Copyright 1992 by The Cerontological Society of America The Cerontologist Vol. 32, No. 4, 498-507
This study applies meta-analysis techniques to the results of 14 descriptive studies of gender differences in caregiving to determine the size and significance of gender differences in caregiving stressors (level of elder impairment and level and type of task involvement) and in caregiver burden. There were essentially no significant gender differences in functional impairment of the frail care recipient, total caregiver involvement in care, or in money management tasks. Female caregivers were more likely to carry out personal care and household tasks and more likely to report greater burden. Given the relatively small size of the effects found, we conclude that future research should focus on the part that gender-role explanations play in assigning meaning to caregiving behaviors. Key Words: Family caregivers, Caregiver burden, Meta-analysis
Gender Differences in Caregiving: Fact or Artifact?1
is the probability of a Type I (false positive) error increased, the meaning of findings of no gender differences tend to be ignored. Integration of findings across articles is needed to fully ascertain the significance and magnitude of gender differences in caregiving. Traditional narrative reviews of the literature that summarize disparate results of many studies cannot easily account for the many sources of variation that may influence study results. In addition, review of large numbers of studies places a difficult information-processing burden on the reviewer and is subject to potential bias (Hunter & Schmidt, 1990). Meta-analysis provides a set of quantitative techniques for integrating study results that make explicit the theoretical perspectives and criteria used in forming judgments. These techniques include: (1) determination of the cumulative probability or statistical significance (Rosenthal, 1984); (2) assessment of the magnitude of relationships (Glass, McGaw, & Smith, 1981); and (3) determination of whether the variance observed across studies results from substantive effects (i.e., moderator variables) or from such methodological artifacts as sampling error, measurement reliability, range restriction, validity, or computational errors (Hunter & Schmidt, 1990). To our knowledge, this paper represents the first application of meta-analysis techniques to combine the results of descriptive studies of gender differences in caregiving. Our purpose in cumulating data across studies is to provide a base for interpreting the theoretical and practical implications of gender differences in caregiving stressors and burden. We address two research questions: 1) What are the size and significance of gender differences in caregiving stressors, e.g., level of elder impairment and level and type of task involvement? 2) What are the size and significance of gender differences in caregiver burden? We interpret our findings within the theo-
The most consistent finding in caregiving research is that the majority of family caregivers are women (Stone, Cafferata, & Sangl, 1987). The gender distribution of caregiving is inseparable from the family relationship of the caregiver: among spouse caregivers, approximately 67% of care is provided by women compared to 80-90% among adult child caregivers. This dominance of women and the tendency to describe the caregiver role in terms of personal care activities highlight the societal image of caregiving as a largely female endeavor. Yet, the extent to which women and men differ in their enactment of the caregiver role remains of high interest. Gender differences are believed to influence the amount and type of care provided, access to social resources that may alleviate caregiver strains, and appraisal of the caregiving experience (Pearlin et al., 1990; Miller, 1990). Recent critiques of the caregiving research literature imply that findings about gender differences in care may be subject to sample bias from overreliance on small and clinically drawn samples and lack of consistent measures of key concepts (Abel, 1990; Barer & Johnson, 1990; Matthews, 1989). Furthermore, published articles tend to emphasize statistically significant gender differences, ignoring findings of no difference. This tendency has two consequences. First, discussion of the size of the gender difference and its practical and clinical implications are often minimized. Second, findings of significance often occur among a series of significance tests, increasing the likelihood that these significant findings occurred by chance. Thus, not only
1 We thank Claudia Lampman and B. L. Dugoni of Loyala University for their helpful comments. department of Medical Social Work (MC 778), University of Illinois at Chicago, 808 South Wood Street, Chicago, IL 60612. department of Developmental Psychology, Loyola University, Chicago, IL.
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Baila Miller, PhD,2 and Lynda Cafasso, BS:
retical context of hypotheses explaining gender patterns of behavior in the stress process. Perspectives on Gender Differences in Caregiving
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Stressors Two classes of primary stressors have been investigated in caregiving research: the level of functional impairment of the frail older person and the amount and type of caregiver task involvement. These stressors are interdependent as the amount and type of caregiver involvement is typically determined by the level and type of impairment (Horowitz, 1985a; Miller, McFall, & Montgomery, 1991). The genderrole socialization hypothesis suggests that female caregivers will be more likely to perform personal care and household tasks than will male caregivers, as these tasks are extensions of the nurturant activities/behaviors performed as mothers and wives. Tasks, such as money management, that are time-limited and may be performed at the discretion of the caregiver will be more congruent with the primary work roles of male caregivers. Furthermore, as a result of gendered expectations of appropriate behaviors by caregivers and frail older persons, female caregivers may be socialized to respond more than men to similar levels of need. The social role hypothesis suggests that the severity of the impairment will determine gender differences in task involvement. To the extent that male and female caregivers are providing care to frail elders with similar levels of impairment, the nature of their task involvement should be similar. Furthermore, this similarity should be more pronounced among spouses than among adult child caregivers. 499
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Gerontological literature has not yet developed a consistent interpretation of gender differences in caregiving. The focus of most studies is descriptive, distinguishing either the differential selection of men and women into the caregiving role or differential enactment of that role. Ad hoc explanations of results draw on theories of household labor (Dwyer & Seccombe, in press; Finley, 1989; Horowitz, 1985b), stress and coping frameworks (Barber, 1988; Barusch & Spaid, 1989; Miller, 1990; Pratt et al., 1985; Quayhagen & Quayhagen, 1988; Young & Kahana, 1989), Gilligan's (1982) views of moral development (Fitting et al., 1986; Stoller, 1990), gender-role expectations (Barusch & Spaid, 1989), adult development perspectives (Pruchno & Resch, 1989), network attributes (Coward & Dwyer, 1990), or different opportunity costs for male and female caregivers (Osterbusch et al., 1987; Stoller, 1990). Since the stress/ coping framework is used in many studies of caregiving effects, we elaborate this perspective to guide our interpretation of results. The stress/coping paradigm (House, Umberson, & Landis, 1988; Pearlin et al., 1990) posits that differences in levels of stressors, psychosocial and environmental resources, and personal dispositions influence adverse outcomes in stress-producing situations. Thus, situation-specific role demands, support resources, and personal dispositions will influence the enactment of the caregiving role and the appraisal of caregiver distress. This model also posits that the stress process is conditioned by such attributes as gender, age, and race, which are associated with differential exposure to structural barriers and opportunities (House, Umberson, & Landis, 1988; Pearlin et al., 1990). Thus, male and female caregivers bring different demographic, occupational, and role socialization backgrounds to caregiving. The extent to which these differences influence caregiver stressors and burden appraisal form the basis of two alternative patterns of explanation within the general psychosocial stress model: the gender-role socialization perspective and the social role perspective (Barnett & Baruch, 1987; Kessler, 1979; Miller, 1990). The gender-role socialization hypothesis argues that women are more vulnerable to effects of stress because of earlier socialization factors such as sensitivity to relationships, nurturing versus instrumental behaviors, illness behaviors, and coping styles (Chodorow, 1978; Gilligan, 1982; Pearlin & Schooler, 1978). This framework assumes that childhood gender-role socialization and ongoing reinforcement by cultural norms and the gender stratification system cause gender roles to become internalized in stable personality orientations. The proposed mechanisms of internalization vary by theorist, but the general consensus is that the outcomes of these socialization patterns are stronger affiliative orientations and be-
haviors in women and more emphasis on autonomy, differentiation, and instrumental behaviors in men (Bardwick & Douvan, 1971; Chodorow, 1978; Gilligan, 1982; Rossi, 1984). These patterns form the basis for attributions of stereotyped male and female behaviors. The social role perspective focuses more explicitly on current social role and situational demands as the primary explanation for gender differences in emotional distress (Aneshensel & Pearlin, 1987; Risman, 1987). Participation in particular social roles or combinations of roles increases the chances of exposure to certain types of stressors. Within specific roles, variations in situational contexts may further condition adaptive behavior and attitudes and the individual's interpretations of the current situation. This perspective assumes that exposure to stressful situations determines stress levels; women are more distressed because they have more stressful experiences and greater role strain (Gore & Mangione, 1983; Kessler, 1979). A variant of the social role perspective is offered by adult development researchers (Hagestad & Neugarten, 1985; Gutmann, 1980; Brubaker, 1985). In postparental and postretirement stages of life as the parental imperative of childrearing and pressures of career and family support no longer apply, gender differences become less salient (Gutmann, 1980). Thus we would expect greater gender differences in stress to be found among daughter and son caregivers than among spouse caregivers.
Method Literature Search The search for published studies that included empirical findings about gender differences in caregiving used both computer and manual methods. We did not include books, dissertations, or unpublished studies in this study. Computer searches used the 1980-1990 data bases of Sociological Abstracts, Social Work Abstracts, Psychological Abstracts, AARP Age Line, Medline, and The National Council of Family Relations. Key words included gender differences, male caregivers, female caregivers and caregiving, family caregivers, caregiver strain, and caregiver burden. Manual searches included reference lists of recent summaries of the caregiving literature and related published research articles and the tables of contents of these journals: The Gerontologist, Journal of Gerontology, Research on Aging, Psychology and Aging, Sex Roles, Journal of Gerontological Social Work, and Journal of Gerontological Nursing. A total of 99 articles was identified from both sources. 500
Studies were included in this review only if the following criteria were met: a) care receivers were noninstitutionalized older persons; b) bivariate analyses of gender differences in stressors or burden of caregiving were reported; and c) sufficient data was available to compute effect sizes. Application of these selection criteria resulted in a final sample of 14 studies published in professional journals between 1983 and 1990: Barber, 1988; Barusch & Spaid, 1989; Finley, 1989; Fitting et al., 1986; Horowitz, 1985b; Miller, McFall, & Montgomery, 1991; Miller & Montgomery, 1990; Pratt et al., 1985; Pruchno & Resch, 1989; Quayhagen & Quayhagen, 1988; Stoller, 1990; Stoller, 1983; Stone, Cafferata, and Sangl, 1987; Young & Kahana, 1989. Many of the unselected articles referred to gender of caregiver in their sample description only. These articles either did not use gender as an analytic variable (n = 20) or examined aspects of the caregiving process other than stressors and distress (n = 61). There was insufficient information for computing effect sizes in four studies that met the other criteria. Separate meta-analyses were conducted for four aspects of the caregiver-stress framework for which sufficient data were available: level of functional impairment of frail elders; total amount of task involvement; type of task involvement (assistance with personal care, money management, and household chores), and caregiver burden. Several studies used data from the National Long-Term Care Survey (Coward & Dwyer, 1990; Miller & Montgomery, 1990; Miller, 1990; Miller, McFall, & Montgomery, 1991; Stone, Cafferata, & Sangl, 1987). These studies had varying emphases, but to avoid overlap in samples, we used only one such study per analysis. Because we anticipated using relationship with the caregiver as a possible moderator variable, we report the Miller and Montgomery (1990) data and the Stone, Cafferata, and Sangl (1987) data as four studies by distinguishing spouse caregivers from those of adult child caregivers in each study. Similarly, depending on the published information, we report the Young and Kahana (1989) study either by gender (females = wives and daughters) or by family relationship (husbands and wives). The number of studies for each meta-analysis ranged from six (impairment in activity of daily living [ADL]) to ten (caregiver burden), with an average sample size that ranged from 245 (burden) to 376 (type of task). It would be premature to draw definitive conclusions on the basis of these relatively few studies. Sackett, Harris, and Orr (1986) suggest that the power to detect a population difference of .1 (a small effect) for meta-analyses based on as few as eight studies with a mean sample size of 200, assuming perfect measurement, is .66. The power rises to .99 for detection of a population difference of .2. With relatively few studies, the magnitude and direction of the average correlation values could be altered by adding a few more large sample studies, analogous to the "file drawer problem" discussed by Rosenthal (1984). In addition, because of the few studies found, we could not assess the possible conThe Gerontologist
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Caregiver Burden Caregiver burden is one facet of caregiver appraisal of the behavioral and cognitive impacts of caregiving. Women tend to report higher levels of emotional distress throughout the life course — a pattern that has also been found within the caregiving literature (Horowitz, 1985a; Schultz, Visitainer, & Williamson, 1990). Findings of gender differences in caregiver burden are less clear cut, but most studies suggest that female caregivers report higher levels of burden than do male caregivers (Horowitz, 1985b; Pruchno & Resch, 1989). The gender-role socialization perspective suggests that appraisal of caregiver burden may be partially explained by women's greater ease in expressing feelings or by men's tendencies toward stoicism (Verbrugge, 1985). The social role hypothesis suggests that few differences in burden should occur as long as the stressors, use of social resources, and other factors are similar for male and female caregivers. This brief review of perspectives on gender differences in caregiving suggests concepts and variables that may help explain gender differences in caregiving stressors and burden. Although these perspectives are not mutually exclusive, they differ in their emphasis on the caregivers' previous socialization and gender-linked personality traits versus behavioral responses to the caregiving situation. Thus, findings of no difference between male and female caregivers in amount and type of task involvement and in appraisal of burden suggest support for the social role hypothesis, especially if little difference in level of elder's impairment is found. On the other hand, stereotypic gender differences in provision of caregiving tasks and expressions of burden may suggest areas in which residual elements of gender-role socialization influence caregivers' response to caregiving.
founding of gender with relationship as we had hoped. Yet, because of the relatively large combined sample sizes, we believe that this preliminary metaanalysis is justified as a method to reduce some of the subjectivity associated with traditional review techniques. Characteristics of the Studies
Plan of Analyses We used the meta-analysis procedures described by Hunter and Schmidt (1990). Their approach considers the extent to which differences among study outcomes are attributable to statistical artifacts. Specifically, the influences of measurement unreliability and sampling error (e.g., relative sample sizes) on correlations between gender and caregiving components are removed to establish population estimates of their "true" relationships. The key element in meta-analysis is the transformation of research findings into a common metric, known as the effect size d, that is, the standardized difference in means expressed in standard deviation units (Cohen, 1987; Glass, McGaw, & Smith, 1981). We used pooled, within-group standard deviations as the denominator. Because the amount and type of information available in each study varied, we used the methods suggested by Holmes (1984) for estimating effect sizes when complete data are not reported. These methods provide a conservative estimate and allowed for the inclusion of a broader range of studies in the meta-analysis. The effect size d is algebraically equivalent to the correlation coefficient r, according to the formula r = dl V (4 + d2) (Hunter & Schmidt, 1990). (The Pearson correlation coefficient is equivalent to the point serial correlation typically recommended when one of the variables is dichotomous.) We converted Vol. 32, No. 4,1992
Results
Level of Functional Impairment The level of functional impairment of the older person is considered a primary stressor for caregivers. The literature provides strong support for the proposition that severity of impairment is associated with level and type of involvement and mixed support for the association between severity of impairment and caregiver burden (Horowitz, 1985a). If gender differences in severity of elders' impairment are found, caregiver differences in level of involvement, type of tasks, and caregiver burden may be interpreted as a consequence of this stressor. Six studies contributed to the analysis of the care receiver's level of impairment. Sample sizes ranged 501
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We coded each study by relationship with caregiver (spouse, adult child, mixed), sample type (probability or nonprobability), source of sample (general community or agency), illness type (dementia or other), and gender and race of respondents. Information about caregiver relationship, percentage of women, sample type, and illness type are provided with the description of studies for each analysis. Approximately half of the studies were of white caregivers only; the proportion of whites ranged from .60 to .91 in the remainder of the studies. Sampling methods varied greatly. Approximately half of the studies selected caregivers directly from service agencies and media recruitment and the remainder came from general community surveys. Community surveys had probability samples and tended to first identify and interview older persons, then conduct interviews with caregivers identified by those older persons. The other studies used non probability samples of caregivers without corresponding interviews with care receivers. Many of the identified studies were designed for other purposes but examined gender differences as a secondary focus.
d to r to enable easier interpretation of strength of association between gender and caregiving characteristic. A positive correlation indicates that women were more likely to have the characteristic than men. The effect size of can be interpreted as average difference between male and female caregivers in terms of the average standard deviation. An effect size of d = + 1 indicates that the mean of the female caregivers is one standard deviation higher than the mean of the male caregiver on that characteristic. The meta-analysis results were based on the following calculations. We first computed the weighted mean correlation rw = %(N^/XNi. The variance of the weighted mean correlation (Vr) is based on the weighted difference between each correlation and the weighted mean, using the formula: {Vr) = £[N,(V, - rw)2] I 2N,. We calculated the sampling error variance (Ve) by the formula: (Ve) = (1 - rw2)2/((ZNJK) 1), where K = N of studies. We subtracted the sampling error variance from the correlation variance to create the estimated population variance and standard deviation. We also created confidence intervals at the .95 level around the population estimates of effect size to test the hypothesis that the association between gender and the dependent variable is zero. For the analysis of burden, we also adjusted the effect (r) for each study by the reported reliability of the dependent variable. A comparable set of formulas was used to calculate the meta-analysis results using the d statistic (Hunter & Schmidt, 1990). The one difference in formulas is that the sampling error variance of of is calculated by the formula: Ve = [(N - 1)/(N - 3)][4/N][1 + D2/8]. Hunter and Schmidt (1990) suggest that if sampling error, measurement unreliability, and range differences between samples account for 75% or more of the observed variance, there is no need to search for moderator variables. Since we could not correct for range differences because so few studies reported scale ranges, we used a lower percentage of artifactual variance, 60%, as the criteria for analyses that only correct for two factors. In other words, if the sampling error variance is higher than 60% of the population variance, the variance is primarily due to sampling error and not other moderator variables.
(Barusch & Spaid, 1989; Horowitz, 1985a; Pruchno & Resch, 1989), or by number of hours (Stoller, 1983; Young & Kahana, 1989). Reliability coefficients were given only for the measures of amount/degree of assistance. In view of the difference in types of measures, we did not adjust for measurement error. Seven studies showed small to moderate positive gender differences in level of caregiver involvement, with correlations ranging from .01 to .30), suggesting slightly greater task involvement by female caregivers (see Table 2). Only one study (Miller & Montgomery, 1990) showed a small negative correlation (-.04), in which caregiving husbands reported performing more tasks than caregiving wives. The mean weighted unadjusted correlation coefficient for the combined sample was .06 (SD = .08). The 95% confidence interval of the correlation ranged from - .09 to .22. Since the confidence interval included zero, we cannot conclude that there is any difference by gender in total amount of task involvement of male and female caregivers. The variation attributed to sampling error is 29%; thus moderator variables and other artifacts may explain some of the variation between the study correlations. Type of Task Involvement The gender-role socialization hypothesis suggests that even if there is no difference in total amount of caregiver involvement, there are traditional gender differences in the household division of labor. Seven studies contributed to the analysis of gender differences in three types of caregiver tasks, personal care, household chores, and money management. The studies ranged in sample size from 132 to 782, with a total sample of 2,632 and a mean of 376. The proportion of women in the samples ranged from .52 to .77. The measures of each type of task involvement typically used one to five items, asking about frequency of performance of a specific task and reporting the proportion of men and women who performed the task. One study reported mean hours spent on each task (Stoller, 1983) and another (Barusch & Spaid,
Level of Total Caregiver Involvement Eight studies contributed to the analysis of gender differences in level of total caregiver involvement. The studies ranged in sample size from 131 to 608, for a total sample of 2,489 and a mean of 311. Four of the studies were of spouse caregivers and four were of adult child caregivers. The proportion of female caregivers in these studies ranged from 53% to 80%. Global task involvement was measured by number of caregiving tasks (Finley, 1989; Miller & Montgomery, 1990), by amount or degree of task assistance
Table 1. Meta-Analysis of Caregiver Gender and Elder's Level of ADL Impairment in Study of Gender Differences in Caregiving 1A. Study characteristics and effect sizes Study Barusch & Spaid, 1989 Fitting et al., 1986 Horowitz, 1985b Miller & Montgomery, 1990a Miller & Montgomery, 1990a Stoller, 1983
N
Sample type
% female
Relationship
Impairment type
131 54 132 559 608 236
NP NP NP P P P
70 48 76 64 79 53
Spouse Spouse Child Spouse
Mixed Dementia Mixed Mixed Mixed Mixed
Child Child
Effect sized
Effect sizer
-.49 .09 .29 .11 .35 .24
-.24 .05 .14 .06 .17 .12
1B. Results of meta-analysis Unadjusted results r Mean S2 •^ error
C2
Standard deviation
.09 .011 .004 .008 .089
Unadjusted results d
Cl - .09, .26
.18 .05 .002 .065 .212
Cl - .23,.595
Note. NP = nonprobability sample; P = probability sample; Cl = confidence interval; S2 = variance. 'Studies listed twice are analyzed separately by relationship of caregiver: spouse or adult child.
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from 54 to 608 for a cumulative total of 1,720 and a mean of 286. The proportion of female caregivers ranged from .48 to .79. Half of the studies were of spouse caregivers and half were of adult child caregivers. Measures of ADL functioning varied, but all measures contained indicators of both ADL and IADL limitations except Barusch and Spaid (1989) (ADL only) and Fitting et al. (1986) (three-stage criteria combining ADL and neuropsychological criteria). Five studies showed a small positive association between caregiver gender and elder's level of impairment, with correlations ranging from .05 to .17. Female caregivers were caring for more severely functionally impaired dependent persons than were male caregivers. Only one study (Barusch & Spaid, 1989) showed that those cared for by women were less disabled than those cared for by men. Table 1 presents the results of the meta-analysis adjusted for sample size. The unadjusted mean weighted correlation coefficient for the combined sample was .09 (SD = .09). The 95% confidence interval of the unadjusted correlation was - . 0 9 to .26. Since the confidence interval includes zero, we cannot conclude that there is any difference by gender in level of severity of care recipient's functional impairment between male and female caregivers of frail older persons. Approximately 36% of the observed variance is accounted for by sampling error, suggesting that other moderator variables may account for the variation between studies.
1989) summed the average number of tasks performed in a specific area. Reliability coefficients generally were not provided. Table 3 shows the results of meta-analysis for the three types of tasks.
1989) showed a small negative association (-.11). The mean weighted correlation coefficient (r = .12, SD = .05) suggests that female caregivers are more likely to carry out personal care activities than male caregivers are. The 95% confidence level is .04 to .20, leading to a rejection of the hypothesis that there are no gender differences in provision of personal care activities. Differences between the proportion of women performing personal care activities and the proportion of men ranged from a low of 1% (Young & Kahana, 1989) to a high of 23.9% (Horo-
Personal care activities. — Personal care activities include dressing, bathing, grooming, and other acts of personal hygiene. Five studies showed small positive correlations ranging from .00 to .16; one study showed a moderate positive correlation of .25 (Horowitz, 1985b); and only one study (Young & Kahana,
Table 2. Meta-Analysis of Caregiver Gender and Total Level of Caregiver Involvement in Study of Gender Differences in Caregiving
2A. Study characteristics and effect sizes Study
Sample type
% female
Relationship
Impairment type
131 325 132 559 608 315 236 183
NP P NP P P NP P NP
70 77 76 64 79 68 53 80
Spouse Child Child Spouse Child Spouse Child Mixed
Mixed Mixed Mixed Mixed Mixed Dementia Mixed Mixed
'
Effect sized
Effect size r
.01 .44 .64 -.08 .03 .06 .23 .34
.01 .21 .30 -.04 .01 .03 .11 .17
2B. Results of meta-analysis Unadjusted results r Mean S2 •^ error
Standard deviation
Unadjusted results d
Cl - .09, .22
.06 .010 .003 .007 .084
.14 .043 .002 .042 .204
Cl - .265,.53
Note. NP = nonprobability sample; P = probability sample; Cl = confidence interval; S2 = variance. "Studies listed twice are analyzed separately by relationship of caregiver: spouse or adult child.
Table 3. Meta-Analysis of Caregiver Gender and Type of Caregiver Involvment in Study of Gender Differences in Caregiving
3A. Study characteristics and effect sizes Personal (:are Study
N
Barusch & Spaid, 1989 Horowitz, 1985b Stoller, 1983 Stoller, 1990 Stone, Cafferata, & Sangl, 1987a Stone, Cafferata, & Sangl, 1987a Young & Kahana, 1989
Sample type NP NP P P P P NP
131 132 236 362 823 782 116
% female
Relationship
70 76 53 59 77 64 52
d
Spouse Child Child Mixed Child Spouse Spouse
.01 .52 .22 .25 .32 .21 -.21
Household chores
r .00 .25 .11 .12 .16 .10 -.11
d
Money management
r
.02 .53 .42 .01 .34
d
- .07
.01 .26 .20 .00 .17 .25 .11
-.51
.22
.22 .18 - .03 .17 .31 - .10
r - .03 .11 .09 - .01 .08 .15 -.05
3B. Results of meta-analysis Household chores
Personal care r Mean Confidence interval S2
S
.12 .04, .20 .005 .003 .002 .042
d .24 - . 0 1 , .49 .019 .002 .017 .131
d
r b
.02 - . 3 3 , . 37 .035 .003 .023 .179
.03" - . 7 1 , . 77 .148 .002 .146 .382
r
M o n e y management
C
.13 .02, .25 .007 .003 .004 .059
503
C
.27 - .25, .79 .029 .002 .026 .163
N o t e . NP = n o n p r o b a b i l i t y sample; P = probability sample; Cl = c o n f i d e n c e interval; S2 = variance. 'Studies listed twice are analyzed separately by relationship of caregiver: spouse or adult c h i l d . b Based o n N = 7. c Based o n N = 6, o m i t t i n g Stone, Cafferata, & Sangl (1987), spouse.
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r
d
d
.08
.16
0, .16 .004 .003 .002 .041
- . 1 5 , .47 .018 .001 .016 .128
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Barusch & Spaid, 1989 Finley, 1989 Horowitz, 1985b Miller & Montgomery, 1990a Miller & Montgomery, 1990a Pruchno & Resch, 1989 Stoller, 1983 Young & Kahana, 1989
N
ment activities and the proportion of men ranged from a low of 1% (Stoller, 1990) to a high of 15.7% (Stone, Cafferata, & Sangl, 1987). The mean weighted correlation coefficient was .08 (SD = .04). The 95% confidence interval of the correlation ranged from 0 to .16. Since the confidence interval included zero, we cannot conclude that there are any gender differences in money management tasks. The proportion of variance due to sampling error was 58.6%, suggesting that although sampling error may account for much of the variance between the studies, other moderator variables may also exist.
witz, 1985b). Because only 50% of the variance is attributed to sampling error, other moderator variables may account for the variation between studies. Household chores. — Five studies showed small positive correlations ranging from .00 to .20; one study showed a moderate positive correlation (Horowitz, 1985b), and only Stone, Cafferata, and Sangl (1987) showed a moderate negative effect (-.25). Stone and colleagues comment that this finding that husbands (78.7%) performed more personal care activities than wives (70.1%) may be an artifact of question wording, which asked about the number of extra hours spent on household chores. Differences between proportion of women performing household chores and the proportion of men ranged from a low of .4% (Stoller, 1990) to a high of 26.2% (Horowitz, 1985b). The mean weighted correlation coefficient for all seven studies was .02 (SD = .18). The 95% confidence interval of the correlation ranged from - .33 to .37. We recomputed the meta-analysis omitting the outlier value contributed by Stone, Cafferata, and Sangl, and found a mean weighted coefficient of .13 (SD = .06; 95% confidence interval = .016 to .246). Since this confidence interval did not include zero, we conclude that there may be a difference, albeit small, by gender in level of performing household chores by male and female caregivers if comparable question wording is used. Proportion of variance due to sampling error in the recomputed analysis is 44%, suggesting that other modifiers may also contribute to this relationship.
Caregiver Burden
Money management. — Individual study correlations ranged from small negative to small positive relationships {r = -.05-.15). Differences between proportion of women performing money manage-
Table 4. Meta-Analysis of Caregiver Gender and Type of Caregiver Burden in Study of Gender Differences in Caregiving 4A. Study characteristics and effect sizes Study Barber, 1988 Barusch & Spaid, 1989 Fitting etal., 1989 Miller, McFall, & Montgomery, 1991a Miller, McFall, & Montgomery, 1991a Pratt etal., 1985 Pruchno & Resch, 1989 Williamson & Schulz, 1990 Young & Kahana, 1989 Zarit, Todd, & Zarit, 1986
Sample type
% female
Relationship
Impairment type
Effect size d
Effect size r
Reliability
Adjusted
N 171 131 54 559 608 240 315 145 183 43
NP NP NP P P NP NP NP NP NP
71 70 48 64 79 78 68 68 80 47
Child Spouse Spouse Spouse Child Mixed Spouse Mixed Mixed Spouse
Mixed Mixed Dementia Mixed Mixed Dementia Dementia Dementia Mixed Dementia
.46 .75 .49 .25 .31 .07 .48 .57 .73 1.25
.22 .34 .24 .12 .15 .03 .23 .27 .34 .53
.79 .79 .79 .76 .76 .79 .89 .82 .79 .79
.25 .38 .27 .15 .19 .04 .25 .30 .38 .60
T
4B. Results of meta-analysis Unadjusted results Mean 9 •^ error
Standard deviation
.19 .010 .004 .006 .075
Cl: .05, .33
Adjusted results
Unadjusted results d
.21 .012 .004 .008 .075
.39 .048 .002 .047 .216
Cl: .07, .35
Cl: - .04, .82
Note. NP = nonprobability sample; P = probability sample; ClI = confidence interval; S2 = variance. 'Studies listed twice are analyzed separately by relationship of caregiver: spouse or adult child.
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Ten studies contained usable data about gender differences in caregiver burden. The studies ranged in sample size from 43 to 608 for a total sample of 2,449 and a mean of 245. The proportion of female caregivers ranged from 47% to 80%. Five studies interviewed spouses only, two interviewed only sons and daughters, and three were mixed. Four studies were of caregivers of persons with dementia and six studies included persons with mixed types of impairment. Seven of the studies used the Zarit Burden Scale as the measure of burden (internal consistency reliability = .79). The Pruchno and Resch (1989) study used a 17-item scale (internal consistency reliability = .75) and the Miller, McFall, and Montgomery (1991) study used a six-item measure of personal burden (internal consistency reliability = .76). Seven of the studies showed moderate to large positive coefficients ranging from .22 to .53; three studies showed smaller coefficients ranging from .03 to .15 (see Table 4). All correlations were positive, showing that female caregivers report higher levels of burden than male caregivers. The mean weighted correlation coefficient adjusted for measurement er-
rorwas .21 (unadjusted r = .18, SD = .075). The 95% confidence interval of the adjusted correlation is .07 to .35. These effects are positive; women perceive higher levels of caregiver burden than men do. Different approaches exist for examining the extent to which the results of a meta-analysis would change if additional studies had been located. Rosenthal's (1984) file drawer analysis estimates a failsafe N, the number of unlocated studies averaging null results that would have to exist to bring the significance level for a set of studies down to the traditional probability value of .05. Based on this criteria, the fail-safe N for caregiver burden is 463 studies. Rosenthal and Rosnow (1984) suggest that any cumulation for which the fail-safe N reaches more than five times the number of studies plus 10 (in this case, 60 studies) may be considered robust. A second method emphasizes how many missing studies averaging null findings would have to exist to bring the mean effect size down to some specific level (Hunter & Schmidt, 1990, p. 513). According to this criteria, eight additional studies averaging null results would have to be " f o u n d " to reduce the significant cumulative effect size of .21 to a nonsignificant value of .10. Although the effect of gender on burden is statistically significant and robust, the question of practical significance of this difference remains. There are no readily agreed-on criteria for this judgment. One traditional approach is to compute the variance explained. Thus, by this criteria, gender differences "explain" approximately 4% of the variance in caregiver burden. Rosenthal and Rubin (1982) offer a binomial effect size display to portray the change in improvement rate attributable to a new treatment procedure. Applying this approach to gender differences in caregiver burden, we find that on the average, female caregivers are 20% more burdened than male caregivers. The extent to which interventions may be able to reduce this gap or the overall mean levels of burden of both men and women remains unknown (Toseland, Rossiter, & Labrecque, 1989; Whitlatch, Zarit, & von Eye, 1991). Only 33% of the variance between studies was accounted for by sampling error; thus moderator variables or other study artifacts may account for some of the additional variation found. According to the social role perspective, we might expect to find differences between spouse and adult child caregivers' reports of burden. Unfortunately, because there were only two studies of adult child caregivers, we could not test for caregiver relationship as a possible modifier. For exploratory purposes, we computed the bivariate correlations between selected study characteristics and effect size. We found strong negative relationships between effect size and total sample size (r = - .61), percentage of women in sample (r = -.49), and use of nonprobability sampling (r = -.43). There was little association between effect size and type of illness (r = -.07). These results are exploratory, but they suggest that sampling attributes of studies also may influence the relationship between caregiver gender and burden.
This meta-analysis cumulated results across studies to estimate the size and significance of gender differences in caregiving stressors and burden. There were essentially no significant gender differences in functional impairment of the frail care recipient or total caregiver involvement in care. Female caregivers were more likely to carry out personal care and household tasks, but the size of this effect was quite small. Female caregivers were more likely to report greater burden. Although this effect was larger than that of provision of personal care and household chores, it is barely in the moderate range and represents a small difference in practical terms. Based on the Hunter and Schmidt (1990) suggested criteria of 60%, statistical artifacts such as sampling error and measurement unreliability account for only a small proportion of the observed variance among studies. Interpretation of these results is subject to conceptual and methodological limitations. Conceptually, by focusing only on bivariate differences in broadly defined areas of caregiving, we minimize the individualization and complexity of most caregiving situations and the relevance of multivariate research analyses. We also compromise serious application of the theoretical perspectives of gender differences in caregiving by including few of the concepts specifically referred to by those theories. Methodologically, despite findings that sampling error explains only a portion of the findings, we were unable to test for modifier variables because of the relatively few studies. Inclusion of additional studies or greater homogeneity of measurement strategies may also shift the conclusions. The power to detect the relatively small differences between male and female caregiving activities is a limitation not only of this meta-analysis but also of most caregiving research to date. Thus these findings remain preliminary and subject to more rigorous evaluation. The results of the meta-analysis support elements of both the gender-role socialization and social role hypotheses. The lack of gender differences in elders' functional limitations, total amount of caregiver involvement, and in money management tasks support the social role hypothesis that caregivers respond to the demands of the situation. The lack of significant aggregate differences in severity of functional impairment is especially important since functional impairment is a major reason for caregiving activities (Horowitz, 1985b). Even though there appear to be statistically significant gender differences in personal care and household chores activities in the direction predicted by gender-role socialization, the size of the effect is small. Thus, we may conclude that the social role hypothesis is more useful in terms of explaining caregiving task behaviors. The speculation that men are more likely to engage in caregiving tasks that are finite and subject to scheduling (e.g., money management) is not supported (Horowitz, 1985a). The gender-role socialization hypothesis appears 505
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Discussion
ence on the identification and selection of caregivers than on intrarole adaptation. The question of the extent to which men and women confront different caregiving situations remains unanswered. In addition to the need for more studies of male and female caregivers in homogenous caregiving situations, more information is needed about gendered expectations of care receivers for care. Gendered expectations influence sick role and help-seeking behaviors (Verbrugge, 1985). It is reasonable to expect that they may influence caregiver/care receiver interactions as well. Older women and men may expect more from female caregivers than from male caregivers. For example, Aronson (1990, p. 239) describes how older women subscribe to the wish to remain independent but also note their "good fortune" at having daughters (not sons) to help them, and their sympathy for age peers who do not. Given the relatively small amount of gender differences, is it important to continue to focus on understanding gender differences in behavior? What difference does it make if men and women experience and enact the caregiving role slightly differently? Should programs and policies be influenced by this difference? Or are there other facets of caregiving that are more important than the socialization and gender-role stereotyped activities assumed to be associated with the dichotomous variable of gender? If so, shouldn't these factors be measured directly and the use of gender per se as a pointer variable be eliminated in examinations of enactment of the caregiving role? We admit to a certain ambivalence about the relevance of additional studies of gender differences in caregiving. The results of this meta-analysis, intragender variations in care situations, and difficulties in nonparadigmatic interpretation of results suggest that documentation of gender differences in various components of care may be a futile exercise without large sample sizes and highly focused studies. Yet, the persistence of sterotypes of gender-role behaviors, and the quickness with which caregivers, older persons, practitioners, and researchers draw on interpretations of traditional gender-role behaviors to bolster their explanations of events suggest continued relevance for study (Fitting et al., 1986). What is needed may be less documentation of specific gender differences in isolated components of caregiving and more attention to the role that gender-role explanations play in assigning meaning to the caregiving experience. Caregiving is seen as a female activity because of its emphasis on nurturance, personal care tasks, and household activities. Yet this definition ignores the authority issues involved in caring for an older person and the supervisory activities involved in coordinating care and medical needs (Miller, 1987; Pruchno & Resch, 1989). The persistence of gender-role expectations of caregiving needs to be examined from a variety of research perspectives. Because of the individualized nature of caregiving, greater emphasis on narrative description may illuminate the meaning of gender in 506
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to be useful in understanding caregiver appraisal or emotional responses to caregiving. Female caregivers express more burden than their male counterparts. Yet the usefulness of this explanation is limited by the difficulty of determining which aspects of gender socialization contribute to women's greater vulnerability to caregiver stress effects. For example, women might be expected to experience less burden because they are better prepared for the caregiving experience by their history of personal care and household management. Or, older men may have greater resilience because the loss of the work role may heighten their involvement in family caregiving as an outlet for growing domestic interests. Other questions remain. Do women experience greater burden because they feel more responsible for providing good care and thus have higher standards of accomplishment? Are women more sensitive to the relationship aspects of providing care and less able to maintain emotional distance (Abel, 1987)? Are women more comfortable in expressing their feelings and thus reporting their perceptions of burden more truthfully than men (Verbrugge, 1985)? The theoretical perspectives suggest additional variables that have rarely been included within studies of caregivers. In addition, male and female are social constructs that vary among women and among men. Intra-gender variation is not fully taken into account by the current emphasis on gender differences. Clearly, no consistent paradigm for interpretation of gender differences in caregiving has yet emerged. Although hypotheses derived from the stress and coping frameworks may be the most highly developed, studies rarely measure the personality attributes, gender-role orientation, or previous genderrole behaviors discussed by these hypotheses. Furthermore, most studies of caregiving focus on the personal and interpersonal level, largely ignoring the existence of macrosocial determinants of levels of adaptation, despite the fact that gender structures the distribution of rewards, privileges, opportunities, and responsibilities at many societal levels (House, Umberson, & Landis, 1988; Pearlin et al., 1990). House and colleagues (1988) suggest that the impact of macrosocial attributes (such as gender) on caregiving can be illuminated by different kinds of research: 1) examination of how the components of caregiving vary across groups of individuals in different structural positions in society (e.g., men vs. women); 2) examination of variations across different organizational units, such as different communities; and 3) examination of variation in the components of caregiving as a function of changes in macrosocial structures of society. Most of the research reviewed in this meta-analysis examines how the components of caregiving vary by gender but pays little attention to the structural or cultural context. References to societal level differences of older men and women in marital patterns, age distributions, financial resources, and health status are rare (see Barusch & Spaid, 1989, Fitting et al., 1986, Miller, 1990, and Stoller, 1990 for exceptions). It is possible, however, that these factors may have a greater influ-
the context of everyday life. Although gender is an enduring attribute, the meaning of gender may change in different cultures or at different points in the caregiving process (Zarit, Todd, & Zarit, 1986). For example, the physical differences between male and female caregivers may be more salient at later stages of the caregiving process when physical disability is more pronounced. At a broader level, research is needed to examine possible differential effects on men and women of policies directed towards development of health care services, home health care, and caregiver support services (see Osterbusch et al., 1987, and Glazer, 1990 for examples of this approach). Most important of all is the need to develop theoretically driven models of research, as little cumulation of knowledge may occur without clear explanations of study findings.
Abel, E. K. (1987). Love is not enough: Family care of the frail elderly. Washington DC: America Public Health Association. Abel, E. K. (1990). Informal care for the disabled elderly: A critique of recent literature. Research on Aging, 12, 139-157. Aneshensel, C. S., & Pearlin, L. I. (1987). Structural contexts of sex differences in stress. In R. Barnett, L. Biener, & C. Baruch (Eds.), Gender and stress. New York: Free Press. Aronson, J. (1990). Women's perspectives on informal care of the elderly: Public ideology and personal experience of giving and receiving care. Aging and Society, 10, 61-84. Barber, C. E. (1988). Correlates of subjective burden among adult sons and daughters caring for aged parents. Journal of Aging Studies, 2,133-144. Barer, B., & Johnson, C. (1990). A critique of the caregiving literature. The Cerontologist, 30, 26-29. Bardwick, J., & Douvan, E. (1971). Ambivalence: The socialization of women. In V. Gornick & B. Moran (Eds.), Women in sexist society. New York: Basic Books. Barnett, R., & Baruch, C. (1987). Social roles, gender, and psychological distress. In R. Barnett, L. Biener, & C. Baruch (Eds.), Gender and stress. New York: Free Press. Barusch, A. S., & Spaid, W. M. (1989). Gender differences in caregiving: Why do wives report greater burden? The Gerontologist, 29, 667-676. Brubaker, T. H. (1985). Later life families. Beverly Hills: Sage. Chodorow, N. (1978). The reproduction of mothering. Berkeley: University of California Press. Cohen, J. (1987). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum. Coward, R. T., & Dwyer, J. W. (1990). The association of gender, sibling network composition, and patterns of parent care by adult children. Research on Aging, 12, 158-181. Dwyer, J. W., & Seccombe, K. (In press). Elder care as family labor: The influence of gender and family position. Journal of Family Issues. Finley, N. J. (1989). Theories of family labor as applied to gender differences in caregiving for elderly parents. Journal of Marriage and the Family, 51, 79-86. Fitting, M., Rabins, P., Lucas, M. J., & Eastham, J. (1986). Caregivers for dementia patients: A comparison of husbands and wives. The Gerontologist, 29, 248-252. Gilligan, C. (1982). In a different voice: Psychological theory and women's development. Cambridge: Harvard University Press. Glass, G. V., McGaw, B., & Smith, M. L. (1981). Meta-analysis in social research. Beverly Hills: Sage. Glazer, N. (1990). The home as workshop: Women as amateur nurses and medical care providers. Gender and Society, 4, 479-499. Gore, S., & Mangione, T. W. (1983). Social roles, sex roles, and psychological distress: Additive and interactive models of sex differences. Journal of Health and Social Behavior, 24, 300-312. Gutmann, D. L. (1980). Psychoanalysis and aging: A developmental view. In S. I. Greenspan & G. H. Pollock (Eds.), The course of life, Vol I. Bethesda, MD: National Institute of Mental Health. Hagestad, G. O., & Neugarten, B. L. (1985). Aging and the life course. In R. Binstock & E. Shanas (Eds.), Handbook of aging and the social sciences (pp. 35-61). New York: Van Nostrand Reinhold.
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References
Holmes, C. T. (1984). Effect size estimation in meta-analysis. Journal of Experimental Education, 52, 105-109. Horowitz, A. (1985a). Family caregiving to the frail elderly. In C. Eisdorfer (Ed.), Annual review of gerontology and geriatrics, Vol. 5. (pp. 194-246). New York: Springer. Horowitz, A. (1985b). Sons and daughters as caregivers to older parents: Differences in role performance and consequences. The Gerontologist, 25, 612-617. House, J., Umberson, D., & Landis, K. (1988). Structures and processes of social support. Annual Review of Sociology, 14, 115-126. Hunter, J. E., & Schmidt, F. L. (1990). Methods of meta-analysis: Correcting error and bias in research findings. Newbury Park, CA: Sage. Kessler, R. (1979). Stress, social status, and psychological distress. Journal of Health and Social Behavior, 20, 259-272. Matthews, S. H. (1989). The burdens of parent care: A critical assessment of the recent literature. Journal of Aging Studies, 2, 157-165. Miller, B. (1987). Gender and control among spouses of the cognitively impaired: A research note. The Gerontologist, 27, 477-453. Miller, B. (1990). Gender differences in spouse caregiver strain: Socialization and role explanations. Journal of Marriage and the Family, 52, 311322. Miller, B., McFall, S., & Montgomery, A. (1991). The impact of elder health, caregiver involvement, and global stress on two dimensions of caregiver burden, journal of Gerontology, 46, S9-S19. Miller, B., & Montgomery, A. (1990). Family caregivers and limitations in social activities. Research on Aging, 12, 72-93. Osterbusch, S., Keigher, S., Miller, B., & Linsk, N. (1987). Community care policies and gender justice. International Journal of Health Services, 17, 217-232. Pearlin, L. I., Mullan, J., Semple, J., & Skaff, M. (1990). Caregiving and the stress process: An overview of concepts and their measures. The Gerontologist, 30, 583-594. Pearlin, L., & Schooler, C. (1978). The structure of coping. Journal of Health and Social Behavior, 19, 2-21. Pratt, C , Schmall, V. L., Wright, J., & Cleland, M. (1985). Burden and coping strategies of caregivers to Alzheimer patients. Family Relations, 34, 2733. Pruchno, R., & Resch, N. (1989). Husbands and wives as caregivers: Antecedents of depression and burden. The Gerontologist, 29, 159-165. Quayhagen, M. P., & Quayhagen, M. (1988). Alzheimer's stress: Coping with the caregiving role. The Gerontologist, 28, 391-396. Risman, B. J. (1987). Intimate relationships from a microstructural perspective: Men who mother. Gender and Society, 1, 6-32. Rosenthal, R. (1984). Meta-analysis procedures for social research. Beverly Hills: Sage. Rosenthal, R., & Rosnow, R. L. (1984). Essentials of behavioral research: Methods and data analysis. New York: McGrawHill. Rosenthal, R., & Rubin, D. (1982). A simple, general purpose display of magnitude of experimental effect. Journal of Educational Psychology, 74,166-169. Rossi, A. (1984). Gender and parenthood. American Sociological Review, 49,1-19. Sackett, P. R., Harris, M. M., & Orr, J. M. (1986). On seeking moderator variables in the meta-analysis of correlational data: A monte carlo investigation of statistical power and resistance to Type I error. Journal of Applied Psychology, 71, 302-310. Schultz, R., Visitainer, P., & Williamson, G. M. (1990). Psychiatric and physical morbidity effects of caregiving. Journal of Gerontology, 45, P181-P191. Stoller, E. P. (1983). Parental caregiving by adult children. Journal of Marriage and the Family, 45, 851-858. Stoller, E. P. (1990). Males as helpers: The role of sons, relatives, and friends. The Gerontologist, 30, 228-235. Stone, R., Cafferata, G., & Sangl, J. (1987). Caregivers of the frail elderly: A national profile. The Gerontologist, 27, 616-626. Toseland, R., Rossitor, C. M., & Labrecque, M. S. (1989). The effectiveness of peer-led and professionally led groups to support family caregivers. The Gerontologist, 29, 465^*71. Verbrugge, L. (1985). Gender and health: An update on hypotheses and evidence. Journal of Health and Social Behavior, 26, 156-182. Whitlatch, C. J., Zarit, S. H., & von Eye, A. (1991). Efficacy of interventions with caregivers: A reanalysis. The Gerontologist, 31, 9-14. Williamson, G. M., & Schulz, R. (1990). Relationship orientation, quality of prior relationship, and distress among caregivers of Alzheimer's patients. Psychology and Aging, 5, 502-509. Young, R. F., & Kahana, E. (1989). Specifying caregiver outcomes: Gender and relationship aspects of caregiving strain. The Gerontologist, 29, 660-666. Zarit, S. H., Todd, P., & Zarit, J. (1986). Subjective burden of husbands and wives as caregivers: A longitudinal study. The Gerontologist, 26, 260266.
This study applies meta-analysis techniques to the results of 14 descriptive studies of gender differences in caregiving to determine the size and significance of gender differences in caregiving stressors (level of elder impairment and level and type of task involvement) and in caregiver burden. There were essentially no significant gender differences in functional impairment of the frail care recipient, total caregiver involvement in care, or in money management tasks. Female caregivers were more likely to carry out personal care and household tasks and more likely to report greater burden. Given the relatively small size of the effects found, we conclude that future research should focus on the part that gender-role explanations play in assigning meaning to caregiving behaviors. Key Words: Family caregivers, Caregiver burden, Meta-analysis
Gender Differences in Caregiving: Fact or Artifact?1
is the probability of a Type I (false positive) error increased, the meaning of findings of no gender differences tend to be ignored. Integration of findings across articles is needed to fully ascertain the significance and magnitude of gender differences in caregiving. Traditional narrative reviews of the literature that summarize disparate results of many studies cannot easily account for the many sources of variation that may influence study results. In addition, review of large numbers of studies places a difficult information-processing burden on the reviewer and is subject to potential bias (Hunter & Schmidt, 1990). Meta-analysis provides a set of quantitative techniques for integrating study results that make explicit the theoretical perspectives and criteria used in forming judgments. These techniques include: (1) determination of the cumulative probability or statistical significance (Rosenthal, 1984); (2) assessment of the magnitude of relationships (Glass, McGaw, & Smith, 1981); and (3) determination of whether the variance observed across studies results from substantive effects (i.e., moderator variables) or from such methodological artifacts as sampling error, measurement reliability, range restriction, validity, or computational errors (Hunter & Schmidt, 1990). To our knowledge, this paper represents the first application of meta-analysis techniques to combine the results of descriptive studies of gender differences in caregiving. Our purpose in cumulating data across studies is to provide a base for interpreting the theoretical and practical implications of gender differences in caregiving stressors and burden. We address two research questions: 1) What are the size and significance of gender differences in caregiving stressors, e.g., level of elder impairment and level and type of task involvement? 2) What are the size and significance of gender differences in caregiver burden? We interpret our findings within the theo-
The most consistent finding in caregiving research is that the majority of family caregivers are women (Stone, Cafferata, & Sangl, 1987). The gender distribution of caregiving is inseparable from the family relationship of the caregiver: among spouse caregivers, approximately 67% of care is provided by women compared to 80-90% among adult child caregivers. This dominance of women and the tendency to describe the caregiver role in terms of personal care activities highlight the societal image of caregiving as a largely female endeavor. Yet, the extent to which women and men differ in their enactment of the caregiver role remains of high interest. Gender differences are believed to influence the amount and type of care provided, access to social resources that may alleviate caregiver strains, and appraisal of the caregiving experience (Pearlin et al., 1990; Miller, 1990). Recent critiques of the caregiving research literature imply that findings about gender differences in care may be subject to sample bias from overreliance on small and clinically drawn samples and lack of consistent measures of key concepts (Abel, 1990; Barer & Johnson, 1990; Matthews, 1989). Furthermore, published articles tend to emphasize statistically significant gender differences, ignoring findings of no difference. This tendency has two consequences. First, discussion of the size of the gender difference and its practical and clinical implications are often minimized. Second, findings of significance often occur among a series of significance tests, increasing the likelihood that these significant findings occurred by chance. Thus, not only
1 We thank Claudia Lampman and B. L. Dugoni of Loyala University for their helpful comments. department of Medical Social Work (MC 778), University of Illinois at Chicago, 808 South Wood Street, Chicago, IL 60612. department of Developmental Psychology, Loyola University, Chicago, IL.
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Baila Miller, PhD,2 and Lynda Cafasso, BS:
retical context of hypotheses explaining gender patterns of behavior in the stress process. Perspectives on Gender Differences in Caregiving
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Stressors Two classes of primary stressors have been investigated in caregiving research: the level of functional impairment of the frail older person and the amount and type of caregiver task involvement. These stressors are interdependent as the amount and type of caregiver involvement is typically determined by the level and type of impairment (Horowitz, 1985a; Miller, McFall, & Montgomery, 1991). The genderrole socialization hypothesis suggests that female caregivers will be more likely to perform personal care and household tasks than will male caregivers, as these tasks are extensions of the nurturant activities/behaviors performed as mothers and wives. Tasks, such as money management, that are time-limited and may be performed at the discretion of the caregiver will be more congruent with the primary work roles of male caregivers. Furthermore, as a result of gendered expectations of appropriate behaviors by caregivers and frail older persons, female caregivers may be socialized to respond more than men to similar levels of need. The social role hypothesis suggests that the severity of the impairment will determine gender differences in task involvement. To the extent that male and female caregivers are providing care to frail elders with similar levels of impairment, the nature of their task involvement should be similar. Furthermore, this similarity should be more pronounced among spouses than among adult child caregivers. 499
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Gerontological literature has not yet developed a consistent interpretation of gender differences in caregiving. The focus of most studies is descriptive, distinguishing either the differential selection of men and women into the caregiving role or differential enactment of that role. Ad hoc explanations of results draw on theories of household labor (Dwyer & Seccombe, in press; Finley, 1989; Horowitz, 1985b), stress and coping frameworks (Barber, 1988; Barusch & Spaid, 1989; Miller, 1990; Pratt et al., 1985; Quayhagen & Quayhagen, 1988; Young & Kahana, 1989), Gilligan's (1982) views of moral development (Fitting et al., 1986; Stoller, 1990), gender-role expectations (Barusch & Spaid, 1989), adult development perspectives (Pruchno & Resch, 1989), network attributes (Coward & Dwyer, 1990), or different opportunity costs for male and female caregivers (Osterbusch et al., 1987; Stoller, 1990). Since the stress/ coping framework is used in many studies of caregiving effects, we elaborate this perspective to guide our interpretation of results. The stress/coping paradigm (House, Umberson, & Landis, 1988; Pearlin et al., 1990) posits that differences in levels of stressors, psychosocial and environmental resources, and personal dispositions influence adverse outcomes in stress-producing situations. Thus, situation-specific role demands, support resources, and personal dispositions will influence the enactment of the caregiving role and the appraisal of caregiver distress. This model also posits that the stress process is conditioned by such attributes as gender, age, and race, which are associated with differential exposure to structural barriers and opportunities (House, Umberson, & Landis, 1988; Pearlin et al., 1990). Thus, male and female caregivers bring different demographic, occupational, and role socialization backgrounds to caregiving. The extent to which these differences influence caregiver stressors and burden appraisal form the basis of two alternative patterns of explanation within the general psychosocial stress model: the gender-role socialization perspective and the social role perspective (Barnett & Baruch, 1987; Kessler, 1979; Miller, 1990). The gender-role socialization hypothesis argues that women are more vulnerable to effects of stress because of earlier socialization factors such as sensitivity to relationships, nurturing versus instrumental behaviors, illness behaviors, and coping styles (Chodorow, 1978; Gilligan, 1982; Pearlin & Schooler, 1978). This framework assumes that childhood gender-role socialization and ongoing reinforcement by cultural norms and the gender stratification system cause gender roles to become internalized in stable personality orientations. The proposed mechanisms of internalization vary by theorist, but the general consensus is that the outcomes of these socialization patterns are stronger affiliative orientations and be-
haviors in women and more emphasis on autonomy, differentiation, and instrumental behaviors in men (Bardwick & Douvan, 1971; Chodorow, 1978; Gilligan, 1982; Rossi, 1984). These patterns form the basis for attributions of stereotyped male and female behaviors. The social role perspective focuses more explicitly on current social role and situational demands as the primary explanation for gender differences in emotional distress (Aneshensel & Pearlin, 1987; Risman, 1987). Participation in particular social roles or combinations of roles increases the chances of exposure to certain types of stressors. Within specific roles, variations in situational contexts may further condition adaptive behavior and attitudes and the individual's interpretations of the current situation. This perspective assumes that exposure to stressful situations determines stress levels; women are more distressed because they have more stressful experiences and greater role strain (Gore & Mangione, 1983; Kessler, 1979). A variant of the social role perspective is offered by adult development researchers (Hagestad & Neugarten, 1985; Gutmann, 1980; Brubaker, 1985). In postparental and postretirement stages of life as the parental imperative of childrearing and pressures of career and family support no longer apply, gender differences become less salient (Gutmann, 1980). Thus we would expect greater gender differences in stress to be found among daughter and son caregivers than among spouse caregivers.
Method Literature Search The search for published studies that included empirical findings about gender differences in caregiving used both computer and manual methods. We did not include books, dissertations, or unpublished studies in this study. Computer searches used the 1980-1990 data bases of Sociological Abstracts, Social Work Abstracts, Psychological Abstracts, AARP Age Line, Medline, and The National Council of Family Relations. Key words included gender differences, male caregivers, female caregivers and caregiving, family caregivers, caregiver strain, and caregiver burden. Manual searches included reference lists of recent summaries of the caregiving literature and related published research articles and the tables of contents of these journals: The Gerontologist, Journal of Gerontology, Research on Aging, Psychology and Aging, Sex Roles, Journal of Gerontological Social Work, and Journal of Gerontological Nursing. A total of 99 articles was identified from both sources. 500
Studies were included in this review only if the following criteria were met: a) care receivers were noninstitutionalized older persons; b) bivariate analyses of gender differences in stressors or burden of caregiving were reported; and c) sufficient data was available to compute effect sizes. Application of these selection criteria resulted in a final sample of 14 studies published in professional journals between 1983 and 1990: Barber, 1988; Barusch & Spaid, 1989; Finley, 1989; Fitting et al., 1986; Horowitz, 1985b; Miller, McFall, & Montgomery, 1991; Miller & Montgomery, 1990; Pratt et al., 1985; Pruchno & Resch, 1989; Quayhagen & Quayhagen, 1988; Stoller, 1990; Stoller, 1983; Stone, Cafferata, and Sangl, 1987; Young & Kahana, 1989. Many of the unselected articles referred to gender of caregiver in their sample description only. These articles either did not use gender as an analytic variable (n = 20) or examined aspects of the caregiving process other than stressors and distress (n = 61). There was insufficient information for computing effect sizes in four studies that met the other criteria. Separate meta-analyses were conducted for four aspects of the caregiver-stress framework for which sufficient data were available: level of functional impairment of frail elders; total amount of task involvement; type of task involvement (assistance with personal care, money management, and household chores), and caregiver burden. Several studies used data from the National Long-Term Care Survey (Coward & Dwyer, 1990; Miller & Montgomery, 1990; Miller, 1990; Miller, McFall, & Montgomery, 1991; Stone, Cafferata, & Sangl, 1987). These studies had varying emphases, but to avoid overlap in samples, we used only one such study per analysis. Because we anticipated using relationship with the caregiver as a possible moderator variable, we report the Miller and Montgomery (1990) data and the Stone, Cafferata, and Sangl (1987) data as four studies by distinguishing spouse caregivers from those of adult child caregivers in each study. Similarly, depending on the published information, we report the Young and Kahana (1989) study either by gender (females = wives and daughters) or by family relationship (husbands and wives). The number of studies for each meta-analysis ranged from six (impairment in activity of daily living [ADL]) to ten (caregiver burden), with an average sample size that ranged from 245 (burden) to 376 (type of task). It would be premature to draw definitive conclusions on the basis of these relatively few studies. Sackett, Harris, and Orr (1986) suggest that the power to detect a population difference of .1 (a small effect) for meta-analyses based on as few as eight studies with a mean sample size of 200, assuming perfect measurement, is .66. The power rises to .99 for detection of a population difference of .2. With relatively few studies, the magnitude and direction of the average correlation values could be altered by adding a few more large sample studies, analogous to the "file drawer problem" discussed by Rosenthal (1984). In addition, because of the few studies found, we could not assess the possible conThe Gerontologist
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Caregiver Burden Caregiver burden is one facet of caregiver appraisal of the behavioral and cognitive impacts of caregiving. Women tend to report higher levels of emotional distress throughout the life course — a pattern that has also been found within the caregiving literature (Horowitz, 1985a; Schultz, Visitainer, & Williamson, 1990). Findings of gender differences in caregiver burden are less clear cut, but most studies suggest that female caregivers report higher levels of burden than do male caregivers (Horowitz, 1985b; Pruchno & Resch, 1989). The gender-role socialization perspective suggests that appraisal of caregiver burden may be partially explained by women's greater ease in expressing feelings or by men's tendencies toward stoicism (Verbrugge, 1985). The social role hypothesis suggests that few differences in burden should occur as long as the stressors, use of social resources, and other factors are similar for male and female caregivers. This brief review of perspectives on gender differences in caregiving suggests concepts and variables that may help explain gender differences in caregiving stressors and burden. Although these perspectives are not mutually exclusive, they differ in their emphasis on the caregivers' previous socialization and gender-linked personality traits versus behavioral responses to the caregiving situation. Thus, findings of no difference between male and female caregivers in amount and type of task involvement and in appraisal of burden suggest support for the social role hypothesis, especially if little difference in level of elder's impairment is found. On the other hand, stereotypic gender differences in provision of caregiving tasks and expressions of burden may suggest areas in which residual elements of gender-role socialization influence caregivers' response to caregiving.
founding of gender with relationship as we had hoped. Yet, because of the relatively large combined sample sizes, we believe that this preliminary metaanalysis is justified as a method to reduce some of the subjectivity associated with traditional review techniques. Characteristics of the Studies
Plan of Analyses We used the meta-analysis procedures described by Hunter and Schmidt (1990). Their approach considers the extent to which differences among study outcomes are attributable to statistical artifacts. Specifically, the influences of measurement unreliability and sampling error (e.g., relative sample sizes) on correlations between gender and caregiving components are removed to establish population estimates of their "true" relationships. The key element in meta-analysis is the transformation of research findings into a common metric, known as the effect size d, that is, the standardized difference in means expressed in standard deviation units (Cohen, 1987; Glass, McGaw, & Smith, 1981). We used pooled, within-group standard deviations as the denominator. Because the amount and type of information available in each study varied, we used the methods suggested by Holmes (1984) for estimating effect sizes when complete data are not reported. These methods provide a conservative estimate and allowed for the inclusion of a broader range of studies in the meta-analysis. The effect size d is algebraically equivalent to the correlation coefficient r, according to the formula r = dl V (4 + d2) (Hunter & Schmidt, 1990). (The Pearson correlation coefficient is equivalent to the point serial correlation typically recommended when one of the variables is dichotomous.) We converted Vol. 32, No. 4,1992
Results
Level of Functional Impairment The level of functional impairment of the older person is considered a primary stressor for caregivers. The literature provides strong support for the proposition that severity of impairment is associated with level and type of involvement and mixed support for the association between severity of impairment and caregiver burden (Horowitz, 1985a). If gender differences in severity of elders' impairment are found, caregiver differences in level of involvement, type of tasks, and caregiver burden may be interpreted as a consequence of this stressor. Six studies contributed to the analysis of the care receiver's level of impairment. Sample sizes ranged 501
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We coded each study by relationship with caregiver (spouse, adult child, mixed), sample type (probability or nonprobability), source of sample (general community or agency), illness type (dementia or other), and gender and race of respondents. Information about caregiver relationship, percentage of women, sample type, and illness type are provided with the description of studies for each analysis. Approximately half of the studies were of white caregivers only; the proportion of whites ranged from .60 to .91 in the remainder of the studies. Sampling methods varied greatly. Approximately half of the studies selected caregivers directly from service agencies and media recruitment and the remainder came from general community surveys. Community surveys had probability samples and tended to first identify and interview older persons, then conduct interviews with caregivers identified by those older persons. The other studies used non probability samples of caregivers without corresponding interviews with care receivers. Many of the identified studies were designed for other purposes but examined gender differences as a secondary focus.
d to r to enable easier interpretation of strength of association between gender and caregiving characteristic. A positive correlation indicates that women were more likely to have the characteristic than men. The effect size of can be interpreted as average difference between male and female caregivers in terms of the average standard deviation. An effect size of d = + 1 indicates that the mean of the female caregivers is one standard deviation higher than the mean of the male caregiver on that characteristic. The meta-analysis results were based on the following calculations. We first computed the weighted mean correlation rw = %(N^/XNi. The variance of the weighted mean correlation (Vr) is based on the weighted difference between each correlation and the weighted mean, using the formula: {Vr) = £[N,(V, - rw)2] I 2N,. We calculated the sampling error variance (Ve) by the formula: (Ve) = (1 - rw2)2/((ZNJK) 1), where K = N of studies. We subtracted the sampling error variance from the correlation variance to create the estimated population variance and standard deviation. We also created confidence intervals at the .95 level around the population estimates of effect size to test the hypothesis that the association between gender and the dependent variable is zero. For the analysis of burden, we also adjusted the effect (r) for each study by the reported reliability of the dependent variable. A comparable set of formulas was used to calculate the meta-analysis results using the d statistic (Hunter & Schmidt, 1990). The one difference in formulas is that the sampling error variance of of is calculated by the formula: Ve = [(N - 1)/(N - 3)][4/N][1 + D2/8]. Hunter and Schmidt (1990) suggest that if sampling error, measurement unreliability, and range differences between samples account for 75% or more of the observed variance, there is no need to search for moderator variables. Since we could not correct for range differences because so few studies reported scale ranges, we used a lower percentage of artifactual variance, 60%, as the criteria for analyses that only correct for two factors. In other words, if the sampling error variance is higher than 60% of the population variance, the variance is primarily due to sampling error and not other moderator variables.
(Barusch & Spaid, 1989; Horowitz, 1985a; Pruchno & Resch, 1989), or by number of hours (Stoller, 1983; Young & Kahana, 1989). Reliability coefficients were given only for the measures of amount/degree of assistance. In view of the difference in types of measures, we did not adjust for measurement error. Seven studies showed small to moderate positive gender differences in level of caregiver involvement, with correlations ranging from .01 to .30), suggesting slightly greater task involvement by female caregivers (see Table 2). Only one study (Miller & Montgomery, 1990) showed a small negative correlation (-.04), in which caregiving husbands reported performing more tasks than caregiving wives. The mean weighted unadjusted correlation coefficient for the combined sample was .06 (SD = .08). The 95% confidence interval of the correlation ranged from - .09 to .22. Since the confidence interval included zero, we cannot conclude that there is any difference by gender in total amount of task involvement of male and female caregivers. The variation attributed to sampling error is 29%; thus moderator variables and other artifacts may explain some of the variation between the study correlations. Type of Task Involvement The gender-role socialization hypothesis suggests that even if there is no difference in total amount of caregiver involvement, there are traditional gender differences in the household division of labor. Seven studies contributed to the analysis of gender differences in three types of caregiver tasks, personal care, household chores, and money management. The studies ranged in sample size from 132 to 782, with a total sample of 2,632 and a mean of 376. The proportion of women in the samples ranged from .52 to .77. The measures of each type of task involvement typically used one to five items, asking about frequency of performance of a specific task and reporting the proportion of men and women who performed the task. One study reported mean hours spent on each task (Stoller, 1983) and another (Barusch & Spaid,
Level of Total Caregiver Involvement Eight studies contributed to the analysis of gender differences in level of total caregiver involvement. The studies ranged in sample size from 131 to 608, for a total sample of 2,489 and a mean of 311. Four of the studies were of spouse caregivers and four were of adult child caregivers. The proportion of female caregivers in these studies ranged from 53% to 80%. Global task involvement was measured by number of caregiving tasks (Finley, 1989; Miller & Montgomery, 1990), by amount or degree of task assistance
Table 1. Meta-Analysis of Caregiver Gender and Elder's Level of ADL Impairment in Study of Gender Differences in Caregiving 1A. Study characteristics and effect sizes Study Barusch & Spaid, 1989 Fitting et al., 1986 Horowitz, 1985b Miller & Montgomery, 1990a Miller & Montgomery, 1990a Stoller, 1983
N
Sample type
% female
Relationship
Impairment type
131 54 132 559 608 236
NP NP NP P P P
70 48 76 64 79 53
Spouse Spouse Child Spouse
Mixed Dementia Mixed Mixed Mixed Mixed
Child Child
Effect sized
Effect sizer
-.49 .09 .29 .11 .35 .24
-.24 .05 .14 .06 .17 .12
1B. Results of meta-analysis Unadjusted results r Mean S2 •^ error
C2
Standard deviation
.09 .011 .004 .008 .089
Unadjusted results d
Cl - .09, .26
.18 .05 .002 .065 .212
Cl - .23,.595
Note. NP = nonprobability sample; P = probability sample; Cl = confidence interval; S2 = variance. 'Studies listed twice are analyzed separately by relationship of caregiver: spouse or adult child.
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from 54 to 608 for a cumulative total of 1,720 and a mean of 286. The proportion of female caregivers ranged from .48 to .79. Half of the studies were of spouse caregivers and half were of adult child caregivers. Measures of ADL functioning varied, but all measures contained indicators of both ADL and IADL limitations except Barusch and Spaid (1989) (ADL only) and Fitting et al. (1986) (three-stage criteria combining ADL and neuropsychological criteria). Five studies showed a small positive association between caregiver gender and elder's level of impairment, with correlations ranging from .05 to .17. Female caregivers were caring for more severely functionally impaired dependent persons than were male caregivers. Only one study (Barusch & Spaid, 1989) showed that those cared for by women were less disabled than those cared for by men. Table 1 presents the results of the meta-analysis adjusted for sample size. The unadjusted mean weighted correlation coefficient for the combined sample was .09 (SD = .09). The 95% confidence interval of the unadjusted correlation was - . 0 9 to .26. Since the confidence interval includes zero, we cannot conclude that there is any difference by gender in level of severity of care recipient's functional impairment between male and female caregivers of frail older persons. Approximately 36% of the observed variance is accounted for by sampling error, suggesting that other moderator variables may account for the variation between studies.
1989) summed the average number of tasks performed in a specific area. Reliability coefficients generally were not provided. Table 3 shows the results of meta-analysis for the three types of tasks.
1989) showed a small negative association (-.11). The mean weighted correlation coefficient (r = .12, SD = .05) suggests that female caregivers are more likely to carry out personal care activities than male caregivers are. The 95% confidence level is .04 to .20, leading to a rejection of the hypothesis that there are no gender differences in provision of personal care activities. Differences between the proportion of women performing personal care activities and the proportion of men ranged from a low of 1% (Young & Kahana, 1989) to a high of 23.9% (Horo-
Personal care activities. — Personal care activities include dressing, bathing, grooming, and other acts of personal hygiene. Five studies showed small positive correlations ranging from .00 to .16; one study showed a moderate positive correlation of .25 (Horowitz, 1985b); and only one study (Young & Kahana,
Table 2. Meta-Analysis of Caregiver Gender and Total Level of Caregiver Involvement in Study of Gender Differences in Caregiving
2A. Study characteristics and effect sizes Study
Sample type
% female
Relationship
Impairment type
131 325 132 559 608 315 236 183
NP P NP P P NP P NP
70 77 76 64 79 68 53 80
Spouse Child Child Spouse Child Spouse Child Mixed
Mixed Mixed Mixed Mixed Mixed Dementia Mixed Mixed
'
Effect sized
Effect size r
.01 .44 .64 -.08 .03 .06 .23 .34
.01 .21 .30 -.04 .01 .03 .11 .17
2B. Results of meta-analysis Unadjusted results r Mean S2 •^ error
Standard deviation
Unadjusted results d
Cl - .09, .22
.06 .010 .003 .007 .084
.14 .043 .002 .042 .204
Cl - .265,.53
Note. NP = nonprobability sample; P = probability sample; Cl = confidence interval; S2 = variance. "Studies listed twice are analyzed separately by relationship of caregiver: spouse or adult child.
Table 3. Meta-Analysis of Caregiver Gender and Type of Caregiver Involvment in Study of Gender Differences in Caregiving
3A. Study characteristics and effect sizes Personal (:are Study
N
Barusch & Spaid, 1989 Horowitz, 1985b Stoller, 1983 Stoller, 1990 Stone, Cafferata, & Sangl, 1987a Stone, Cafferata, & Sangl, 1987a Young & Kahana, 1989
Sample type NP NP P P P P NP
131 132 236 362 823 782 116
% female
Relationship
70 76 53 59 77 64 52
d
Spouse Child Child Mixed Child Spouse Spouse
.01 .52 .22 .25 .32 .21 -.21
Household chores
r .00 .25 .11 .12 .16 .10 -.11
d
Money management
r
.02 .53 .42 .01 .34
d
- .07
.01 .26 .20 .00 .17 .25 .11
-.51
.22
.22 .18 - .03 .17 .31 - .10
r - .03 .11 .09 - .01 .08 .15 -.05
3B. Results of meta-analysis Household chores
Personal care r Mean Confidence interval S2
S
.12 .04, .20 .005 .003 .002 .042
d .24 - . 0 1 , .49 .019 .002 .017 .131
d
r b
.02 - . 3 3 , . 37 .035 .003 .023 .179
.03" - . 7 1 , . 77 .148 .002 .146 .382
r
M o n e y management
C
.13 .02, .25 .007 .003 .004 .059
503
C
.27 - .25, .79 .029 .002 .026 .163
N o t e . NP = n o n p r o b a b i l i t y sample; P = probability sample; Cl = c o n f i d e n c e interval; S2 = variance. 'Studies listed twice are analyzed separately by relationship of caregiver: spouse or adult c h i l d . b Based o n N = 7. c Based o n N = 6, o m i t t i n g Stone, Cafferata, & Sangl (1987), spouse.
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r
d
d
.08
.16
0, .16 .004 .003 .002 .041
- . 1 5 , .47 .018 .001 .016 .128
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Barusch & Spaid, 1989 Finley, 1989 Horowitz, 1985b Miller & Montgomery, 1990a Miller & Montgomery, 1990a Pruchno & Resch, 1989 Stoller, 1983 Young & Kahana, 1989
N
ment activities and the proportion of men ranged from a low of 1% (Stoller, 1990) to a high of 15.7% (Stone, Cafferata, & Sangl, 1987). The mean weighted correlation coefficient was .08 (SD = .04). The 95% confidence interval of the correlation ranged from 0 to .16. Since the confidence interval included zero, we cannot conclude that there are any gender differences in money management tasks. The proportion of variance due to sampling error was 58.6%, suggesting that although sampling error may account for much of the variance between the studies, other moderator variables may also exist.
witz, 1985b). Because only 50% of the variance is attributed to sampling error, other moderator variables may account for the variation between studies. Household chores. — Five studies showed small positive correlations ranging from .00 to .20; one study showed a moderate positive correlation (Horowitz, 1985b), and only Stone, Cafferata, and Sangl (1987) showed a moderate negative effect (-.25). Stone and colleagues comment that this finding that husbands (78.7%) performed more personal care activities than wives (70.1%) may be an artifact of question wording, which asked about the number of extra hours spent on household chores. Differences between proportion of women performing household chores and the proportion of men ranged from a low of .4% (Stoller, 1990) to a high of 26.2% (Horowitz, 1985b). The mean weighted correlation coefficient for all seven studies was .02 (SD = .18). The 95% confidence interval of the correlation ranged from - .33 to .37. We recomputed the meta-analysis omitting the outlier value contributed by Stone, Cafferata, and Sangl, and found a mean weighted coefficient of .13 (SD = .06; 95% confidence interval = .016 to .246). Since this confidence interval did not include zero, we conclude that there may be a difference, albeit small, by gender in level of performing household chores by male and female caregivers if comparable question wording is used. Proportion of variance due to sampling error in the recomputed analysis is 44%, suggesting that other modifiers may also contribute to this relationship.
Caregiver Burden
Money management. — Individual study correlations ranged from small negative to small positive relationships {r = -.05-.15). Differences between proportion of women performing money manage-
Table 4. Meta-Analysis of Caregiver Gender and Type of Caregiver Burden in Study of Gender Differences in Caregiving 4A. Study characteristics and effect sizes Study Barber, 1988 Barusch & Spaid, 1989 Fitting etal., 1989 Miller, McFall, & Montgomery, 1991a Miller, McFall, & Montgomery, 1991a Pratt etal., 1985 Pruchno & Resch, 1989 Williamson & Schulz, 1990 Young & Kahana, 1989 Zarit, Todd, & Zarit, 1986
Sample type
% female
Relationship
Impairment type
Effect size d
Effect size r
Reliability
Adjusted
N 171 131 54 559 608 240 315 145 183 43
NP NP NP P P NP NP NP NP NP
71 70 48 64 79 78 68 68 80 47
Child Spouse Spouse Spouse Child Mixed Spouse Mixed Mixed Spouse
Mixed Mixed Dementia Mixed Mixed Dementia Dementia Dementia Mixed Dementia
.46 .75 .49 .25 .31 .07 .48 .57 .73 1.25
.22 .34 .24 .12 .15 .03 .23 .27 .34 .53
.79 .79 .79 .76 .76 .79 .89 .82 .79 .79
.25 .38 .27 .15 .19 .04 .25 .30 .38 .60
T
4B. Results of meta-analysis Unadjusted results Mean 9 •^ error
Standard deviation
.19 .010 .004 .006 .075
Cl: .05, .33
Adjusted results
Unadjusted results d
.21 .012 .004 .008 .075
.39 .048 .002 .047 .216
Cl: .07, .35
Cl: - .04, .82
Note. NP = nonprobability sample; P = probability sample; ClI = confidence interval; S2 = variance. 'Studies listed twice are analyzed separately by relationship of caregiver: spouse or adult child.
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Ten studies contained usable data about gender differences in caregiver burden. The studies ranged in sample size from 43 to 608 for a total sample of 2,449 and a mean of 245. The proportion of female caregivers ranged from 47% to 80%. Five studies interviewed spouses only, two interviewed only sons and daughters, and three were mixed. Four studies were of caregivers of persons with dementia and six studies included persons with mixed types of impairment. Seven of the studies used the Zarit Burden Scale as the measure of burden (internal consistency reliability = .79). The Pruchno and Resch (1989) study used a 17-item scale (internal consistency reliability = .75) and the Miller, McFall, and Montgomery (1991) study used a six-item measure of personal burden (internal consistency reliability = .76). Seven of the studies showed moderate to large positive coefficients ranging from .22 to .53; three studies showed smaller coefficients ranging from .03 to .15 (see Table 4). All correlations were positive, showing that female caregivers report higher levels of burden than male caregivers. The mean weighted correlation coefficient adjusted for measurement er-
rorwas .21 (unadjusted r = .18, SD = .075). The 95% confidence interval of the adjusted correlation is .07 to .35. These effects are positive; women perceive higher levels of caregiver burden than men do. Different approaches exist for examining the extent to which the results of a meta-analysis would change if additional studies had been located. Rosenthal's (1984) file drawer analysis estimates a failsafe N, the number of unlocated studies averaging null results that would have to exist to bring the significance level for a set of studies down to the traditional probability value of .05. Based on this criteria, the fail-safe N for caregiver burden is 463 studies. Rosenthal and Rosnow (1984) suggest that any cumulation for which the fail-safe N reaches more than five times the number of studies plus 10 (in this case, 60 studies) may be considered robust. A second method emphasizes how many missing studies averaging null findings would have to exist to bring the mean effect size down to some specific level (Hunter & Schmidt, 1990, p. 513). According to this criteria, eight additional studies averaging null results would have to be " f o u n d " to reduce the significant cumulative effect size of .21 to a nonsignificant value of .10. Although the effect of gender on burden is statistically significant and robust, the question of practical significance of this difference remains. There are no readily agreed-on criteria for this judgment. One traditional approach is to compute the variance explained. Thus, by this criteria, gender differences "explain" approximately 4% of the variance in caregiver burden. Rosenthal and Rubin (1982) offer a binomial effect size display to portray the change in improvement rate attributable to a new treatment procedure. Applying this approach to gender differences in caregiver burden, we find that on the average, female caregivers are 20% more burdened than male caregivers. The extent to which interventions may be able to reduce this gap or the overall mean levels of burden of both men and women remains unknown (Toseland, Rossiter, & Labrecque, 1989; Whitlatch, Zarit, & von Eye, 1991). Only 33% of the variance between studies was accounted for by sampling error; thus moderator variables or other study artifacts may account for some of the additional variation found. According to the social role perspective, we might expect to find differences between spouse and adult child caregivers' reports of burden. Unfortunately, because there were only two studies of adult child caregivers, we could not test for caregiver relationship as a possible modifier. For exploratory purposes, we computed the bivariate correlations between selected study characteristics and effect size. We found strong negative relationships between effect size and total sample size (r = - .61), percentage of women in sample (r = -.49), and use of nonprobability sampling (r = -.43). There was little association between effect size and type of illness (r = -.07). These results are exploratory, but they suggest that sampling attributes of studies also may influence the relationship between caregiver gender and burden.
This meta-analysis cumulated results across studies to estimate the size and significance of gender differences in caregiving stressors and burden. There were essentially no significant gender differences in functional impairment of the frail care recipient or total caregiver involvement in care. Female caregivers were more likely to carry out personal care and household tasks, but the size of this effect was quite small. Female caregivers were more likely to report greater burden. Although this effect was larger than that of provision of personal care and household chores, it is barely in the moderate range and represents a small difference in practical terms. Based on the Hunter and Schmidt (1990) suggested criteria of 60%, statistical artifacts such as sampling error and measurement unreliability account for only a small proportion of the observed variance among studies. Interpretation of these results is subject to conceptual and methodological limitations. Conceptually, by focusing only on bivariate differences in broadly defined areas of caregiving, we minimize the individualization and complexity of most caregiving situations and the relevance of multivariate research analyses. We also compromise serious application of the theoretical perspectives of gender differences in caregiving by including few of the concepts specifically referred to by those theories. Methodologically, despite findings that sampling error explains only a portion of the findings, we were unable to test for modifier variables because of the relatively few studies. Inclusion of additional studies or greater homogeneity of measurement strategies may also shift the conclusions. The power to detect the relatively small differences between male and female caregiving activities is a limitation not only of this meta-analysis but also of most caregiving research to date. Thus these findings remain preliminary and subject to more rigorous evaluation. The results of the meta-analysis support elements of both the gender-role socialization and social role hypotheses. The lack of gender differences in elders' functional limitations, total amount of caregiver involvement, and in money management tasks support the social role hypothesis that caregivers respond to the demands of the situation. The lack of significant aggregate differences in severity of functional impairment is especially important since functional impairment is a major reason for caregiving activities (Horowitz, 1985b). Even though there appear to be statistically significant gender differences in personal care and household chores activities in the direction predicted by gender-role socialization, the size of the effect is small. Thus, we may conclude that the social role hypothesis is more useful in terms of explaining caregiving task behaviors. The speculation that men are more likely to engage in caregiving tasks that are finite and subject to scheduling (e.g., money management) is not supported (Horowitz, 1985a). The gender-role socialization hypothesis appears 505
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Discussion
ence on the identification and selection of caregivers than on intrarole adaptation. The question of the extent to which men and women confront different caregiving situations remains unanswered. In addition to the need for more studies of male and female caregivers in homogenous caregiving situations, more information is needed about gendered expectations of care receivers for care. Gendered expectations influence sick role and help-seeking behaviors (Verbrugge, 1985). It is reasonable to expect that they may influence caregiver/care receiver interactions as well. Older women and men may expect more from female caregivers than from male caregivers. For example, Aronson (1990, p. 239) describes how older women subscribe to the wish to remain independent but also note their "good fortune" at having daughters (not sons) to help them, and their sympathy for age peers who do not. Given the relatively small amount of gender differences, is it important to continue to focus on understanding gender differences in behavior? What difference does it make if men and women experience and enact the caregiving role slightly differently? Should programs and policies be influenced by this difference? Or are there other facets of caregiving that are more important than the socialization and gender-role stereotyped activities assumed to be associated with the dichotomous variable of gender? If so, shouldn't these factors be measured directly and the use of gender per se as a pointer variable be eliminated in examinations of enactment of the caregiving role? We admit to a certain ambivalence about the relevance of additional studies of gender differences in caregiving. The results of this meta-analysis, intragender variations in care situations, and difficulties in nonparadigmatic interpretation of results suggest that documentation of gender differences in various components of care may be a futile exercise without large sample sizes and highly focused studies. Yet, the persistence of sterotypes of gender-role behaviors, and the quickness with which caregivers, older persons, practitioners, and researchers draw on interpretations of traditional gender-role behaviors to bolster their explanations of events suggest continued relevance for study (Fitting et al., 1986). What is needed may be less documentation of specific gender differences in isolated components of caregiving and more attention to the role that gender-role explanations play in assigning meaning to the caregiving experience. Caregiving is seen as a female activity because of its emphasis on nurturance, personal care tasks, and household activities. Yet this definition ignores the authority issues involved in caring for an older person and the supervisory activities involved in coordinating care and medical needs (Miller, 1987; Pruchno & Resch, 1989). The persistence of gender-role expectations of caregiving needs to be examined from a variety of research perspectives. Because of the individualized nature of caregiving, greater emphasis on narrative description may illuminate the meaning of gender in 506
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to be useful in understanding caregiver appraisal or emotional responses to caregiving. Female caregivers express more burden than their male counterparts. Yet the usefulness of this explanation is limited by the difficulty of determining which aspects of gender socialization contribute to women's greater vulnerability to caregiver stress effects. For example, women might be expected to experience less burden because they are better prepared for the caregiving experience by their history of personal care and household management. Or, older men may have greater resilience because the loss of the work role may heighten their involvement in family caregiving as an outlet for growing domestic interests. Other questions remain. Do women experience greater burden because they feel more responsible for providing good care and thus have higher standards of accomplishment? Are women more sensitive to the relationship aspects of providing care and less able to maintain emotional distance (Abel, 1987)? Are women more comfortable in expressing their feelings and thus reporting their perceptions of burden more truthfully than men (Verbrugge, 1985)? The theoretical perspectives suggest additional variables that have rarely been included within studies of caregivers. In addition, male and female are social constructs that vary among women and among men. Intra-gender variation is not fully taken into account by the current emphasis on gender differences. Clearly, no consistent paradigm for interpretation of gender differences in caregiving has yet emerged. Although hypotheses derived from the stress and coping frameworks may be the most highly developed, studies rarely measure the personality attributes, gender-role orientation, or previous genderrole behaviors discussed by these hypotheses. Furthermore, most studies of caregiving focus on the personal and interpersonal level, largely ignoring the existence of macrosocial determinants of levels of adaptation, despite the fact that gender structures the distribution of rewards, privileges, opportunities, and responsibilities at many societal levels (House, Umberson, & Landis, 1988; Pearlin et al., 1990). House and colleagues (1988) suggest that the impact of macrosocial attributes (such as gender) on caregiving can be illuminated by different kinds of research: 1) examination of how the components of caregiving vary across groups of individuals in different structural positions in society (e.g., men vs. women); 2) examination of variations across different organizational units, such as different communities; and 3) examination of variation in the components of caregiving as a function of changes in macrosocial structures of society. Most of the research reviewed in this meta-analysis examines how the components of caregiving vary by gender but pays little attention to the structural or cultural context. References to societal level differences of older men and women in marital patterns, age distributions, financial resources, and health status are rare (see Barusch & Spaid, 1989, Fitting et al., 1986, Miller, 1990, and Stoller, 1990 for exceptions). It is possible, however, that these factors may have a greater influ-
the context of everyday life. Although gender is an enduring attribute, the meaning of gender may change in different cultures or at different points in the caregiving process (Zarit, Todd, & Zarit, 1986). For example, the physical differences between male and female caregivers may be more salient at later stages of the caregiving process when physical disability is more pronounced. At a broader level, research is needed to examine possible differential effects on men and women of policies directed towards development of health care services, home health care, and caregiver support services (see Osterbusch et al., 1987, and Glazer, 1990 for examples of this approach). Most important of all is the need to develop theoretically driven models of research, as little cumulation of knowledge may occur without clear explanations of study findings.
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