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Coping With Late-Life Challenges: Development and Validation of the Care-Receiver Efficacy Scale

Correspondence: Address correspondence to Dr. Enid Cox, University of Denver, Graduate School of Social Work, Denver, CO 80208. E-mail: ecox{at}du.edu

	Abstract

TOP Abstract Methods Phase 1: Planning Phase 2: Item Pool... Phase 3: Quantitative Evaluation Results of the Quantitative... Phase 4: Validation Discussion References

 
Purpose: Measures are lacking that address the challenges that people think they face in their roles as elderly care receivers. However, the development of a sense of efficacy in this role by mentally competent care receivers is critical to successful partnerships between caregivers and care receivers. The purpose of this article is to report the development and psychometric analysis of the Care-Receiver Efficacy Scale (CRES). Design and Methods: Content validity, internal consistency reliability, factor structure, and convergent validity were assessed through a pilot study, expert review, and field administration with 177 participants. Results: Results suggest that the CRES comprises five subscales, with strong reliability evidenced for three subscales but marginal reliability for the remaining two. Strong support was found for content validity from expert review and moderate support from the relationship between empirical and expert judgment of item location. Support for validity also was found from correlation with the Geriatric Depression Scale–Short Form and the Philadelphia Geriatric Center Morale Scale. Implications:The CRES may be useful as an outcome measure for psycho-socio-behavioral interventions aimed at increasing the capacity of care receivers to direct and improve their own care. Future measure revision and validation are important to optimize its utility.

Key Words: Caregiver • Care receiver • Psychometric • Scale development • Self-efficacy

As some researchers have noted, the concept of self-efficacy has been applied to the caregiving of elderly persons (Gignac & Gottlieb, 1996; Steffen, McKibbin, Zeiss, Gallagher-Thompson, & Bandura, 2002). Steffen and colleagues noted that work done with respect to caregiving and self-efficacy "suggests that self-efficacy theory holds significant promise for explaining the variability in family members' ability to cope with the chronic demands and challenges of caregiving" (p. 74). Attempts to measure caregiving self-efficacy and consequently to measure effects of interventions have led to the development of scales that facilitate this effort (Steffen et al.; Zeiss, Gallagher-Thompson, Lovett, Tose, & McKibbin, 1999).

	Methods

TOP Abstract Methods Phase 1: Planning Phase 2: Item Pool... Phase 3: Quantitative Evaluation Results of the Quantitative... Phase 4: Validation Discussion References

 
The initial work on care-receiver efficacy that we used to develop the CRES included a number of studies eliciting the perspectives of care receivers (Cox, 2003; Cox & Dooley, 1996; Cox, Dooley, Liston, & Miller, 1998). We conducted in-depth interviews with more than 450 functionally disabled elderly persons, including Euro-English, African American, Mexican American, Native American, and Asian care receivers. The care receivers we selected for inclusion were individuals older than 55 years of age who required at least 6 to 8 hours of personal care per week to accomplish the activities of daily living. All individuals had more than the minimum requirement of care hours.

Elderly participants in these qualitative studies described their roles as care receivers; they also explained the challenges they faced and their ways of coping. The studies suggest that the majority of these cognitively competent care receivers struggled for ways to provide self-care and maintain control over the care process. Achieving a sense of self-efficacy with increased disability is a key challenge (Cox & Dooley, 1996; Cox et al., 1998).

We derived seven themes or components of the care-receiver role from these studies. These components of the care-receiver role included self-care strategies; ways of assisting caregivers; relationship to professional caregivers; use of health and social services; participation in social support networks; ways of coping with feelings and values about increasing dependency; and ways of maintaining or developing meaningful life pursuits. We used these findings to create the dimensions and the related item pools for this study. We then developed a scale to measure individual care-receivers' perceptions of self-efficacy, the CRES, in four multistep phases as listed in Table 1. We followed the recommendations of Benson and Clark (1982) and DeVellis (2003) in our scale development.

	Phase 1: Planning

TOP Abstract Methods Phase 1: Planning Phase 2: Item Pool... Phase 3: Quantitative Evaluation Results of the Quantitative... Phase 4: Validation Discussion References

The first author (E. Cox), together with colleagues in gerontology, created an item pool from the identified components of care receiving. We grouped items for presentation purposes into the categories listed herein. All of the components of care-receiver self-efficacy were represented by the pool of items; however, we made no attempt to create an equal number of items for each component. We did not theoretically derive these categories; we created them from an extensive review of the literature and a thematic analysis of qualitative interview data. We did not intend them to reflect the final structure of a measure. Whereas we anticipated that the final measure would be multifaceted, we later assessed the empirical structure by using exploratory factor analysis. The initial item pool comprised 123 items, approximately three times as many items as we desired for the final measure as recommended by DeVellis (2003).

	Phase 2: Item Pool Creation

TOP Abstract Methods Phase 1: Planning Phase 2: Item Pool... Phase 3: Quantitative Evaluation Results of the Quantitative... Phase 4: Validation Discussion References

 
Expert Review for Content Validation
We asked four experts in gerontological social work to review all items and comment on item clarity and appropriateness as well as how well the item reflected the construct of care-receiver self-efficacy. In order to provide a rough estimate of item location on a trait continuum, we also asked these experts to classify each item as easy, moderate, or difficult to agree with.

Two of the experts were assistant professors of social work, with extensive prior careers as gerontological social workers. Two of the four experts have authored books, book chapters, and journal articles on health care, abuse, empowerment, and caregiving for elderly persons, in addition to other issues associated with aging. One expert spent more than a decade as an analyst for the U.S. Senate Special Committee on Aging; another was state ombudsman for elderly persons for more than 25 years and is a nationally recognized advocate for the rights of older disabled residents of nursing homes and assisted care facilities. All four of the experts have a strong interest in the empowerment of frail elders.

We asked experts to (a) evaluate whether the items related to perceptions of care-receiving efficacy; (b) judge item quality and make suggestions for item revision; (c) judge social desirability of item response and make suggestions for rewording; and (d) identify and comment on the relationships among components—that is, whether single or multiple subscales were represented by the items and what they might be titled. We sent forms by means of postal mail to the four experts in 2003–2004. We made follow-up telephone calls after 3 weeks to anyone who had not yet completed the review.

Results
Experts commented that subscales, as they identified them, were likely to be highly related and that items would likely relate to more than one subscale. Reviewers did not agree with the division of items into the proposed list of seven categories, but they did agree that multiple facets of care receiving were represented by the items. The idea of a multifaceted measure was supported at this phase, although it was not expected that items would factor according to the original category designation.

Experts judged 10 items to be confusing as a result of wording or an unclear relationship with care-receiver efficacy (e.g., "I feel guilty because my health care costs so much," "I refuse help as often as possible even when I need it"). Nineteen more items failed to relate to care-receiver self-efficacy, as judged by two or more of the four experts. We retained items that all or three of the four experts judged as related to care-receiver efficacy. In total, we flagged 29 items, the content of which experts found ineffective, for deletion.

Pilot Testing
A sample of 43 care receivers, referred by gerontological social workers employed in numerous service programs for the aging, responded to the items. Briefly, demographic characteristics reported by the majority of participants were as follows: Health status was either fair or good (about 46% in each category); 72% lived in their own homes; approximately 64% lived with family; 64% were married; and about 91% were Caucasian. The mean age of the participants was 78.40 (SD =10.81, range = 62–97). The 43 care receivers completed the 123 items individually in the presence of a research associate. Items were read aloud if the care receiver wished it. Care receivers were encouraged to respond to all items, although not past the point of fatigue. Completion of the inventory took about 45 to 60 minutes. To access these participants, research associates traveled to independent senior housing, assisted living facilities, and skilled nursing facilities.

Results
We flagged 27 items as having low (<.60) variance or low (<.20) item-total discrimination coefficients. We chose these criteria to result in deletion of an additional 25% of the items. Fifteen of the 27 items had been flagged as poorly functioning by the expert panel as well. After we completed the content validation and pilot testing, 71 workable items remained. As we did not know the extent of the correlation among items at this stage of scale development, we retained a sufficiently large number of items to allow us to make further refinement when examining internal consistency (DeVellis, 2003).

	Phase 3: Quantitative Evaluation

TOP Abstract Methods Phase 1: Planning Phase 2: Item Pool... Phase 3: Quantitative Evaluation Results of the Quantitative... Phase 4: Validation Discussion References

 
Participant Sample
We recruited a total of 177 participants from the Denver, CO metropolitan area as part of a larger intervention study (study description available from E. Cox). Individuals were referred by health, aging, and social service programs; churches and senior social or political groups; and other study participants. To participate in the study, an individual had to (a) be 55 years of age or older (b) require a minimum of 6 hours of personal care per week, and (c) be cognitively able to participate in the intervention program as determined by the Mini-Mental State Exam from the Diagnostic Interview Schedule (Folstein, Folstein, & McHugh, 1975) and the judgment of the clinical social worker who was working with the project. One individual under the age of 55 was selected for participation because of her disability and need for care.

The mean age of participants was 78.42 (SD = 9.78), with ages ranging from 51 to 96. A majority of the participants were female (76.3%), Caucasian (78.5%), and widowed (51.4%). The modal living status was "living alone" (76.3%), with much smaller numbers "living with family" (17.5%) and "living with a nonrelative" (6.2%). The modal residential location was an independent retirement community (40.7%), with 27.1% of the participants in assisted living, 24.9% in their own homes, 5.6% in a relative's home, and 1.7% in a skilled nursing facility. The self-reported health status of participants was mostly fair or good (39.5% in each category), with 13.0% of the participants in poor and 7.3% in excellent health. The modal income category was $4,860–11,064 (42.9%), with income categories ranging from $0–4,860 (6.8%) to over $45,000 (2.3%).

Instruments
We presented items to participants in booklet form. We administered the Geriatric Depression Scale–Short Form (GDS-SF; Sheikh & Yesavage, 1986) and the Philadelphia Geriatric Center Morale Scale (PGCMS; Lawton, 1975) in order to explore the links between self-efficacy, depression, and morale. We selected the GDS-SF and the PGCMS for a test of convergent validity, because these two instruments are commonly used in studies focused on psychological well-being in geriatric populations (Blazer, 2002). Recent focus on factors related to depression in mentally competent disabled elderly care recipients has established the relationship between depression and morale and mediating factors related to care-receiver efficacy, as identified in the CRES. These factors include social support, a sense of reciprocity, and sense of mastery (Wolff & Agree, 2004; Yuri, Borenstein, Chiriboga, & Mortimer, 2005). We hypothesized that some facets of self-efficacy would be negatively correlated with depression and positively related to morale in elderly care receivers; specifically, the efficacy facet related to increasing dependence would relate to depression and the quality of life facet would relate to morale.

Procedure
During the first contact with project staff, often by telephone, we had participants given a general description of the project, including information on the development of the CRES as well as details about the intervention. At this time, if the individual wished to participate, project staff determined a contact site for his or her interview. This was typically the participant's home, though on occasion the home of relatives, a senior center, health care facility, or other site was used. All participants were interviewed individually for the purpose of completion of the consent form and study instruments (i.e., the CRES, the GDS-SF, and the PGCMS). During the interview, interviewers read all survey items to the participant and recorded his or her answers. Individuals trained in the fields of social work and gerontology conducted the interviews. We employed Spanish- and Russian-speaking social workers to conduct the interviews for participants speaking those languages. We collected data between January 2002 and July 2003.

	Results of the Quantitative Analysis

TOP Abstract Methods Phase 1: Planning Phase 2: Item Pool... Phase 3: Quantitative Evaluation Results of the Quantitative... Phase 4: Validation Discussion References

 
Exploratory Principal Components Analysis
We submitted the 71 items remaining after expert review and pilot testing to iterative principal components analyses with oblique rotation in order to winnow out yet more items. In the first iteration, we identified and deleted 15 items that did not load above an arbitrarily chosen value of.30 on the first seven factors; in the second iteration, we deleted an additional 7 items, based on cross-loading or low communality, with 49 items remaining. We examined solutions with three to seven factors. The four-factor solution, accounting for 43.6% of the variance, seemed the most interpretable. We selected no cross-loading items to represent a factor (we defined cross-loading as two loadings that differed by less than.10). We selected items as representing a factor if (a) loadings were at least.40 on the factor and (b) items were conceptually appropriate to the idea of the item set. Of the 49 items, we retained 46. Appendix A presents the structure and pattern loadings of the 49 items.

Conceptual Review of Subscales
The first author and two gerontology students reviewed the four subscales with respect to fidelity to the initial conceptual content used to generate items. Self-care strategies, relationship to professional caregivers, and use of health and social services were captured in Subscale 1 (self-care strategies). Ways of assisting caregivers were captured in Subscale 2 (relational coping with caregivers); values about increasing dependency were reflected in Subscale 3 (perceptions of dependence), and participation in social networks and maintaining meaningful life pursuits were captured in Subscale 4 (performance-related quality of life). However, we found a deficiency in terms of a conceptual area missing from the content represented by the four subscales: feelings about dependency. We considered this conceptual area to be necessary to a scale that would be useful in interventions with care receivers. Therefore, we identified 10 items that reflected feelings about increased dependency on the basis of item content in the 71 items initially factored. These 10 items had inadequate loadings on the first seven factors, and so we had removed them from consideration in the first iteration of the factor analysis. The ad hoc subscale formed by this item set was viewed as likely to be weak on the basis of empirical structure and also might overlap other subscale content. However, in this case, we gave the conceptual review and experts' support of these items precedence over the exploratory factor analysis that led to the deletion of those 10 items. We labeled the tentative fifth subscale "accepting help."

Internal Consistency Reliability
We estimated Cronbach's alpha for each of the five subscales (see Table 2). Eight of 56 total items failed to contribute to their intended subscale and were deleted. Reliability of Subscales 3 (perceptions about dependence) and 5 (accepting help) were low compared with that of the other subscales. These scales come close to a minimum standard of.70 for reliability (Nunnally, 1978) and were judged to be of questionable practical use, but we retained them for further analysis and potential future modification. A 48-item measure is still lengthy and may challenge the energy and attention of elderly care receivers. To optimize scale length, we identified the 5 most internally consistent items per subscale by means of repeated item analyses, deleting the least effective items one at a time. Table 2 also lists the reliabilities of each shortened subscale. (Italicized items in Appendix B are the 5 items retained for each subscale.)

	Phase 4: Validation

TOP Abstract Methods Phase 1: Planning Phase 2: Item Pool... Phase 3: Quantitative Evaluation Results of the Quantitative... Phase 4: Validation Discussion References

Validation by Means of Correlation With Experts' Ratings
We obtained item difficulty or item location ratings from (a) the four experts, described in Phase 2, and (b) the field administration of the measure, described in Phase 3. We calculated empirical item locations by using Winsteps (Linacre, 2005) in a Rasch model analysis. Item location values are nonlinear transformations of item raw scores that are on an interval scale. We used Spearman's rho to correlate empirical item locations with the average (mean) judged item locations by subscale.

Correlations were moderate to high for three subscales, although they were statistically significant at p <.05 for only two subscales (Table 4). This suggests that, for three subscales, experts understood the items in a manner similar to care receivers and thus supports the validity of subscales by means of this mutual agreement. For Subscales 1 and 2, mean experts' ratings were unrelated to empirical item locations. For these two subscales, experts were in substantial disagreement about item location ratings and empirical item means did not vary greatly.

Summary
Internal consistency reliability estimates supported the utility of the subscales, with the possible exception of the shortest subscale, perceptions of dependence. The internal consistency reliability estimate for Subscale 5, accepting help, was also lower than desired, barely exceeding the minimum.70 standard. We did find support for convergent validity, with stronger support for content validity from experts' judgments. The 5-point response scale could be replaced with a 4-point scale, and the construct coverage could be expanded by the inclusion of items that are written to be more difficult to agree with, thus yielding more variability in item means. Finally, empirical item location agreed to a considerable extent with expert-judged item location, providing support for the construct validity of three of the five subscales.

	Discussion

TOP Abstract Methods Phase 1: Planning Phase 2: Item Pool... Phase 3: Quantitative Evaluation Results of the Quantitative... Phase 4: Validation Discussion References

 
From a social policy, financial, and humanitarian perspective, the capacity of cognitively able care receivers to organize and manage their own care should be maximized. Our purpose in the study reported here was to develop a measure of care-receiver self-efficacy that was currently lacking in the literature. The resultant CRES is intended for use with psychoeducational interventions aimed at increasing the capacity of lucid care receivers to direct and improve their own care.

The CRES generally showed adequate internal consistency reliability. We found support for validity through low to moderate correlations with the GDS-SF and the PGCMS, correlations with experts' ratings of item difficulty, and expert review of item content. Several limitations and suggestions for further use should be noted. First, reliability estimates of two of the five subscales were lower than desired. Second, the breadth of coverage of the items was less than desired. Third, expert and empirical item ordering were unrelated for Subscales 1 and 2, possibly as a result of restricted breadth of coverage. Fourth, correlations with validation measures were modest and involved only two external measures (the GDS-SF and PGCMS). Fifth, we used three sources of validity evidence, but there are many more that remain to be explored. Goodwin and Leech (2003) recommend that measure validity be supported by multiple sources of evidence. We did not include evidence sources such as examination of response processes, discriminant validity, group-comparison studies, and criterion-related validity studies in this project, as they would have exceeded the study scope and resources. Future research should address the regression of caregiver stress and satisfaction with caregiving on CRES subscales.

In future scale revisions, researchers could address limitations by revising or adding items to extend scale coverage and length. In future revisions they might also address the improvement of item wording by simplification and clarification, such as by the use of less complex words. Relationships with additional validation measures such as locus of control and a coping inventory would be of interest. Future study of discriminant and criterion-related validity would also be appropriate, as would a reexamination of the factor structure by means of confirmatory factor analysis, particularly in light of the inclusion of an ad hoc subscale in the measure.

Despite challenges with respect to reliability regarding Subscale 3 and both reliability and structure regarding Subscale 5, neither was deleted at this point, because of the critical significance of beliefs and attitudes about needing and accepting care to successfully meeting the demands of the care-receiving role. Although strong with respect to representing stated feelings about care receiving among elderly respondents in a series of qualitative studies across culturally diverse populations of elderly persons (Cox & Dooley, 1996), the items in Subscale 3 do not assist in assessing change in perspective or willingness to overcome these beliefs in order to be effective as care receivers. Items in Subscale 5 are more indicative of ways some elderly care receivers have rationalized their need for care in a manner that makes acceptance of assistance less difficult. It is evident that more research has to be done with regard to creating items that capture both attitudes toward acceptance of assistance and the changes necessary to allow for proactive involvement in the care-receiving role.

More than 78% of the sample participants were Caucasian and 76% were female; in combination, over 55% of the participants were female Caucasian care receivers. As a result of this disproportionate number of female and Caucasian participants, the generalizability of the findings in this study has to be assessed with male care receivers, as well as groups of care receivers having diverse racial and ethnic backgrounds.

Furthermore, self-efficacy might be a contextually dependent concept. Thus, all subscales of the CRES may not be equally applicable in all settings. Instead of applying all CRES subscales, researchers, program evaluators, and practitioners may need to choose the most relevant subscales of the CRES, depending on practice setting, client population, intervention objectives, and policy purpose.

The continued development and use of the CRES can be an important step in encouraging researchers to pay attention to the complexity of the care-receiving role, the critical importance that care receivers play in their care process, and the potential for persons to develop competencies as care receivers. Gaining a sense of self-efficacy as it relates to the care-receiver role is critical to both care receivers and caregivers as they struggle to forge effective partnerships.

	Footnotes

 
¹ Graduate School of Social Work, University of Denver, CO.

² College of Education, University of Denver, CO.

³ Faculty of Languages and Cultures, University of Kyushu, Fukuoka, Japan.

⁴ Children's Medical Center, University of Texas at Arlington.

Decision Editor: Linda S. Noelker, PhD

Received for publication November 6, 2005. Accepted for publication May 9, 2006.

	References

TOP Abstract Methods Phase 1: Planning Phase 2: Item Pool... Phase 3: Quantitative Evaluation Results of the Quantitative... Phase 4: Validation Discussion References

 

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