Gain in the Caregiving Experience: Where Are We? What Next?
Transcription
Gain in the Caregiving Experience: Where Are We? What Next?
Copyright 1997 by The Cemntological Society of America The Cerontologist Vol.37, No.2, 218-232 This critical review of 29 studies published through 1996 on the gain experienced among informal caregivers of older adults, identifies 13 conceptual (i.e., definitions and theoretical frameworks) and methodological (i.e., sampling, design, measurement, analysis) observations. Key limitations of prior research are highlighted and recommendations necessary for the advancement of research in this area of inquiry are made. Drawing upon relevant theoretical frameworks and the observations noted in this review, a conceptual framework is proposed to bring some consistency to the ways in which future research on positive aspects of caregiving proceeds. Key Words: Family caregiver, Elderly, Well-being, Satisfaction, Benefits Gain in the Caregiving Experience: Where Are We? What Next?1 Betty J. Kramer, PhD2 1 The author gratefully acknowledges the comments of Aaron M. Brower, Jan S. Greenberg, Nadine F. Marks, Marsha M. Seltzer, and the anonymous reviewers on earlier drafts. This is article no. 95-19 from the Madison Veterans Administration, Geriatric Research, Education and Clinical Center (GRECO. Assistant Professor at the University of Wisconsin-Madison. Address all correspondence to Betty J. Kramer, PhD, University of Wisconsin-Madison, School of Social Work, 1350 University Avenue, Madison, Wl 53706. 218 have been reported in the social-psychological literature (Ryff, 1989a; 1989b). The focus on detrimental caregiving consequences is somewhat consistent with the long trend in social science research to focus on general measures of psychological dysfunction (e.g., depression, lack of health, anxiety). Ryff and Keyes (1995, p. 719) noted that "prior endeavors have grappled minimally with the core underlying question: What does it mean to be well psychologically?" Drawing upon literatures from developmental psychology, clinical psychology, and mental health, Ryff (1989a; 1989b) developed six distinct dimensions of more positive contours of well-being that include personal growth, purpose in life, autonomy, environmental mastery, positive relations with others, and self-acceptance. Recent structural analysis, using a nationally representative sample, provided support for this 6-factor model, and extensive research has demonstrated that these well-being dimensions possess distinguishing age trajectories (Ryff & Keyes, 1995), gender profiles (Ryff, 1989b; Ryff, Lee, & Na, 1993; Ryff, Lee, Essex, & Schmutte, 1994), and cultural profiles (Ryff etal.,1993). This discussion of more positive psychological functioning is raised because the field needs a wholesale rethinking about caregiving experiences and outcomes to include positive aspects of caregiving and positive indicators of well-being. Clearly, there is more to mental health than the absence of pathology, and people experience both positive and negative emotions. Lack of attention to the positive dimension of caregiving seriously skews perceptions of the caregiving experience and limits our ability to enhance theory of caregiver adaptation. In recent years, there have been numerous calls to take a more holistic view by considering positive aspects of caregiving and the ways in which these differ from burden in their correlates and predictors (Greenberg, The Gerontologist Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 The primary thrust of caregiving research over the past two decades has centered on the negative and detrimental aspects of the caregiving process. Investigations have been driven by the desire to understand variations in caregiver adaptation so that interventions and policies may be designed to enhance well-being. While early investigations focused primarily on the study of caregiver burden as a means to this end, George and Cwyther (1986) compelled the field to use indicators of well-being, citing their advantage of tapping multiple dimensions and of being conceptually distinct to caregiving, thus allowing for noncaregiver comparisons. Since that time, the caregiving literature has seen an expansion in the use of multidimensional outcome indicators such as depression (Haley, Levine, Brown, Berry, & Hughes, 1987; Pruchno & Resch, 1989), affect (Franks & Stephens, 1992; Lawton, Moss, Kleban, Glicksman, & Rovine, 1991), health (Franks & Stephens, 1992; Killeen, 1990, Young & Kahana, 1989), life satisfaction (Guerriero-Austrom, & Hendrie, 1992; Wallhagen, 1992; Wright, Lund, Caserta, & Pratt, 1991), and social life (Stull, Kosloski, & Ketcher, 1994). This line of inquiry has enhanced understanding of the challenges facing family caregivers to older adults with cognitive and physical impairments and has led to a proliferation of intervention studies designed to reduce caregiver stress (Toseland & Rossiter, 1989). A striking omission in this research is of attention to positive psychological functioning and the rich array of theoretically grounded well-being indicators that practical, methodological, and theoretical relevance. The term "gain" will be used to refer to the more positive appraisals of the caregiving experience. While strain (or burden) has been defined as "the extent to which the caregiving role is judged to infringe upon an individual's life space and be oppressive" (Montgomery, 1989, p. 204), gain may be defined very broadly as the extent to which the caregiving role is appraised to enhance an individuals' life space and be enriching. Gain may include any positive affective or practical return that is experienced as a direct result of becoming a caregiver. As such, a distinction must be made between gain that is a specific referent to the caregiving role, and psychological well-being that may be influenced by, but is potentially independent of, the caregiving experience. The purpose of this article is to critically review the literature that examines gain associated with caregiving. With particular attention given to conceptual and methodological issues, the intent of this review is to examine how gain has been studied, to identify what has been learned in the process, and to put forth recommendations necessary for the advancement of research in this area of inquiry. Literature Review A computerized literature search was completed that extended back to 1974 using the following data bases: Social Science Citation Sociological Abstracts, Social Work Abstracts, Dissertation Abstracts, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and Psych Lit. As discussed above, gain was defined broadly to include any positive affective or practical return that resulted from caregiving. Key terms used to identify gain included variations of the following: benefits, rewards, satisfactions, gratifications, gains, pleasures, enjoyment, uplifts, and positive aspects. Given the relative lack of attention to this area of inquiry, all efforts were made to first identify any and all manuscripts that included the topic of caregiver gain. A total of 47 studies were identified. The following criteria were then developed to select research articles for this review: 1. Study participants were providing assistance in one or more activities of daily living (ADLs) or instrumental activities of daily living (lADLs); 2. Care receivers were community-dwelling older adults with cognitive, emotional, or physical impairments; 3. Sufficient detail was provided so as to allow for replicability of the study; 4. Data were generated beyond descriptions or anecdotal reports of gain; and 5. Attempts were made to analyze the relationship between gain and other variables within the caregiving context. Using these criteria, 29 studies were analyzed and are presented in alphabetical order in Table 1. As shown in this Table, the vast majority of studies have been published since 1988, reflecting a very recent and persistent surge of interest in the study of caregiving gain during the past decade. Because both theory and research on positive aspects of caregiving are still in their developmental stages, a review of the literature permits description of the trends in this investigative area that have Vol. 37, No. 2,1997 219 Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 Seltzer, & Greenley, 1993, Kramer, 1993a; 1993b; Miller, 1989; Motenko, 1989; Stephens, Franks, & Townsend, 1994). Indeed, the benefits of providing care for persons with a variety of illnesses such as AIDS (Ferrari, McCown, & Pantano, 1993; Wardlaw, 1994), schizophrenia (Bulger, Wandersman, & Goldman, 1993), traumatic brain injury (Allen, Linn, Gutierrez, & Wilier, 1994), developmental disabilities and mental illness (Greenberg et al., 1993) are beginning to surface in the literature. Why is it important to investigate positive aspects of caregiving? First, it is an aspect of care provision that is reported by many caregivers and one that caregivers seem to want to talk about. Recognition of positive experiences in caregiving initially surfaced from anecdotal and qualitative reports of caregiver's who indicated that giving care increased their feelings of pride in their ability to meet challenges, improved their sense of self-worth, led to greater closeness in relationships, and provided an enhanced sense of meaning, warmth, and pleasure (Archbold, 1983, Motenko, 1988; Reese, Walz, & Hageboeck, 1983). In a recent qualitative study, 90% of the 94 caregivers interviewed reported that they valued positive aspects in caregiving (Farran, KeaneHagerty, Salloway, Kupferer, & Wilken, 1991). Second, understanding positive aspects of caregiving may help clinicians and practitioners to work more effectively with the family caregiver. This may be accomplished by improving both assessment and intervention methods once predictors of positive outcomes are identified via research. Research may provide clues as to how to enhance or increase positive aspects of care provision or may identify caregivers who are less likely to need intervention. By recognizing the ways in which individuals feel enriched by caregiving, professionals may more appropriately validate feelings and experiences. Clinicians have voiced concern that a preoccupation with burdens and problems "empowers the problem and disempowers the person" (Graber & Nice, 1991, p. 3). Attention to positive aspects is consistent with a strengths perspective that recognizes the capacity for continued growth in each individual (Weick, Rapp, Sullivan, & Kisthardt, 1989). Third, positive aspects of caregiving may be important determinants of the quality of care provided to older adults, which has to date received minimal attention (Orbell & Gillies, 1993a). Finally, an important potential contribution of this line of inquiry is to provide information to enhance theories of caregiver adaptation and psychological well-being. It is somewhat surprising that theoretical perspectives have neglected to take positive experiences into consideration (see Biegel, Sales, & Schulz, 1991, for a review) given that the positive dimension of caregiving has the potential to improve understanding of the variability found among caregivers in other enduring outcomes (Lawton, Rajagopal, Brody, & Kleban, 1992). ore © n © M = 77; dementia 49-92; M = 72; dementia Cohen, Gold, Shulman, & Zucchero (1994) Farran, Keane-Hagerty, Salloway, Kupferer, & Wilken (1991) Elderly; not specified Brody, Litvin, Hoffman, & Kleban (1992) M = 77; dementia M = 77; stroke dementia and cardiovascular, muscular, skeletal, and gastrointestinal disorders Braithwaite (19%) Cohen, Gold, Shulman, Wortley, McDonald, and Wargon (1993) M = 81; not specified Albert (1992) Author(s) Care Receiver Age& Diagnosis N = 94; 66% spouses, 27% adult children, and 7% other; 81% Caucasian; middle and upper-middle socioeconomic status; ages 30-78, M = 61; recruited from community agencies, the Alzheimer's Association, media announcements, and the Rush Alzheimer's Disease Center Caregivers asked to report aspects of caregiving they enjoyed; coded into 6 categories, then treated as single item, continuous variable from no enjoyment to multiple categories of enjoyment How caregivers grow and find meaning through the caregiving experience Open ended questions that elicited information on positive aspects of caregiving included: what are the most pleasant aspects of caregiving?, what keeps you going or gives you hope?, what are the good things in your life?; verbatim and summary comments were recorded Enjoyable aspects Number of enjoyable aspects of being a reported; see Cohen et al. (1993) caregiver N = 1%, 59% spouses, 27% adult Enjoyment of children; M age = 64; 76% women caregiving N = 196 caregivers recruited from medical and community social agencies; 57% spouses, 26% adult children; 17% other relatives; M age = 64; 76% women Four items identified via factor analytic techniques (i.e., being appreciated, being care receiver's confidant, knowing there would be things missed if caregiving ended, and having asked for and received help in the past); alpha not specified Caregiving Satisfaction Scale (see Lawton et al., 1989); used 7 items rather than 5; alpha = .86 Measurement Approach Caregiver Caregiving Satisfaction Scale (see satisfaction in the Lawton et al., 1989); alpha = .92 caregiving role Positive aspects are appraisals seen as mutually rewarding which reflect intimacy and love N = 144 Australian caregivers recruited from adult day cares and community home health care agencies; 75% female; 86% co-residing with care receiver; M age = 58; 43% spouses; 51% adult child; 6% other N = 492 daughters; 69% co-resided with their parent; 84% Caucasian; care receivers were spouseless; recruited from public media, work place or religious organizations, and word of mouth "Caregiver satisfaction taps the pleasures and rewards of caregiving" (p. 702) Definiton of Gain N = 214 persons caring for parent or in-law; drawn from the Philadelphia Geriatric Center's caregiver registry; 92% female; 56% co-residing Sample Characteristics Table 1 . Summary of Studies on Caregiver Gain Appraisal dimensions identified have parallels in work of Lawton et al. (1989; 1991); greater intimacy and love correlated with less negative affect, more positive affect, more affect balance, and fewer minor psychiatric symptoms Although differences across marital status categories of daughters were found for caregiver and parent characteristics, and multiple indices of caregiver well-being, no difference in caregiver satisfaction across marital status categories were reported Number of enjoyable aspects associated with decision to place relative in a nursing home, but not related to actual placement in nursing home 55% listed at least one enjoyable aspect of carenumber of enjoyable aspects correlated with lower burden, better health, better prior relationship quality, more satisfaction with social support, higher incomes, and fewer negative reactions to care receiver problems; those caring for females reported more enjoyable aspects of care 90% of respondents reported "Valuing Positive Aspects" of caregiving; in another subcategory called "Searching for Provisional Meaning," caregivers reported that they were growing and finding meaning through the experience of caregiving; valuing positive aspects was not correlated with any of the quantitative measures; search for provisional meaning was associated with higher levels of social support Utilized Lawton and colleagues (1989; 1991) conceptualization of subjective variables as appraisals Not specified Not specified Not specified Existentialism and a model in which stages, responses, and phases of suffering are proposed to assist caregivers to find meaning and grow (continued on next page) Satisfaction correlated with thinking of obligation in communal terms (i.e., feeling a part of one's parent; own care to parent; return of warmth, spoiling parent, perform care because parent needs me) Reported Findings Not specified Theoretical/ Conceptual Framework Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 K3 p u> M = 71; major depressive disorder; excluding dementia 55-94; M = 73; Alzheimer's disease 57-91; M = 71; stroke 57-88; M = 7b; Alzheimer's disease 57-88; M = 76; Alzheimer's disease Hinrichsen, Hernandez, & Pollack (1992) Kinney & Stephens (1989) Kinney, Stephens, Franks, & Norris (1995) Kramer (1993a) Kramer (1993b) Author(s) Care Receiver Age& Diagnosis N = 72 wives; co-residing with husbands, age range = 57-82, M = 70; primarily Caucasian; living in Western Washington; recruited from community agencies, support group, word of mouth, and media announcements N = 72 wives; co-residing with husbands, age range = 57-82, M = 70; primarily Caucasian; living in Western Washington; recruited from community agencies, support group, word of mouth, and media announcements N = 78 caregivers recruited through patient medical records at 2 hospitals; 76% female; 94% Caucasian; Mage = 60 (range 27-81; 74% spouses, 22% daughters or daughters-in-law, 4% other family N - 60; 81% female; spouses, daughters and other included; M age = 57 N = 150; 23% wives, 30% husbands, 30% daughters, 17% were sons; recruited from hospital Sample Characteristics The Caregiving Satisfaction Scale (Strawbridge, 1991); 15-item scale designed to capture long-term satisfactions and rewards; responses coded on a 4-point scale from 1 = strongly disagree to 4 = strongly agree; alpha = .90 Caregiving Hassles and Uplifts Scale (Kinney & Stephens, 1987; see Kinney & Stephens, 1989); reliability coefficients ranged from .74 to .94 Caregiving Hassles and Uplifts Scale (Kinney & Stephens, 1987); 110 events appraised on a 4-point scale as a hassle or uplift; total uplift and 4 subscale scores were computed; alpha coefficients ranged from .71 to .90 Caregivers asked what they found most difficult and rewarding about caregiving; no more than five responses were recorded for each of the two questions and responses were content-analyzed Measurement Approach Caregiver The Caregiving Satisfaction Scale satisfaction in the (Strawbridge, 1991; see Kramer, caregiving role; 1993a) form of positive outcome Caregiver satisfaction in the caregiving role; form of positive outcome Uplifts are daily events that evoke feelings of joy, gladness or satisfaction "Uplifts are events that make you feel good; they can make you joyful, glad or satisfied" (p. 408) Rewards experienced in caregiving role Definiton of Gain Table 1 . Summary of Studies on Caregiver Gain (Continued) Caregivers reported more uplifts than hassles; care recipient characteristics were stronger predictors of hassles and uplifts than caregivers characteristics; hassles demonstrated strongest associations with well-being (i.e., depression, activity restriction and negative relations); when uplifts outweighed hassles, caregivers reported lower levels of distress Caregiving satisfaction correlated with activities of daily living (ADL), caregiver age, quality of the prior relationship, and satisfaction with social involvement; in multivariate models, differential predictors found for negative versus positive outcomes; predictors of depression included symptoms, caregiving duration, marital history, and perceived stress regarding IADL; predictors of satisfaction were ADL and quality of prior relationship After controlling for stressors and caregiver resources, emotion-focused coping predicted depression; whereas caregiver age, social resources, problem-focused and relationship-focused coping predicted satisfaction Referred to transactional theories of stress Resiliency Model of Family Stress, Adjustment, and Adaptation Theoretical framework drawn from personenvironment stress and coping theories (continued on next page) Caregiver and receiver characteristics not associated with uplifts; types of uplifts were associated with various types of symptoms; women reported more uplifts than men; younger caregivers who spent more time in caregiving activities reported more behavior uplifts; uplifts not correlated to well-being Stress Model Reported Findings 51% reported rewards; 103 rewards identified to include enhancement in the relationship; rewards with self (e.g., personal growth), and relationship with others; rewards not correlated with patient illness characteristics, caregiver depression, burden, or psychiatric symptoms; rewards with relationship negatively correlated with relationship strain Not specified Theoretical/ Conceptual Framework Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 3" rv K5 Elderly; dementia N = 50 wives identified through Alzheimer's Disease support groups, a Memory Disorders Center in Massachusetts and public service announcements; ages 58-87 (M = 70) Motenko (1989) Not specified Stress Theory and Two-Factor Theory of Happiness Stress Model Theoretical/ Conceptual Framework Not specified One item based on magnitude scaling techniques: "How many points would you give to show how good it makes you feel to help (your parent?) The better it makes you feel, the bigger the number." (p. 280) Caregiving Satisfaction Scale (see Lawton et al., 1989); alpha = .67 for both samples Caregiving Satisfaction Scale (see Lawton et al., 1989). Alpha = .71 Five items identified via factor analytic techniques (i.e., enjoying the care receiver, feeling pleasure, feeling closer, being appreciated, and increased self-esteem); items scored on 5-point frequency scale; alpha = .67 for respite sample and .76 for nursing home applicant sample; retest reliability = .76 Measurement Approach Rewards and Four separate questions; one Not specified gratification from 4-point scale item regarding caregiving frequency of warmth, comfort, and pleasure, and three dichotomous indicators regarding satisfactions about changes in relationships, gratification in marital relationship, and enjoyment experienced in husband's presence in the home N = 575; sons and daughters Satisfaction in drawn from the 1982 National Long the caregiving Term Care Survey; 83% Caucasian; role M age = 52; 79% had help from others; 79% daughters Elderly, M age = 81; chronic functional limitations Miller (1989) M = 78 (African Lawton, American); M = Rajagopal, Brody, & Kleban 76 (Caucasian); dementia (1992) N = 285 spouses; Mage = 69; 71% female; 85% Caucasian; N • 244 adult children; Mage = 51; 88% female; 72% Caucasian; drawn from support groups, agencies, and public media M = 76; Alzheimer's disease Lawton, Moss, Kleban, Glicksman, & Rovine (1991) Caregiving satisfaction viewed as one major dimension of caregiving appraisal; "benefits accruing to the caregiver through his or her own efforts" (p.P64) Definiton of Gain Satisfactions are "subjectively perceived gains from desirable aspects of, or positive affective returns from caregiving" (p. P182) N = 472 Caucasian and N = 157 "Caregiving African American caregivers drawn satisfaction is the from a respite-care evaluation result of study; approximately 80% female; caregiving primarily spouses and adult experiences that children but in-laws, siblings, give life a friends, and other relatives positive flavor" included (p. S157) N = 632 for respite sample; drawn from support groups, agencies, and media; M age = 60; N = 239 for nursing home applicant sample drawn from nursing home applications or at-risk state screening program; Mage = 57 Respite sample M = 76; dementia; Nursing home applicant sample M = 83; any type of impairment Sample Characteristics Lawton, Kleban, Moss, Rovine, & Glicksman (1989) Author(s) Care Receiver Age& Diagnosis Table 1. Summary of Studies on Caregiver Gain (Continued) Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 ierontolo (continued on next page) African American caregivers expressed greater caregiving satisfaction, and less burden, depression, and perceived intrusion; greater effort associated with more satisfaction and burden for both samples; the "parallel channel" hypothesis was supported in findings that demonstrated positive affect was differentially affected by satisfactions, while depression was more strongly affected by burden for both caregiver groups Satisfaction positively correlated with stress, more time and effort in caregiving, more problems and costs and negatively correlated with income and education; multivariate analysis revealed alternative sets of explanatory variables for satisfaction and stress; adult children who exerted most effort in caregiving reported both high stress and high satisfaction Wives who perceived the same degree of marital closeness had greater gratification than those who had not; wives who provided care to reciprocate past attention and to nurture their husbands were more gratified than wives who gave care out of obligation; gratification correlated with higher general well-being Caregiving satisfaction associated with help given, caregiver burden, positive affect and depression; in multivariate models, satisfaction was not related to stressors, but was a significant determinant of positive affect for spouses; for adult children, high levels of caregiving effort resulted in both greater burden and greater satisfaction Exploratory and confirmatory factor analysis used to investigate dimensions of caregiving appraisal which consisted of subjective burden, satisfaction, impact, mastery, and traditional caregiving ideology; bivariate correlations revealed that satisfactions were associated with quality of the relationship, burden, affect, and relationship to care receiver Reported Findings p Z 58-95, M = 78; not specified 58-95, M = 78; not specified 58-95, M = 78; not specified > 53; M age = 81; dementia > 53; Mage = 81; dementia Not specified; dementia Orbell & Gillies (1993a) Orbell & Gillies (1993b) Orbell, Hopkins, & Gillies (1993) Picot (1995a) Picot (1995b) Pruchno, Michaels, & Potashnik (1990) Author(s) Care Receiver Age& Diagnosis Satisfaction is "extent to which carers derived a sense of enhanced self-worth" (p. 279) Satisfaction viewed as a positive dimension of caregiving impact appraisals Satisfaction defined as appraisals of "self-worth gains from caring" (p. 101) Definiton of Gain N = 83 female African American Rewards are the caregivers; M age = 59; 60% positive daughters; 4% daughters-in-law; perceptions of 13% wives, 6% sisters, 17% other; caregiving 63% unemployed; 55% of household incomes were under $10,000; drawn from agencies and public media N = 83 female African American Rewards are the caregivers; M age = 59; 60% positive daughters; 4% daughters-in-law; perceptions of 13% wives, 6% sisters, 17% other; caregiving 63% unemployed; 55% of household incomes were under $10,000; drawn from agencies and public media N = 220 spouses recruited from The positive community agencies, hospitals, component of support groups, and public media; caregiving; ages 45-94; M = 70; 68% female perceptions of caregiving as uplifts N = 108 adults identified from a General Practitioner's registry; 63% female, 25% co-residing with care receiver; 59% adult children; 7% were spouses; 34% distant relative, friend, or neighbor; M age = 50 (range 18-76) N = 108 adults identified from a General Practitioner's registry; 63% female, 25% co-residing with care receiver; 59% adult children; 7% were spouses; 34% distant relative, friend, or neighbor; M age = 50 (range 18-76) N = 108 adults identified from a General Practitioner's registry; 63% female, 25% co-residing with care receiver; 59% adult children; 7% were spouses; 34% distant relative, friend, or neighbor; M age = 50 (range 18-76) Sample Characteristics Reported Findings Satisfaction scores lowest and strain scores highest when demand (behavior problems and difficulty with tasks) was high and discretion (perceived reliance) was low Scale consisting of eight items assessed frequency of perceptions (using 3-point scale) regarding companionship, affection, enjoyment, appreciation, cheerfulness of care receiver, closeness of relationship, and extent to which they prevent further deterioration in care receiver Picot Caregiver Rewards Scale (see Picot, 1995a); alpha coefficient = .86 Caregivers who placed their spouses reported fewer uplifts than those continuing care; after controlling for demographic, stressor, and resource variables, uplifts were marginally significant predictors of desire to and actual institutionalization Conceptual framework for predicting desire and actual institutionalization drawn from literatures on family stress and placement risk factors (continued on next page) In multivariate models controlling for care recipient characteristics, perceived rewards significantly predicted palliative coping (i.e., reframing); perceived costs significantly predicted emotive coping Stress and coping theory, and choice and social exchange theory Factor analysis identified dimensions of appraisal which consisted of care work strain, care work satisfaction, relationship dissatisfaction, and care lifestyle satisfaction; to examine validity of scales bi-variate correlations were computed revealing that satisfactions were positively associated with lifestyle satisfaction, willingness to care, and inversely associated with relationship dissatisfaction, behavior problems and care work demands Picot Caregiver Rewards Scale; Choice and social Younger and more educated caregivers perceived 24-item Likert-type scale consisting exchange theory significantly fewer rewards than older less educated of a variety of rewards; caregivers caregivers; there was no relationship between asked to rate the extent to which duration of caregiving and rewards each are experienced; ratings are summed with a possible range of 0 - % ; alpha coefficient = .86 DemandDiscretion Theory of Job Strain and Satisfaction Theories of Work Satisfaction positively associated with perceived caring self-competence and negatively associated Motivation with the number and frequency of behavior problems and care receiver's age; satisfaction the strongest predictor of the caregiver's preference not to be involved in caregiving Theoretical/ Conceptual Framework Not specified Care work satisfaction measured using a factor-analytically derived 6-item scale; each item scored on a 7-point scale (strongly agree to strongly disagree); alpha = .92 Care Work Satisfaction Scale (see Orbell, Hopkins, & Gillies, 1993) Care Work Satisfaction Scale (see Orbell, Hopkins, & Gillies, 1993) Measurement Approach Table 1. Summary of Studies on Caregiver Gain (Continued) Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 o era O_ 3 O n o n KJ KJ Elderly; frail or impaired Elderly; not specified Wallsten & Snyder (1990) 60-90; cognitive dysfunction and physical disabilities > 64; median age = 84; not specified but excluded cognitive impairment Walker, Shin, & Bird (1990) Worcester & Quayhagen (1983) M = 84; not specified; no cognitive impairment Walker, Martin, & Jones (1992) Talkington-Boyer 44-94; M = 74; & Snyder (1994) Alzheimer's disease Stephens, 60-91; M = 76; Franks, & not specified Townsend (1994) Sheehan & Nuttall (1988) Author(s) Care Receiver Age& Diagnosis Defi niton of Gain Satisfaction includes the appraisal of benefits gained through caregiving effort Benefits; rewards from caring or from the relationship between the mother and daughter 5-item scale assessing feeling appreciated, providing opportunity to repay elder, increased confidence, sense of enjoyment rather than duty, and enjoying the elder's personality; alpha not specified Role Stress and Rewards Questionnaire; caregiver role rewards consisted of 12 items (e.g., •affection, appreciation, improved relationship, improved care recipient health) rated on a 4-point scale from did not happen (0) to very rewarding (4); alpha = .87 Caregiving Satisfaction Scale (see Lawton et al., 1989); alpha for current sample not specified Measurement Approach Caregivers asked how often they experienced seven benefits (e.g., learning, helping, saving money, improving the relationship, ana sense of meaning); mothers asked how often they experienced feeling loved and a sense that one's daughter cares N = 133 adult daughters residing Satisfaction with Single 7-point item satisfaction in Western Oregon; median age = the caregiving scale ana a 10-item semantic 53; 99% Caucasian role differential measure (e.g., enjoyable, miserable; full, empty) (Campbell, Converse, & Rogers, 1976); each rated on 7-point scale (1 = positive to 10 = negative); mean score computed; reliability alpha not specified N = 21 caregivers; 17 females; 18 Uplifts; Routines, Uplifts, Challenges, and spouses; 3 adult children; all experiences that Hassles List (RUCHL); 112 events co-residing with care receiver; 81% make one feel appraised as routine, uplift, Caucasian; Mage = 68; N = 20 good; sources of challenge, or hassle; events also noncaregivers; 15 females; 80% satisfaction, appraised as having a positive or Caucasian; Mage = 68 peace, negative impact on 5-point scale; happiness, or joy reliability alphas not specified; some items not caregiving-specific N = 19 co-resident caregivers; (M Satisfaction in Single item, global rating using a age = 50) compared to 29 nursing the caregiving 5-point scale home caregivers recruited from role home health care agencies; lower middle class; relationship type not specified N = 110 caregivers recruited from support groups and an Alzheimer's Association; 76% female; Mage = 60 (range 28-81); 67% co-resided with care receiver; 25% caring for persons in a nursing home N = 141 adult daughters residing in Western Oregon; median age = 52; 99% Caucasian N = 98; recruited from community agencies and personal contacts; ages 21-83 (M = 53); 94% Caucasian; 84% primary caregivers; mostly adult children, but also spouses and "other" Satisfaction; positive emotions; positive perceptions of the caregiving experience Rewards in N = 95; 75 daughters and 20 caregiving role; daughters-in-law recruited from public notices and hospital medical also evaluated rewards specific records of elderly patients; 42% co-residing with the care receiver; to being wife and 94% were Caucasian; M age = 44 mother; positive (range 28-59) experiences Sample Characteristics More satisfaction correlated with higher marital satisfaction, older age of patient, greater ADL impairment, lower caregiver depression, greater problem-solving coping response, greater satisfaction with informal supports, and less subjective burden Factor analytic techniques employed; none of the positive items loaded tor daughters; therefore eliminated from further analysis; two benefit items loaded for mothers to form a factor called "Feeling Loved"; predictors of feeling more loved included worse health and less amount of care needed Not specified Daughters who reported positive or no change in their relationships with their mothers were more likely to report satisfaction than daughters reporting a negative change in the relationship; satisfaction was higher among caregivers who were providing assistance in a greater number of areas and among those who were caring for older mothers Ratings of positive impact higher than for negative impact for caregivers and noncaregivers; negative impact ratings predicted psychological symptoms; positive ratings did not; caregivers endorsed more hassles than noncaregivers but no difference in uplifts, routines, or challenges Satisfaction higher among older and co-resident caregivers; lower when care receivers were younger; more satisfaction among those caring for females; psychological problems of care receiver had strongest negative influence on satisfaction Social Exchange Theory Stress Model Not specified Social Exchange Theory After controlling for stressors in the roles of caregiver, mother, and wife, caregiver role rewards significantly predicted positive affect, but not physical health, negative affect, or role overload. An accumulation of role rewards was related to better well-being, whereas an accumulation of stress across roles was related to poorer well-being Role Quality Perspective and the Expansion Hypothesis Reported Findings Satisfaction not associated with strain; inversely associated with depression and negative affect but this relationship disappeared in multivariate analysis; much stronger associations observed between strain and negative emotions and outcomes of depression, anxiety and somatization Theoretical/ Conceptual Framework Not specified Table 1. Summary of Studies on Caregiver Gain (Continued) Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 Conceptual issues that were considered in this review included the use and definition of constructs, the theoretical orientations utilized, and the study findings that have potential implications for theory. The most common term used to describe gain in caregiving was "satisfactions," which was reported in 15 of the 29 studies. Other terms included uplifts (n = 4), rewards (n = 4), gratifications (n = 1), growth and meaning (n = 1), enjoyment (n = 2), positive aspects (n = 1), and benefits (n = 1). Based on this review of studies, the following observations are noted regarding conceptual issues: Observation #7: Demonstration of Greater Conceptual Clarity Among Theoretically Based Studies. — As shown in Table 1, nearly half of the studies reviewed were atheoretical (i.e., no theoretical base). The most prominent theoretical perspectives consisted of variations of a stress and adaptation model or theory (n = 9). Other frameworks included social exchange theory (n = 4), theories of work motivation and job satisfaction (n = 2), role theory (n = 1), and existentialism (n = 1). Few of the authors provided explanations for the meaning and definitions for the terms used. Most of the definitions provided in Table 1 were gleaned from the descriptions of measures provided in the methods sections of the articles reviewed. Specific meanings and definitions were provided in only 11 of the studies, most of which were theoretically based. Observation #2: Conceptualization of Gain as "Appraisal." — Across the majority of theoretical orientations specified in this review, gains were either explicitly or implicitly conceptualized, defined, or measured as appraisals of the caregiving role. The term appraisal is drawn from the transactional model of stress and coping proposed by Lazarus and Folkman (1984), and it refers to the individual's evaluation of the extent to which caregiving is harmful, beneficial, or irrelevant to well-being. Lawton and colleagues were the first to introduce "satisfaction" as one of the major dimensions of caregiving appraisal that was identified via factor analytic techniques (Lawton, Kleban, Moss, Rovine, & Glicksman, 1989). A similar approach was taken in subsequent studies focusing on the multidimensional nature of caregiver appraisals (Braithwaite, 1996; Orbell, Hopkins, & Gillies, 1993). Gain as appraisal is referred to in social exchange theory whereby caregivers "actively appraise their situations and assess their current and potential for future positive outcomes. . . " (Walker, Shin, & Bird, 1990, p. 147). Exceptions to this construction of gain as appraisal include the qualitative study by Farran et al. (1991), which focused on explorations of caregiver growth and meaning and the study by Stephens et al. (1994), which focused on the types and amount of rewards incurred. Observation #3: Distinction Between Appraisal of Gain as Event Versus Role-Specific. — Two general Vol. 37, No. 2,1997 Observation #4; Limitations in Establishing Consistent Empirical Linkages. — Numerous studies have focused on understanding the correlates and predictors of strain and gain as appraised outcomes of caregiving (Albert, 1992; Hinrichsen, Hernandez, & Pollack, 1992; Kramer, 1993a, 1993b; Miller, 1989; Orbell & Gillies, 1993b; Picot, 1995a; TalkingtonBoyer & Snyder, 1994; Walker et al., 1990; Worcester & Quayhagen, 1983). Unfortunately, conclusions that can be drawn from many of these studies are limited by the methodological problems detailed below, which likely contribute to the contradictory findings reported to date concerning relationships between gain and care receiver characteristics and caregiver characteristics, resources, and burden. For example, all of these studies were cross-sectional and only three reported findings that included essential covariates (i.e., stressors and caregiver characteristics; Kramer, 1993a, 1993b; Miller, 1989). Observation #5: Differential Predictors of Strain and Gain. —There is limited but suggestive evidence that the predictors for strain and gain are somewhat unique, and that attitudinal variables, such as motivations for helping and ideology, may be useful for understanding gain, but that this may be influenced by ethnicity. All of the studies that included negative and positive aspects of care and that controlled for stressor and demographic variables in their analysis found some differential predictors for strain and gain (Kramer, 1993a, 1993b; Lawton et al., 1991, 1992; Miller, 1989). Three studies documented significant relationships between attitudinal variables and gain (Albert, 1992, Lawton et al., 1992, Motenko, 1989). 225 Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 conceptualizations of gain noted in the literature include those that are responses to specific caregiving events or tasks, and those that are more general appraisals of the caregiving role. Event-specific appraisals are evidenced by the definition and the measurement approach for "uplifts." Researchers interested in the "uplifts" construct focus on multidimensional appraisals in which daily tasks or events are appraised as uplifts, hassles (Kinney & Stephens, 1989; Kinney, Stephens, Franks, & Norris, 1995; Wallsten & Snyder, 1990) routines, and challenges (Wallsten & Snyder, 1990). Kinney and Stephens (1989) were the first to introduce the concept of "uplifts" of caregiving events in the literature. Their measurement presents caregivers with 110 daily tasks or events associated with care recipients' limitations in ADL, care recipients' cognitive status, care recipients' behavior, and the practical/logistical aspects of caregiving, and asks them to appraise each one as a hassle or an uplift. Only one other study took an event-specific approach, and they too were measuring uplifts (Wallsten & Snyder, 1990). Lawton et al. (1989) suggested the notion that "the culmination of daily caregiving uplifts may be thought of as composing" a more enduring state of "caregiving satisfactions" (p. P62). Pruchno, Michaels, & Potashnik (1990), were the only researchers to use the term uplifts, and not use events-specific measures. Conceptual Issues Given that two out of three of these studies did not control for other variables, such findings are tentative. In a multivariate model, Lawton et al. (1992) found a caregiving ideology that included reasons for providing care (e.g., reciprocity, continuing a family tradition, mutual concern) to be an important predictor of gain for Caucasian, but not for African American caregivers. Methodological Issues Methodological problems stemming from sampling, design, measurement, and analysis procedures have a long history in the caregiving literature (Barer & Johnson, 1990). Based on this review of studies, the following observations are noted regarding methodological issues: Observation #7: Reliance on Samples of Convenience. — The majority of the studies reviewed used samples of convenience. Only one sample was 226 Observation #8: Inattention to Subgroup Differences and the Experience of Males. — The majority of investigations used heterogeneous samples that lumped together different caregiver groups, including spouses, adult children, other relatives, neighbors, and friends. The next most frequently studied group were adult children, primarily focusing on daughters and/or daughters-in-law (Brody, Litvin, Hoffman, & Kleban, 1992; Stephens et al., 1994; Walker et al., 1990, 1992), although Miller (1989) investigated sons and daughters. There was one report on spouses (Pruchno et al., 1990) and three reports on wives (Kramer, 1993a, 1993b; Motenko, 1989). Absent were studies of the male caregiver and careful investigations of differences by gender and relationship type. Most investigations focused on gain experienced among caregivers to persons with dementia (n = 14). It is noteworthy that nine did not specify the type of care receiver impairment. Observation #9: Reliance on Quantitative Data and Cross-Sectional Design. — Only two of the 29 studies utilized qualitative methods to explore positive aspects of caregiving, and none of the studies reviewed obtained cross-time data on caregiver gain. Four studies reported on follow-up contact with caregivers; however, the only measure taken at follow-up was living arrangements (i.e., community or nursing home; Braithwaite, 1996; Cohen et al., 1993, 1994; Pruchno et al., 1990). Thefore, major questions remain regarding the direction of causality between gain and other variables studied. Observation #10: Identification of Multiple Gains Found Through Qualitative Investigations. — The open-ended method of data collection used in two of the studies revealed that caregivers experienced a wide variety of positive feelings and experiences. For example, Farran et al. (1991) reported that 90% of respondents reported "Valuing Positive Aspects" of the following: family and social relationship, the care recipient's love for them, the positive relationship that they experienced with the care recipient, memories of and accomplishments with others, feeling appreciated by the care recipient and feeling good about the quality of care that they were providing. Hinrichsen etal. (1992) noted 103 rewards, including enhanced relationships with the care receiver (e.g., greater liking of the patient, satisfaction in seeing one's efforts are helping), rewards with oneself (e.g., The Gerontologist Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 Observation #6: Conceptualization of Gain as an Intervening Variable. — Although both strain and gain were often conceptualized as appraised outcomes of providing care, approximately one third of the studies reviewed focused on the relationship between caregiver gain and other, more enduring outcomes, such as desire to institutionalize or actual institutionalization (Cohen etal., 1993; Cohen, Cold, Shulman, & Zucchero, 1994; Pruchno et al., 1990), depression (Kinney et al., 1995; Lawton et al., 1992; Sheehan & Nuttall, 1988), positive and/or negative affect (Braithwaite, 1996; Lawton et al., 1991, 1992; Stephens et al., 1994); and physical health (Stephens et al., 1994). In general, however, studies did not utilize statistical methods that would allow for the evaluation of moderating or mediating effects (Baron & Kenney, 1986), thereby limiting the conclusions that may be drawn. There is limited but suggestive evidence that strain and gain may be differentially related to negative versus positive indicators of psychological wellbeing, and that they may vary depending upon certain caregiver characteristics. The work of Lawton and colleagues (1991,1992), perhaps the most methodologically rigorous work conducted to date, drew upon the two-factor theory of happiness proposed by Bradburn (1969), to hypothesize that "one aspect of mental health, positive affect, would be differentially affected by the uplifting aspects of caregiving (caregiving satisfaction), while the second aspect of mental health, depression, would be more strongly affected by caregiving burden" (p. S163). One study supported this hypothesis for both Caucasian and African American caregivers (Lawton et al., 1992) and another study reported different patterns for spouses versus adult children (Lawton et al., 1991). These findings are compatible with other research that has reported differential correlates of negative and positive affect (Costa & McCrae, 1980; Diener & Emmons, 1984, Emmons, 1986) and suggest that strain and gain are not simply opposites on a unidimensional continuum. drawn from a national data base (Miller, 1989), and sample sizes across the 29 studies varied tremendously, ranging from 19 to 632. As convenience samples, most tended to be primarily Caucasian and middle-class. Picot (1995a, 1995b) was the only researcher to study an exclusively African American sample, and only one study reported on the differential experience of gain by ethnicity, with African American caregivers expressing greater caregiver satisfaction and less burden, depression, and perceived intrusion than Caucasian caregivers (Lawton etal., 1992). (Campbell, Converse, & Rodgers, 1976, p. 38). This scale consisted of 10 semantic differential pairs which are rated on a 7-point positive to negative continuum. Caregivers were asked to consider their responses in terms of how they feel about providing care. While some of the items clearly suggest caregiver gain (e.g., "rewarding," "enjoyable," "brings out the best in me"), others are conceptually less clearly related (e.g., "friendly-lonely" seems to evaluate aspects of social support;, "free-tied down" may reflect amount of responsibility). feeling that one grew as a person), and enhanced or satisfying relationships with others (e.g., family and health care providers). Given that appraisal of gain is a complex evaluative process, it is unlikely that the single-item, dichotomous, and frequency indicators of gain, reported in five of the studies, adequately tap the construct (Cohen et al., 1993, 1994; Miller, 1989; Motenko, 1989; Worcester & Quayhagen, 1983). One exception to this measurement approach was described by Walker and colleagues (1990), who used a satisfaction scale that was originally developed as a measure of "perceived quality of life" Vol.37, No. 2,1997 Observation #12. Inattention to Potential Confounding of Measures. — Examination of item content of the measures used reflects considerable conceptual overlap and potential confounding with other constructs. For example, gain items reflecting improved relationships with the care receiver and other family members create problems when researchers attempt to document the relationship between gain and the quality of the relationship, which, not surprisingly, has been strong and positive (Hinrichsen et al., 1992; Kramer, 1993a; Lawton et al., 1989; Motenko, 1989; Walker et al., 1990). Orbell et al. (1993) circumvented this problem by using factor analysis to separate out the factor related to relationship quality. Conceptual and item overlap may obfuscate the meaning of observed correlations between measures of gain and strain when burden measures both tap interpersonal relationships (e.g., see Montgomery, Gonyea, & Hooyman, 1985; Novak & Guest, 1989; Zarit & Zarit, 1987). Similarly, some dimensions of psychological well-being (e.g., personal growth and purpose in life) are reflected in a number of the gain measures. Observation #13: Limitations in the Analytic Methods Utilized. —There was a tendency for researchers to rely on bivariate correlations for documenting associations between gain and other variables. Most did not control for the fact that caregivers were at different phases of the caregiving career, or that they were likely to be managing different stressors. As mentioned previously, studies largely neglected to control for the following: differences in the caregiver's relationship to the care receiver, gender, ethnicity, and other distinguishing background and contextual variables that may influence the appraisal of caregiver gain or strain. Discussion An Agenda for Future Research In order for the field to advance, future research efforts must work toward addressing the limitations and knowledge gaps of prior investigations outlined in this review. Two central criticisms are noted. A first problem stems from lack of conceptual clarity that is notably evidenced by the absence of a theoretical base in nearly half of the studies, or the failure to elaborate broader theoretical contexts for investigating gain. This neglect of theory has resulted in two 227 Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 Observation #11: Initiation of Tool Development. — There is, on a limited basis, the beginning of the development of tools to measure the caregiver gain construct. Three studies reported on factor analytic methods used to identify appraisal of gain as distinct from other appraisals of caregiving (Braithwaite, 1996; Lawton et al., 1989; Orbell et al., 1993); however, information provided about the psychometric properties for these measures is somewhat limited. For example, Braithwaite (1996) did not report reliability coefficients for her appraisal dimensions, testretest reliability is lacking from all studies, and inconsistent findings and limited elucidation of potential relationships of gain with other outcome measures have made it difficult to establish construct validity. The most frequently reported and perhaps the most methodologically rigorous measure is the 5-item caregiving satisfaction measure that was developed by Lawton and colleagues (1989). The reliability alphas reported across studies that have used this measure vary widely according to the samples that are investigated (e.g., lowest alpha = .67 for respite care sample, Lawton etal., 1989; and highest alpha = .92 for daughter caregiver sample, Brody et al., 1992). Aside from the two qualitative reports, the singleitem, dichotomous, or frequency ratings, and the events-specific uplifts measures, most of the measures reviewed were multi-item scales in which caregivers were asked to rate each item according to their occurrence or frequency. Across these measures there is considerable item overlap regardless of the terms that were used to identify gain. For example, measures that consisted of similar items across studies included the following: improved relationship with the care receiver or other family members (Albert, 1992; Brody et al., 1992; Farran et al., 1991; Hinrichsen et al., 1992; Kramer, 1993a, 1993b; Lawton et al., 1989, 1991, 1992; Motenko, 1989; Picot, 1995a; Pruchno et al., 1990; Stephens et al., 1994); increased self-esteem (Kramer, 1993a, 1993b; Lawton et al., 1989; Orbell et al., 1993; Picot, 1995a); feeling appreciated (Braithwaite, 1996; Lawton et al., 1989; Picot, 1995a; Pruchno etal., 1990; Sheehan&Nuttall, 1988; Stephens et al., 1994); enhanced sense of meaning or purpose (Kramer, 1993a, 1993b; Walker et al., 1992); feelings of pleasure (Lawton et al., 1989; Orbell et al., 1993; Picot, 1995a); and prevention of further care receiver deterioration (Kramer, 1993a, 1993b; Pruchno et al., 1990; Stephens et al., 1994). 228 out the relationships among various caregiver groups. Studies that have investigated the role of gender or kin relationship have reported important differences across other domains investigated (Horowitz, 1985; Jutras & Veilleux, 1991; Kramer & Kipnis, 1995; Miller & Caffasso, 1992; Young & Kahana, 1989). Gain may be appraised very differently by adult children, husbands, wives, and friends. Similarly, nearly half of the samples consisted of care receivers with a variety of diagnoses, never distinguishing between the experiences of these caregivers, and only three reported on the gain experienced by non-Caucasian caregivers (Lawton et al., 1992; Picot, 1995a, 1995b). Future investigations should attempt to disentangle the effects of gender, race, relationship, and type of illness to help bring clarity to our understanding of caregiving benefits. Basic questions that have yet to be answered include: Who is most likely to experience gain in caregiving? How do gender, age, race, and kinship relationship affect the likelihood and extent of gain? Other methodological and conceptual issues that warrant further attention include the extent to which gain is subject to socially desirable responses and the function of caregiver gain in relation to general wellbeing. Future studies that control for social desirability and that investigate the moderating or mediating properties of gain are urged. Greater clarity is needed with regard to the conceptual distinction between gain and well-being, and the processes through which the effects of caregiving are moderated by caregiver gain. It would be useful to have prospective data that allows for comparison of the magnitude of relationships with indices of positive psychological well-being, and more reliable evaluation of the direction of causality. Caregiver Adaptation: A Model of Synthesis As indicated above, much work has yet to be done in developing a sound theoretical framework for understanding caregiver gain. As an emerging and relatively new field of interest, it seems natural for researchers to explore the topic from multiple theoretical and conceptual perspectives. Ultimately, however, the study of caregiver gain would be enhanced if researchers could come to some consistency in the ways in which gain is conceptualized and studied within the broader context of caregiver adaptation. Without such a framework, it is difficult to establish the construct validity of the measures used; there is the problem of confounding of measures, and the challenge of interpreting inconsistent findings. Much research has been guided by theoretical and conceptual models that were developed to understand how caregivers adapt to stress or that do not fully articulate the key variables that should be important in understanding this realm of the caregiving process. It is likely that stress theories have dominated this area of inquiry because they are the most comprehensive, taking into consideration the context, stressors, resources, and outcomes. Other theories such as social exchange, role theory, existenThe Gerontologist Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 related problems: namely, absent or unclear definitions and the subsequent hindered efforts to develop empirically distinct measures. Having elusive definitions is problematic because "lack of precision in use of terms leads to and promotes theoretical confusion; hinders operationalization of the constructs; promotes gaps between theoretical and operational levels; and ultimately impedes development of knowledge" related to caregiver adaptation (Hurley-Wilson, 1993, p. 134). While there are some beginning attempts to evaluate the psychometric properties of existing measures, it is not clear that these measures capture the full repertoire of gain experienced by caregivers. Several important questions remain unanswered in the context of measurement and operational definition of the gain construct. Given the conceptual overlap in existing measures and definitions, should we conclude that rewards, satisfactions, gratifications, and benefits are synonymous? Is gain unidimensional or multidimensional? Is there merit in considering objective gain in addition to subjective gain, as has been the case in the study of burden? Objective burden has been examined as the prevalence count of potentially disruptive experiences (Vitaliano, Young, & Russo, 1991), and as disruptions that are observable or verifiable (Platt, 1985). Are there gains that caregivers experience that might also be counted, observed, or verified? Walker, Martin, and Jones (1992) suggested that gain may be both emotional and knowledge-based. Knowledge and skills are two types of gain that are potentially observable, but would doing so enhance understanding of caregiver well-being? Given that this is a relatively new area of inquiry, qualitative approaches, such as those utilized by Farran et al. (1991) and Hinrichsen et al. (1992) would offer a useful approach for developing comprehensive measures and exploring these issues. Clearly, the development of psychometrically sound measures of gain would constitute a considerable contribution to the field. A second problem concerns the methodological limitations inherent in the studies reviewed that permits restricted comparisons between studies, constrains generalizability, hampers study validity, and contributes to limited cumulative knowledge. The most notable limitations included insufficient attention to the validity and reliability of measures, use of limited analytic methods, failure to control for extraneous variables, reliance on cross-sectional data, failure to disaggregate diverse caregiver subsamples, reliance on convenience samples, and the wide variability in the foci, methods, and measurement used across studies. These methodological problems likely contribute to the many contradictory findings reported in the literature regarding the relationship between gain and care receiver characteristics, caregiver characteristics, and caregiver's resources and burden. They also restrict understanding of a number of potentially important variables that should be addressed in future research. For example, as noted previously, the majority of samples were heterogeneous and were often not large enough to separate Background and Context. — Care receiver and caregiver characteristics and the context of the caregiving situation potentially play a central role in understanding all other aspects of the caregiver's experience (Kramer & Kipnis, 1995). These contextual variables are conceptualized to determine the types of caregiving activities the individual is engaged in, the types of resources that are available to manage these responsibilities, the appraisal of gain and strain, and ultimately, well-being. In stress-based theories that have been applied to caregiving, care receiver characteristics (i.e., illness severity, type of illness, cognitive status, functional status, and problematic behavior) are often conceptualized as the stressors the caregiver is called upon to manage and are central to investigations of caregiver adaptation (Biegel et al., 1991; Kramer & Vitaliano, 1994). Social exchange and role theory have also recognized the importance of contextual variables. The most influential social exchange theory, equity theory, hypothesizes that individuals will provide care with the expectation of receiving some form of material, social, or psychological benefit in return, without which negative affective reactions would be expected (Buunk & Hoorens, 1992). The extent to which a beneficial return is expected is largely determined by the type of relationship (Mills & Clark, 1982). The nature and duration of the illness (sudden or insidious), prognosis (recuperative, stable, degenerative, or terminal), and the symptoms are also likely to influence the degree of expected reciprocity. This further suggests that it is essential to refrain from aggregating diverse groups of caregivers and care receivers and treating them as a homogenous group, and to look carefully at gender and kin relationship differences. In addition, role theory suggests the importance of considering other essential roles (e.g., parenting, employment) that have the potential to impact caregiver well-being either positively or negatively (Thomas & Biddle, 1966). For example, role theory suggests that the "successful enactment of roles and identities is expected to bring social esteem and intrinsic gratification from the experience of instantiated social competence" (Marks, 1995, p. 10). Alternatively, there is also the potential for role conflicts to occur when caregivers attempt to juggle multiple roles. Individual differences in attitudinal variables (i.e., motives, values, goals) help to explain how a situa- INTERVENING PROCESSES BACKGROUND AND CONTEXT WELL-BEING OUTCOMES CARE RECEIVER CHARACTERISTICS/ POTENTIAL STRESSORS CAREGIVER ATTITUDINAL VARIABLES AND EFFORT POSITIVE INDICATORS APPRAISAL OF ROLE STRAIN NEGATIVE INDICATORS RESOURCES CAREGIVER CHARACTERISTICS/ OTHER LIFE RESPONSIBILITIES Figure 1. A conceptual model of caregiver adaptation. Vol. 37, No. 2,1997 APPRAISAL OF ROLE GAIN 229 Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 tialism, and theories of work motivation offer additional insights regarding potentially important considerations. These theories need not be considered incompatible with stress models; they simply tend to more narrowly highlight areas of foci (e.g., rewards/ costs ratio, number/types of roles, search for meaning). For example, elsewhere in this symposium (pp. 250-256), Farran identifies similarities and points of divergence for stress and existential paradigms, and proposes that a combination of these two approaches could enhance understanding of the caregiving process. While no single theory currently provides an adequate basis for understanding caregiver gain, a useful model can be generated through the integration of several different theoretical perspectives. As a first step, the conceptual framework shown in Figure 1 is proposed, integrating theoretical perspectives that seem to be relevant to the study of caregiver adaptation, and taking into consideration the theoretical observations elucidated in this review. According to this model, the adaptation process is made up of three primary domains: background and context; intervening processes; and well-being outcomes. only with strain and depression (Kramer, 1993a, 1993b; Lawton et al., 1991). Similarly, positive and negative outcomes were associated with differing types of coping strategies among two caregiving samples (i.e., African Americans, Picot, 1995b; and Caucasian wives, Kramer, 1993a). Further work is needed to replicate and document these differential relationships. As noted previously, there has been some initial progress, based on the two-factor theory of happiness (Bradburn, 1969), in documenting intervening mechanisms that appraisals of strain and gain have in understanding negative versus positive indicators of psychological well-being (Lawton et al., 1991,1992). Drawing upon role theory, it is suggested that future investigations should go beyond appraisals of the caregiving role to include appraisals of other significant roles. Recent research has documented the utility of examining caregiver adaptation in the context of other roles and resources. For example, using panel data on 293 women, Moen, Robinson, and Dempster-McClain (1995) found that the effects of caregiving on well-being were moderated by multiple role involvements and other nonfamily roles. Stephens et al. (1994) found that an accumulation of role stress across roles was related to poorer wellbeing, whereas an accumulation of role rewards was related to better well-being. Interestingly, investigations regarding roles and well-being have been based on perspectives of role-enhancement or role strain (Moen et al., 1995), paralleling the interest in positive versus negative impacts. Outcomes. — In the model shown in Figure 1, well-being outcomes include both positive and negative indicators. Consistent with the caregiving literature in general, well-being indicators reported in the gain studies reviewed excluded positive dimensions Intervening Processes. — It is widely acknowl- of well-being or utilized extremely narrow and limited definitions of positive well-being (e.g., positive edged that resources play a central role in underaffect). The understanding of caregiver adaptation standing caregiver outcomes. They can be generally defined as either internal, when they are characteris- would be greatly advanced through a program of research that carefully investigates the correlates and tics within the individuals (e.g., coping, personal predictors of theoretically grounded indicators of control, self-efficacy, health, knowledge, hardiness) "positive" psychological well-being. Those that or external, when they are factors or assets outside seem particularly relevant to the study of caregiver the individual (e.g., social support, tangible regain include environmental mastery (i.e., a sense of sources; Lazarus & Folkman, 1984). Resources are competence in managing one's environment), perhypothesized to be important in explaining the tresonal growth (i.e., a sense of development and of mendous variation in strain found among caregivers realizing one's potential), purpose in life (i.e., sense (Pearlin, Mullan, Semple, & Skaff, 1990). Some of the studies reviewed have begun to document a relation- of meaning to life), and self-acceptance (i.e., a sense ship between resources and gain (Farran et al., 1991 ; of positive attitude toward the self; Ryff, 1989a, 1989b). As noted previously, because some of these Kramer, 1993a, 1993b; Orbell & Gillies, 1993a); howdimensions are currently represented as single items ever, the nature of this relationship is not consisin measures of caregiver gain, it is imperative that tently reported. As shown in Figure 1, resources are future studies that include both constructs ensure posited to directly influence role appraisal, and they that the problem of item overlap is addressed. indirectly or directly influence well-being. However, Positive indicators of well-being seem particularly there is some evidence to suggest that specific types relevant to gerontologists, given evidence of reof resources may have unique relationships with ported declines in purpose in life and personal various indicators. For example, social support was growth across the life span (Ryff, 1989b, 1991) and correlated with both positive and negative indices reported differences between women and men (Kramer, 1993a, 1993b), but health was associated 230 The Gerontologist Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 tion can be appraised as stressful by one person and beneficial by another (Folkman & Lazarus, 1988). One of the observations noted in this review is that attitudinal variables (i.e., motivations for helping, caregiving ideology) were found to be associated with caregiver gain (Albert, 1992; Lawton et al., 1992; Motenko, 1989). Biegel et al. (1991) suggested that motivations for helping may be a combination of altruistic or egoistic factors, depending upon the nature of the care receiver's illness and emotional status, and that they are inextricably linked to the amount of effort exerted in caregiving. Motivations for providing care may also be central to the daily and more global life goals of the caregiver. Recent shifts in personality psychology that focus on social cognition suggest that one's goals or strivings directly influence behavior (Brower & Nurius, 1993; Emmons, 1986). Personal strivings represent what individuals are aiming to accomplish through their behavior (Emmons, 1986). Given the demands of the caregiving situation and its centrality to the lives of most caregivers, it is not unlikely that the personal strivings of many caregivers would involve aspects of caregiving. One does not have to look far to find a caregiver who is striving to help an impaired spouse feel useful, to keep the household running smoothly, and to maintain a loving relationship. If caregiving tasks are central to one's goals, then the caregiver is likely to exert effort and draw upon their resources to meet these goals. The extent to which resources help or hinder this effort will likely influence both positive and negative indicators of appraisal and well-being. Caregivers whose goals are directed outside of the caregiving realm, but who nevertheless maintain their caregiving role, are likely to negatively appraise their experience as it detracts from their ability to achieve their desired goals. Conclusion In summary, although there is evidence of the growing interest in the construct of caregiver gain, lack of conceptual clarity, methodological problems, and the wide variability in the foci of the studies contributes to limited cumulative knowledge. As studies proceed in this fertile research area, attention to the operational definition of the construct, development of psychometrically sound measures that consider the full repertoire of gain, and increasing methodological rigor in the execution of research designs and analysis of data could lead to notable advances in the field. As a beginning step for bringing some consistency to the ways in which future research proceeds, a conceptual framework is proposed that considers resources and the appraisal of gain and strain as intervening processes in understanding both negative and positive indicators of well-being within the broader context of caregiver adaptation. Programs of research must continue to explore, replicate, extend, and further develop this model, with particular emphasis on elucidating positive dimensions of caregiving and addressing broad gaps in knowledge (e.g., the roles of gender, ethnicity, kin relationship, and type of illness). The methodological, conceptual, and theoretical efforts advocated here are necessary if we hope to improve assessment methods and better design and target interventions for caregivers of older adults who need assistance. Vol. 37, No. 2,1997 References Albert, S. M. (1992). Psychometric investigation of a belief system: Caregiving to the chronically ill parent. Social Science Medicine, 35, 699-709. Allen, K., Linn, R. T., Gutierrez, H., & Wilier, B. S. (1994). Family burden following traumatic brain injury. Rehabilitation Psychology, 39, 29-48. Archbold, P. C. (1983). Impact of parent-caring on women. Family Relations, 32, 39-45. Barer, B. M., & Johnson, C. L. (1990). A critique of the caregiving literature. The Gerontologist, 30, 26-29. Baron, R. M., & Kinney, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51,1173-1182. Biegel, D., Sales, E., & Schulz, R. (1991). Theoretical perspectives on caregiving. Family caregiving in chronic illness (pp. 29-61). Newbury Park, CA: Sage. Bradburn, N. (1969). The structure of psychological well-being. Chicago, IL: Aldine. Braithwaite, V. (19%). Between stressors and outcomes: Can we simplify caregiving process variables? The Gerontologist, 36, 42-53. Brody, E. M., Litvin, S. J., Hoffman, C , & Kleban, M. H. (1992). Differential effects of daughters' marital status on their parent care experiences. The Gerontologist, 32, 58-67. Brower, A., & Nurius, P. (1993). Social cognition and individual change. Newbury Park, CA: Sage. Bulger, M. W., Wandersman, A., & Goldman, C. R. (1993). Burdens and gratifications of caregiving: Appraisal of parental care of adults with schizophrenia. American Journal of Orthopsychiatry, S3, 255-265. Buunk, B., & Hoorens, V. (1992). Social support and stress: The role of social comparison and social exchange processes. British journal of Clinical Psychology, 31, 445-457. Campbell, A., Converse, P., & Rodgers, W. (1976). The quality of American life: Perceptions, evaluations, and satisfaction. New York: Russell Sage. Cohen, C. A., Gold, D. P., Shulman, K. I., Wortley, J. T., McDonald, G., & Wargon, M. (1993). Factors determining the decision to institutionalize Dementing individuals: A prospective study. The Gerontologist, 33, 714-720. Cohen, C. A., Gold, D. P., Shulman, K. I., & Zucchero, C. A. (1994). Positive aspects in caregiving: An overlooked variable in research. Canadian Journal on Aging, 13, 378-391. Costa, P., & McCrae, R. (1980). Influence of extroversion and neuroticism on subjective well-being: Happy and unhappy people. Journal of Personality and Social Psychology, 38, 668-678. Diener, E., & Emmons, R. (1984). The independence of positive and negative affect. Journal of Personality and Social Psychology, 47, 1105-1117. Emmons, R. (1986). Personal strivings: An approach to personality and subjective well-being. Journal of Personality and Social Psychology, 51, 1058-1068. Farran, C. J. (1997). Positive aspects of caring for elderly persons with dementia: A theoretical examination. The Gerontologist, 37, 250-256. Farran, C. J., Keane-Hagerty, E., Salloway, S., Kupferer, S., & Wilken, C. S. (1991). Finding meaning: An alternative paradigm for Alzheimer's disease family caregivers. The Gerontologist, 31, 483-489. Ferrari, J. R., McCown, W., Pantano, J. (1993). Experiencing satisfaction and stress as an AIDS care provider. Evaluation and The Health Professions, 76, 295-310. Folkman, S., & Lazarus, R. S. (1988). The relationship between coping and emotion: Implications for theory and research. Social Science & Medicine, 26, 309-317. Franks, M., & Stephens, M. (1992). Muitple roles of middle-generation caregivers: Contextual effects and psychological mechanisms. Journal of Gerontology: Social Sciences, 47, S123-S129. Graber, L., & Nice. (1991). The family unity model: The advanced skill of looking for and building on strengths. The Prevention Report, Fall, 3-4. George, L., & Gwyther, L. (1986). Caregiver well-being: A multidimensional examination of family caregivers of demented adults. The Gerontologist, 26, 253-259. Greenberg, J., Seltzer, M., & Greenley, J. (1993). Aging parents of adults with disabilities: The gratifications and frustrations of later-life caregiving. The Gerontologist, 33, 542-550. Guerriero-Austrom, M., & Hendrie, H. (1992). Quality of life: The family and Alzheimer's disease. Journal of Palliative Care, (Special Issue: Quality of life), 8, 56-60. Haley, W., Levine, E., Brown, L., Berry, J., & Hughes, G. (1987). Psychological, social, and health consequences of caring for a relative with senile dementia. Journal of the American Geriatrics Society, 35, 405-411. Hinrichsen, G. A., Hernandez, N. A., & Pollock, S. (1992). Difficulties and rewards in family care of the depressed older adult. The Gerontologist, 32, 486-492. Horowitz, A. (1985). Sons and daughters as caregivers to older parents: Differences in role performance and consequences. The Gerontologist, 25, 612-617. Hurley-Wilson, B. (1993). Perceptions, appraisal and meaning as mediators of the stress-health linkage. In J. S. Barnfather and B. L. Lyon (Eds.), Stress and coping: State of the science and implications for nursing 231 Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 across these variables (Ryff, 1989b, 1991; Ryff et al., 1993). We know that caregivers report much higher scores on negative indicators of well-being (e.g., depression, psychotropic drug use) when compared to noncaregivers (George & Gwyther, 1986), but what about comparisons on positive dimensions? Could caregiving serve to enhance one's sense of purpose in life, particularly for older adults? One recent study found that caregivers reported a higher sense of mastery than noncaregivers (Moen et al., 1995). Further inquiry comparing caregivers and noncaregivers on dimensions of appraisal and psychological wellbeing are urged. The model outlined in Figure 1 provides a very basic foundation from which further inquiry may proceed. Additional questions that have yet to be explored include the following: What are the relative strengths of positive and negative appraisals of caregiving and the indicators of well-being? If virtually all caregivers experience both, which is the stronger reaction to the caregiving role? Does the experience of gain in the caregiving role predict better general well-being? What else might gain bring to the caregiver — more effectiveness in this role? How does the temporal dimension come into play? Is gain experienced uniformly at various stages of the caregiving career or are they more likely to be felt in earlier or later phases? What are the mechanisms by which gain is promoted (e.g., social comparison processes, development of new areas of expertise leading to increased self-esteem)? 232 Pruchno, R. A., Michaels, J. E., & Potashnik, S. L. (1990). Predictors of institutionalization among Alzheimer disease victims with caregiving spouses. Journal of Gerontology: Social Sciences, 45, S259-S266. Pruchno, R. A, & Resch, N. (1989). Mental health of caregiving spouses: Coping as mediator, moderator, or main effect? Psychology and Aging, 4t 454-463. Reese, D., Walz, T., & Hageboeck, H. (1983). Intergenerational care providers of non-institutionalized frail elderly: Characteristics and consequences. Journal of Gerontological Social Work, 5, 21-34. Ryff, C. D. (1989a). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57, 1069-1081. Ryff, C. D. (1989b). In the eye of the beholder: Views of psychological wellbeing among middle-aged and older adults. Psychology and Aging, 4, 195-210. Ryff, C. D. (1991). Possible selves in adulthood and old age: A tale of shifting horizons. Psychology and Aging, 6, 286-295. Ryff, C. D., & Keyes, C. L. M. (1995). The structure of psychological wellbeing revisited. Journal of Personality and Social Psychology, 69, 719-727. Ryff, C. D., Lee, Y., Essex, M., & Schmutte, P. (1994). My children and me: Midlife evaluations of grown children and self. Psychology and Aging, 9, 195-205. Ryff, C. D., Lee, Y., & Na, K. (1993, November). Through the lens of culture: Psychological well-being at midlife. Paper presented at the Annual Scientific Meeting of The Gerontological Society of America, New Orleans, LA. Sheehan, N. W., & Nuttall, P. (1988). Conflict, emotion, and personal strain among family caregivers. Family Relations, 37, 92-98. Stephens, M. A., Franks, M. M., & Townsend, A. L. (1994). Stress and rewards in women's multiple roles: The case of women in the middle. Psychology and Aging, 9, 45-52. Stull, D., Kosloski, K., & Ketcher, K. (1994). Caregiver burden and generic well-being: Opposite sides of the same coin? The Gerontologist, 34, 88-94. Strawbridge, W. S. (1991). The effects of social factors on adult children caring for older parents (Doctoral dissertation, University of Washington). Dissertation Abstracts International, 52, 1094. Talkington-Boyer, S., & Snyder, D. (1994). Assessing impact on family caregivers to Alzheimer's disease patents. The American Journal of Family Therapy, 22, 57-66. Thomas, E., & Biddle, B. (1966). Basic concepts for classifying the phenomena of role. In B. Biddle and E. Thomas (Eds.), Role theory: Concepts and research, pp. 23-45. New York: Wiley. Toseland, R. W., & Rossiter, C. M. (1989). Group interventions to support family caregivers: A review and analysis. The Gerontologist, 29, 438-448. Vitaliano, P. P., Young, H. M., & Russo, J. (1991). Burden: A review of measures used among caregivers of individuals with dementia, The Gerontologist, 31, 67-75. Walker, A. J., Martin, S. S., & Jones, L. (1992). The benefits and costs of caregiving and care receiving for daughters and mothers. Journal of Gerontology: Social Sciences, 47, S130-S139. Walker, A. J., Shin, H., & Bird, D. (1990). Perceptions and relationship change and caregiver satisfaction. Family Relations, 39, 147-152. Wallhagen, M. (1992). Caregiving demands: Their difficulty and effects on the well-being of elderly caregivers. Scholarly Inquiry for Nursing Practice, 6,111-127. Wallsten, S. M., & Snyder, S. (1990). A comparison of elderly family caregivers' and noncaregivers' perceptions of stress in daily experiences. Journal of Community Psychology, 18, 228-238. Wardlaw, L. A. (1994). Sustaining informal caregivers for persons with AIDS. Families in Society, 75, 373-384. Weick, A., Rapp, C , Sullivan, W., & Kisthardt, W. (1989). A strengths perspectve for social work. Social Work, 34, 350-354. Worcester, M. I., & Quayhagen, M. P. (1983). Correlates of caregiving satisfaction: Prerequisites to elder home care. Research in Nursing and Health, 6, 61-67. Wright, S., Lund, D., Caserta, M., & Pratt, C. (1991). Coping and caregiver well-being: The impact of maladaptive strategies. Journal of Gerontological Social Work, 17, 75-91. Young, R. F., & Kahana, E. (1989). Specifying caregiver outcomes: Gender and relationship aspects of caregiver strain. The Gerontologist, 29, 660-666. Zarit, S. H., & Zarit, J. M. (1987). The memory and behavior problems checklist and the burden interview (Technical Report). University Park, PA: Pennsylvania State University. Received October 1,1996 Accepted October 6, 7996 The Gerontologist Downloaded from http://gerontologist.oxfordjournals.org/ by guest on February 6, 2015 theory, research, and practice (pp. 129-149). Indianapolis, IN: Center Nursing Press of Sigma Theta Tau International. Jutras, S., & Veilleux, F. (1991). Gender roles and care giving to the elderly: An empirical study. Sex Roles, 25(1/2), 1-18. Killeen, M. (1990). The influence of stress and coping on family caregivers' perceptions of health. International journal of Aging and Human Development, 30, 197-211. Kinney, J. M., & Stephens, M. A. (1989). Hassles and uplifts of giving care to a family member with dementia. Psychology and Aging, 4, 402-408. Kinney, J. M., Stephens, M. A. P., Franks, M. M., & Norris, V. K. (1995). Stresses and satisfactions of family caregivers to older stroke patients. The Journal of Applied Gerontology, 74(1), 3-21. Kramer, B. J. (1993a). Marital history and the prior relationship as predictors of positive and negative outcomes among wife caregivers. Family Relations, 42, 367-375. Kramer, B. J. (1993b). Expanding the conceptualization of caregiver coping: The importance of relationship-focused coping strategies. Family Relations, 42,383-391. Kramer, B. J., & Kipnis, S. (1995). Eldercare and work-role conflict: Toward an understanding of gender differences in caregiver burden. The Gerontologist, 35, 340-348. Kramer, B. J., & Vitaliano, P. P. (1994). Coping: A review of the theoretical frameworks and the measures used among caregivers of individuals with dementia. Journal of Cerontological Social Work, 23(1/2), 151-174. Lawton, M. P., Kleban, M. H., Moss, M., Rovine, M., & Clicksman, A. (1989). Measuring caregiving appraisal. Journal of Gerontology: Psychological Sciences, 44, P61-P71. Lawton, M. P., Moss, M., Kleban, M. H., Clicksman, A., & Rovine, M. (1991). A two-factor model of caregiving appraisal and psychological wellbeing. Journal of Gerontology: Psychological Sciences, 46, P181-P189. Lawton, M. P., Rajagopal, D., Brody, E., & Kleban, M. (1992). The dynamics of caregiving for a demented elder among black and white families. Journal of Gerontology: Social Sciences, 47, S156-S164. Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Marks, N. (1995). Midlife marital status differences in social support relationships with adult children and psychological well-being. Journal of Family Issues, 76(1), 5-28. Miller, B. (1989). Adult children's perceptions of caregiver stress and satisfaction. The Journal of Applied Gerontology, 8, 275-293. Miller, B., & Cafasso, L. (1992). Gender differences in caregiving: Fact or artifact? The Gerontologist, 32, 498-507. Mills, J., & Clark, M. (1982). Exchange and communal relationships. In L. Wheeler (Ed.), Review of Personality and Social Psychology, 3, Beverly Hills, CA: Sage. Moen, P., Robinson, J., & Dempster-McClain, D. (1995). Caregiving and women's well-being: A life course approach. Journal of Health and Social Behavior, 36, 259-273. Montgomery, R. J. V. (1989). Investigating caregiver burden. In K. S. Markides & C. L. Cooper (Eds.), Aging, stress, and health. New York: John Wiley & Sons. Montgomery, R., Gonyea, J., & Hooyman, N. (1985). Caregiving and the experience of subjective and objective burden. Family Relations, 34, 19-26. Motenko, A. (1988). Respite care and pride in caregiving: The experience of six older men caring for their disabled wives. In S. Reinharz&G. Rowles (Eds.), Qualitative Gerontology. New York, NY: Springer. Motenko, A. K. (1989). The frustrations, gratifications, and well-being of dementia caregivers. The Gerontologist, 29,166-172. Novak, M., & Guest, C. I. (1989) Application of a multidimensional caregiver burden inventory. The Gerontologist, 29, 798-803. Orbell, S., & Gillies, B. (1993a). Factors associated with informal carers' preference not to be involved in caring. The Irish Journal of Psychology, 14, 99-109. Orbell, S., & Gillies, B. (1993b). What's stressful about caring? Journal of Applied Social Psychology, 23, 272-290. Orbell, S., Hopkins, N., & Gillies, B. (1993). Measuring the impact of informal caring. Journal of Community & Applied Social Psychology, 3, 149-163. Pearlin, L. I., Mullan, J. T., Semple, S. J., & Skaff, M. M. (1990). Caregiving and the stress process: An overview of concepts and their measures. The Gerontologist, 30, 583-591. Picot, S. J. (1995a). Choice and social exchange theory and the rewards of African American caregivers. Journal of National Black Nurses Association, 7(2), 29-40. Picot, S. J. (1995b). Rewards, costs, and coping of African American caregivers. Nursing Research, 44, 147-152. Platt, S. (1985). Measuring the burden of psychiatric illness on the family: An evaluation of some rating scales. Psychological Medicine, 15, 383-393.