipient has severe cognitive impairment. Another reason that may account for our findings is that the frequency of problem behaviors among our sample of care recipients was fairly low, thus potentially minimizing differences in caregiver stress.
The second hypothesis that was not confirmed by our study concerned the moderating role of care-recipient helpfulness on care-recipient problem behaviors. That is, we found no support for our hypothesis that care-recipient helpfulness would exaggerate the relationships between problem behaviors and stress for caregiving wives and offset this relationship for caregiving husbands. In fact, two important findings that emerged were contrary to our expectations, though they must be considered with caution because the three-way interaction effect used to test these results was only marginally significant.
First, for caregiving wives, spousal helpfulness was inconsequential in influencing the effect of problem-behavior frequency on stress. Apparently, their husbands' attempts to be helpful had no impact on the detrimental effects of their problem behaviors. For wife caregivers, there may be other resources more influential than spousal helpfulness in moderating the relationship between problem behaviors and caregiver stress. For example, obtaining adequate respite care and sufficient time away from caregiving responsibilities may serve as more important moderators of the relationship between their husbands' problem behaviors and caregiver stress, because such resources enable wife caregivers to address their own needs.
Second, spousal helpfulness had a significant moderating effect for caregiving husbands but in a direction that was opposite from what we had expected. Rather than reducing the impact of problem behaviors on husbands' caregiver stress, spousal helpfulness increased the negative impact of problem behaviors. More specifically, when caregiving husbands did not receive gifts or help with chores from their care-recipient spouses, the impact of problem-behavior frequency on caregiver stress was minimal. However, this impact was sizeable when caregiving husbands did receive help from their care-recipient spouses. Consistent with gender-role changes that occur in later life (Gutmann, 1994), it may be that older husbands gain a sense of efficacy by caring for their wives. If, however, these impaired wives are providing help, the caregiving husbands may feel inadequate in their efforts to provide nurturance or feel guilty that they are receiving help from someone who needs it. Alternatively, the help provided by care-receiving wives may actually interfere with the husbands' caregiving activities. For example, a care-receiving wife may insist upon continuing to cook. However, her attempts to prepare meals may be hampered by problems such as an inability to remember recipes and negligence concerning kitchen safety. As suggested by Bowers (1987), caregivers often exert extraordinary efforts to preserve their care recipients' fragile sense of competence. They may eat meals that are poorly prepared or they may need to remain constantly vigilant to prevent kitchen fires. Such attempts to protect care recipients from their own problem behaviors may enhance the husbands' stress.
One major contribution of the present research is to the growing body of literature on gender differences in spousal caregiving. Specifically, we illuminated care-recipient characteristics that may result in greater vulnerability to distress for caregiving husbands. Because previous research on gender differences in caregiving has emphasized wives' caregiving stress, the unique challenges of husband caregivers may be less well understood (Carpenter & Miller, 2002). By examining the interaction between problem behaviors and helping behaviors among care recipients, we identified husband caregivers who may be particularly susceptible to distress: those whose wives have problem behaviors and are also attempting to help their husbands. In such instances, the helpfulness of their care-receiving wives may be detrimental. Rather than offsetting the negative effects of their problem behaviors, their helpful efforts can add to the caregivers' stress.
Another contribution of this research is to the literature on the negative side of social support (Rook, 1990; Talbott, 1990; Vinokur & Vinokur-Kaplan, 1990). Although there has been a growing interest in negative social interactions characterized by criticism and excessive demands (Akiyama, Antonucci, Takahashi, & Langfahl, 2003; Krause & Rook, 2003), less is known about well-intended social interactions that backfire. Early work in this latter area emphasized negative support to victims in crisis (Wortman & Lehman, 1985). More recent research has examined this phenomenon in relation to caregiving relationships (Ingersoll-Dayton et al., 2001). By focusing on the supportive efforts of care-recipient spouses, we enhance our understanding of why such efforts may backfire. As suggested by our findings, the spousal-caregiving relationship offers a rich opportunity to further understand supportive efforts that have negative consequences.
Limitations and Implications
Although this study extended previous research in several significant ways, there are also limitations that should be addressed by future research. For example, unlike other measures of caregiver strain and burden that include numerous items (Prunchno & Resch, 1989; Zarit et al., 1986), our caregiver-stress measure was composed of only four items. Consequently, our caregiver-stress measure may not have captured the full range of strains experienced by caregivers. In addition, the care-recipient helping behaviors were measured by three items that were scored dichotomously, thus limiting the amount of information gained. Finally, we had no assessment of the caregiver's evaluation of the care recipient's helping behavior. It may be, for instance, that care recipients' helpful behaviors are judged as beneficial in some situations and as detrimental in others. Further research on care-recipient helping behaviors should include measures that tap into a broader range and frequency of helping behaviors, as well as indicators that provide caregivers' appraisals of these behaviors.
Our findings have implications for practitioners who are working with caregiving husbands and wives. One implication is that when practitioners try to help caregivers reduce their feelings of burden, they should inquire about care recipients' helping behaviors as well as their problem behaviors. Although standardized questionnaires assist gerontological practitioners in their assessment of care-recipient problem behaviors (Zarit & Zarit, 1982), no comparable tool is available to analyze their helping behaviors. Practitioners should also assess whether care recipients' attempts to be helpful augment or decrease caregiver stress.
Another application to practice is the identification of two groups of spousal caregivers who may be particularly susceptible to distress. One group is the caregiving wives whose stress is not reduced by help from their care-receiving husbands. These wives may benefit from assistance in developing strategies that increase the helpfulness of their care-recipient spouses or others in their support network. The second group is caregiving husbands whose wives exhibit problem behaviors and are also attempting to be helpful. These husbands may need assistance in developing methods to channel their wives' helping behaviors. Such efforts on the part of practitioners can enable care recipients to help their caregiving spouses without exacerbating their stress.
Findings from this study contribute to our understanding of gender differences in spousal caregiving distress and point the way for further needed research. We examined how problem behaviors and helping behaviors account for variations in caregiver stress among husbands and wives. More study is warranted to examine both the separate effects of these care-recipient characteristics as well as the interaction between problem behaviors and helpfulness. By continuing to explore care-recipient characteristics in the context of spousal caregiving, we can potentially augment our understanding of the mechanisms that undergird gender differences, illuminate the positive and negative consequences of care recipients' efforts to be helpful, and identify specific ways to enhance the well-being of caregiving husbands and wives.
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Footnotes |
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1 School of Social Work, The University of Michigan, Ann Arbor.
2 Department of Social Work, University of Minnesota, Duluth.
Decision Editor: Linda S. Noelker, PhD
Received for publication December 11, 2002. Accepted for publication June 18, 2003.
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