31163
urnal of Applied Gerontology
JAG32410.1177/0733464811431163L
Article
Korean American Dementia Caregivers’ Attitudes Toward Caregiving: The Role of Social Network Versus Satisfaction With Social Support
Journal of Applied Gerontology 32(4) 422–442 © The Author(s) 2012 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464811431163 jag.sagepub.com
Youjung Lee1 and Sunha Choi2
Abstract The purpose of this study was to explore how Korean American family caregivers view the services they offer to patients with dementia. It also investigated the roles of social networks and satisfaction with social support on attitudes toward caregiving. Social network, satisfaction with social support, demographic characteristics, caregiving-related stress factors, and cultural factors were examined. We used a convenience sample of 85 Korean American dementia caregivers. The results from hierarchical multiple regression models show that the level of satisfaction with social support significantly contributed to Korean American caregivers’ attitudes toward working with patients with dementia, while no statistically significant associate was found for social network. Higher levels of satisfaction with social support were associated with greater positive attitudes toward caregiving among Korean American caregivers (b = 0.26, p = .024). The implications for mental health professionals and policy makers are discussed.
Manuscript received: December 1, 2010; final revision received: September 27, 2011; accepted: November 4, 2011 1
Binghamton University, Binghamton, NY, USA University of Tennessee, Knoxville, TN
2
Corresponding Author: Youjung Lee, Binghamton University, College of Community and Public Affairs, Binghamton, NY 13902, USA. Email: [email protected]
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Lee and Choi Keywords
Korean American, caregiving of persons with dementia, culture, social networks, satisfaction with social support
Introduction Approximately 3.4 million people are affected by dementia in the United States (Plassman et al., 2007), and almost 10 million Americans provide unpaid care for a person with dementia (Alzheimer’s Association, 2009). In minority groups in the United States, including Korean Americans, family members often serve as caregivers for loved ones with dementia. These caregivers make up a large portion of the unpaid backbone of the national health care system. According to the 2000 U. S. Census, there were 1,076,872 Koreans in the United States, making Koreans the fourth-largest Asian group in the United States (U.S. Census Bureau, 2002). Among them, 66,254 (6.15%) were older than 65. As the population of older Koreans in the United States grows, the number of older Korean adults suffering from dementia will increase as well, causing the number of family caregivers to increase. Despite the growth of this population in the United States, relatively little is known regarding the effect of dementia caregiving on caregivers in the Korean American community, especially in relation to the positive aspects of caregiving and the impact of social support. To address this gap in the literature, this study focused on the degree to which Korean American dementia caregivers positively perceive their caregiving experiences and the relative roles of social support and social networks as factors that affect these positive attitudes toward caregiving. Korean American dementia caregivers are expected to be different from American caregivers with respect to its collectivistic family culture and expected caregiving roles in the culture. Korean culture is significantly influenced by Confucianism, which emphasizes family cohesion and continuity for sustaining community and state (Park, & Cho, 1995). Korean and Korean American caregivers, therefore, tend to have higher familism compared to White caregivers (Chun, Knight, & Youn, 2007) even though they have been exposed to the Western culture. Caregiving-related decisions (i.e., institutionalization of dementia patients) that Korean and Korean American caregivers make are based on cultural expectations in the collective culture. Moreover, the decisions can be influenced by the unique situation of care receivers who immigrate at the age of 55 and older for family reunion. The older adults, who are mainly expected to rear grandchildren and help housework, have had limited access to the U.S. systems. Therefore, care receivers’ unfamiliarity with the social and health system of the United States affects the caregiving-related decision making; Korean American dementia patients may want to use only senior centers or nursing
Downloaded from jag.sagepub.com at The University of Iowa Libraries on June 7, 2015
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homes that provide Korean meals and Korean staff. This phenomenon limits possible social services the caregiving families can utilize and eventually limits the service utilization. Even though there are psychosomatic and other negative outcomes associated with dementia caregiving (Pinquart & Sorenson, 2007), caregivers also report that dementia caregiving involves positive outcomes (Schultz & Sherwood, 2008) such as a sense of self-worth and mastery, greater family cohesion, marital satisfaction (Martire, Stephens, & Atienza, 1997), an appreciation from family members (Cummings & MacNeil, 2008), and having an opportunity to give back and finding personal strengths (Peacock et al., 2011). The caregiving research paradigm has shifted its focus toward the positive aspects of dementia caregiving (Boerner, Schulz, & Horowitz, 2004). Dementia caregivers report that “caregiving made [the participants] feel needed, useful, and good about themselves” (Tarlow et al. 2004, p. 446). In a study of caregivers of older adults with severe mental illnesses, Cummings and MacNeil (2008) found that caregivers enjoyed their involvement with their relatives and felt appreciated because they were providing such care. In the dementia caregiving setting, social support is an important determinant of a dementia caregiver’s well-being (Chappell & Reid, 2002). The components of high levels of social support include large social networks and frequent social interactions. A lack of informal social support is significantly related to worse physical health (Pinquart, & Sorensen, 2007), and aid from friends and relatives of caregivers is known to decrease the severity of depressive symptoms (Sorenson, Duberstein, Gill, & Pinquart, 2006). The positive role of social support can be found in Korean and Korean American culture as well; informal social support significantly reduces the perception of caregiving-related stressors among Korean caregivers (Lee, Yoon, & Kropf, 2007). Yong and McCallion (2003) argue that culturally appropriate social support can buffer the negative impact of dementia caregiving on the well-being of Korean American dementia caregivers. In their qualitative study, dementia caregivers articulated the importance of having quality social support in the caregiving process. The narrative analysis confirmed the positive influence of social support from family members on the caregiver’s mental health. Considering the limited resources and cultural barriers the immigrant dementia caregivers face (Janevic, & Connell, 2001), having adequate social support in the dementia caregiving process is a crucial factor for the maintenance of the well-being of immigrant caregivers and their family members.
Conceptual Framework: Role of Satisfaction With Social Support This study was developed based on the Alzheimer Caregivers’ Stress Model that Pearlin, Mullan, Semple, and Skaff (1990) presented. According to them, family
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Satisfaction with Social Support
Demographic Factors Age, Gender, Income, Education, Relationship Cultural Factors Acculturation Familism
Stressor Factors Amount of caregiving, Duration of caregiving Problem behavior of care receiver
Attitude toward Caregiving
Social Network
Figure 1. Conceptual framework.
caregiving experiences contain the following factors: (a) contextual variables, such as gender, age, relationship to the care receiver, (b) stress variables, such as the care receiver’s problem behaviors, and amount of caregiving, (c) a caregiver’s appraisal of the caregiving situation as demanding or satisfying, (d) potential mediators, such as social support and coping styles, and (e) the outcome from the caregiving, such as emotional distress, psychological and physical well-being. Recognizing the role of social support as a potential mediator, Pearlin and associates describe two types of social support: availability of instrumental support and perceived availability of support. Using the Alzheimer Caregivers’ Stress Model as a reference, a modified conceptual framework (Figure 1) is proposed to examine the relationship among satisfaction with social support and social network on dementia caregivers’ attitudes toward caregiving. As Pearlin and associate explain, it is important to investigate the size of the social network (i.e., the quantity of social support) and satisfaction with social support (i.e., the quality of the social support) independently. Clay, Roth, Wadley, and Haley (2008) found that satisfaction with social support is a more significant indicator of life satisfaction than the amount of available social support. Stuckey and Smyth (1997) also argued that social ties are conceptually distinct from social support. Their research with 203 dementia caregivers found not only that social ties and social support are separate constructs but also that a caregiver’s subjective awareness of the adequacy of their social ties is a stronger predictor of positive health outcomes than their objective level of social ties. The importance of quality social support in caregivers’ health generally is consistent with findings from Korean American caregivers. In Kim and Knight’s (2008) research, caregivers with lower quality instrumental social support presented with greater physiological distress. The quantity of informational social support was not found
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to mediate the relationship to caregivers’ health (Kim & Knight, 2008). The importance of the quality of social support in the caregiver population has also been recognized in other Asian cultures; Chiou, Chang, Chen, and Wang (2009) found that perceived social support predicts a caregiver’s experience of burden better than received social support among Taiwanese caregivers.
Research Hypotheses On the basis of the previous literature, three hypotheses were tested in this study: Hypothesis 1: There is a positive relationship between the availability of social support and the level of positive attitudes toward caregiving among Korean American dementia caregivers. Hypothesis 2: There is a positive relationship between the level of satisfaction with social support and the level of positive attitudes toward caregiving among Korean American dementia caregivers. Hypothesis 3: The level of satisfaction with social support has a greater impact on increasing the level of positive attitudes toward caregiving than the availability of social support among Korean American dementia caregivers. These hypotheses were tested after controlling for the impact of age, income, education, relationship to care receiver, acculturation, and familism on positive attitudes toward caregiving.
Method Sample and Data Collection For the purposes of this study, a “Korean American dementia caregiver” was defined as a Korean individual responsible for a community-dwelling spouse, parent, or other family member who had been diagnosed with dementia. Participants reported their care receiver’s health status regarding diagnosis of dementia. Based on caregivers’ reports, differential diagnoses of dementia were provided by a variety of community service providers. Because of practical limitations, a convenience sample of Korean American dementia caregivers was obtained from various Korean American organizations, including the Korean Adults Health and Day Care Centers (ADHC) in Los Angeles and Chicago and from Korean churches in Houston. The data were collected by mail and personal visits between December 2006 and May 2007. A total of 85 Korean American
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dementia caregivers were recruited in the parent study (Lee, 2007). This study was approved by the Institutional Review Board of the University of Texas at Austin. All participants provided written informed consent. The study aimed to recruit at least 60 caregivers to test the hypotheses outlined above and to perform multivariate tests with 12 predictors; multiple regression requires the minimum ratio of cases to predictor to be at least 5:1 (Hair, Anderson, Tatham, & Black, 1998). Because of missing responses in certain variables, sample size varied between 83 and 85 depending on the variable used for a statistical test (e.g., 2 missing responses for the amount of care the respondents provide daily). No pattern was found in the missing data.
Measures All measurements were translated into Korean by the principal investigator and back-translated into English by another Korean doctoral student specializing in gerontology. A Korean-speaking social worker and a native Korean speaker from outside the social work discipline reviewed the translation of the measurements. Items were modified by the reviewers for conceptual equivalence and metric equivalence. Dependent variable: Attitude toward caregiving. The attitude toward caregiving was conceptually defined as a caregiver’s perception of the experience of caring for a relative. This variable was measured using Farren’s Finding Meaning Through Caregiving Scale (FMTCS; Farren, Miller, Kaufman, Donner, & Fogg, 1999). The FMTCS has strong reliability (α = .84) and convergent and discriminant validity (Farren et al., 1999). This measurement consists of 43 Likert-type scale items that are measured on a scale of 0 (strongly disagree) to 4 (strongly agree). Possible scores ranged from 0 to 172, with higher scores reflecting more positive attitudes toward caregiving. Cronbach’s alpha for the FMTCS among the current study participants was .87. Independent variables: Social network and satisfaction with social support. The social network was measured using the short form of the Lubben Social Network Scale (LSNS; Lubben, 1988), which was originally composed of questions related to family networks, friend networks, confidant relationships, helping others, and living arrangements (e.g., “How many relatives do you see or hear from at least once a month?”). For the sake of parsimony, only family networks, friend networks, and confidant relationships were utilized in this study. The response options for the social network ranged from 0 (none) to 5 (nine or more), corresponding to the number of people in one’s own network, and 0 (less than monthly) to 5 (daily), corresponding to the frequency of contact with one’s social network. Possible scores ranged from 0 to 40, with higher scores reflecting a greater
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amount of social support. Satisfaction with social support was measured by three questions that were designed to measure tangible, emotional, and informational social support (Krause & Markides, 1990) (e.g., “Overall, how satisfied in the last month have you been with the suggestions, clarifications, and sharing of similar experiences you have received from others?”). Response options for satisfaction with social support ranged from 0 (not at all) to 3 (very). The possible score ranged from 0 to 9, with higher scores reflecting more satisfaction with social support. Two expert reviewers with extensive research backgrounds related to social support and caregiving reviewed the validity of the measurements. Both experts agreed that the modified instruments measured the social network and satisfaction with social support. The reliabilities of the measurements were then tested with 20 Korean American seniors at the Houston Korean American Senior Center (Lee, 2007). Most of the participants were born in Korea, and some were caregivers to their spouses or grandchildren. The average age of these participants was 65. Cronbach’s alphas for the modified social support measurement on the social network and satisfaction with social support were .81 and .83, respectively. With the current study sample, the alphas were .80 and .86, respectively. Control variables. Demographic factors included the caregiver’s age (in years), gender, education, relationship to a care receiver (0 = nonspouse, 1 = spouse), and annual household income. To increase the response rate, income was collected as an ordinal variable rather than an actual amount; this particular group of minority respondents tends to be uncomfortable with disclosure of financial information. Ages of caregivers and care receivers were measured in years. Caregiving-related stress factors included a care receiver’s problem behaviors, the amount of care provided, and the duration of caregiving. A care receiver’s problem behaviors were measured using the 24-item Revised Memory and Behavior Problems Checklist (RMBPC; Teri et al., 1992). The amount of care provided was measured by asking how many hours of direct care or supervision were offered per day. Duration of caregiving was measured by asking participants to indicate how many years he or she had provided care. Cultural factors included two variables: level of acculturation and level of familism. Acculturation is conceptually defined as a process that involves adopting or acquiring the language, customs, values, and so forth of a dominant or alternative culture (Skinner, 2002) while maintaining one’s original culture. Because of the complexity and the multidimensionality of acculturation, current measurements of acculturation created by other researchers did not meet the specific needs of this research. For example, the Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA; Suinn, Richard-Figueroa, Lew, & Vigil, 1987) measures several important constructs of acculturation, such as language and
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food preferences. However, the scale includes several redundant questions on the same construct. Moreover, it was developed to measure Asian students’ acculturation, so some questions are not relevant to adult caregivers. The Short Acculturation Scale for Hispanics (SASH; Marin, Sabogal, & Marin, 1987) measures acculturation succinctly compared with the Suinn-Lew Asian Self-Identity Acculturation Scale. However, it misses an important question regarding the respondent’s self-evaluation of his or her acculturation level. Therefore, for this study, four major questions from the two measurements were selected to measure the level of acculturation of Korean American dementia caregivers. The possible score ranged from 4 to 20, with higher scores reflecting more acculturation. Two expert reviewers with extensive research backgrounds in culturally sensitive social work reviewed the validity of the acculturation measurement. Both agreed that, conceptually, the instrument measured the acculturation of Korean dementia caregivers. The modified acculturation scale was found to have moderate reliability with Cronbach’s alpha of .7 when tested with Korean American older adults (Lee, 2007). For the current study sample, the alpha was .77. Familism was defined as the perceived strength of family bonds and sense of commitment to family (Luna et al., 1997). Familism was assessed using the Familism Scale (Bardis, 1959a), a 16-item scale designed to measure ideal and typical familism that includes evaluations of feeling related to group feelings, emphasis on family goals, common property, mutual support, and the desire to pursue the perpetuation of the family (Bardis, 1959b). This measurement consists of 16 Likert-type scale items that are measured on a scale of 0 (strongly disagree) to 4 (strongly agree). The possible score ranged from 0 to 64, with higher scores reflecting a more positive attitude toward familism. The familism scale had good discriminant validity and reliability (α = .84; Bardis, 1959a, 1959b). For the study sample, the alpha was .75.
Statistical Analyses Bivariate correlations among study variables were calculated to understand the relationships among the study variables and to identify factors related to the attitude toward caregiving at the bivariate level. Hierarchical multiple regression was employed to determine the relative influence of social network and satisfaction with social support on the attitudes of the caregivers toward caregiving. To achieve parsimony, the first step of the analysis included only control variables (i.e., age, income, education, relationship to care receiver, acculturation, and familism) that were significant (p < .1) in the bivariate correlations. Then, social network was entered as a second block, followed by the level of satisfaction with social support as a third block. The order of the entry of the blocks was based on
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theoretical considerations that are described in the literature on the role of social support in dementia caregiving (Clay et al., 2008; Stuckey & Smyth, 1997). The omitted variables, caregiver’s gender (Andren & Elmstahl, 2008), care receivers’ problem behaviors (Campbell et al., 2008), amount of care (Pinquart & Sorenson, 2007), and duration of care (Pinquart & Sorenson, 2003) have shown weaker or not-significant associations with caregiving outcomes in other caregiving research. Tolerance values were examined to assess the degree of multicollinearity among the prediction variables included in the final hierarchical regression model. The values ranged from .46 (age) and .49 (relationship with care receiver) to 0.91 (familism). Because all tolerance values were above the widely used cutoff of .25 (Fox, 1991), multicollinearity was not regarded as an issue.
Results Sample Description The caregivers’ mean age was 62.56 (SD = 13.23). Consistent with previous studies, the majority (77.6%) of the caregivers were female; the largest groups were spouse caregivers (38.8.0%), followed by daughters (25.9%), daughters-inlaw (10.6%), and sons (9.4%) (Table 1).
Bivariate Findings Dementia caregiver attitudes toward caregiving were significantly associated with their satisfaction with social support (r = .406, p < .001), level of acculturation (r = .304, p < .01), income (r = .302, p < .01), familism (r = .297, p < .01), social network (r = .289, p < .01), relation to care receiver (r = –.281, p < .01), and education (r = .256, p < .05) (Table 2).
Multivariate Findings The multivariate hypotheses were tested using hierarchical multiple regression analyses (Table 3). With all predictors in the equation (Step 3), the model accounted for 28.3% of the variance in the attitudes of Korean American dementia caregivers toward caregiving (R2 = .283; adjusted R2 = .208). Caregiver’s age, income, education, relationship to care receiver, acculturation, and familism were included in Step 1 as control variables. The control variables explained 21.7% of the variance in the attitudes of Korean American dementia caregivers toward caregiving (R2 = .217; adjusted R2 = .157).
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Lee and Choi Table 1. Demographic Characteristics of the Study Participants (N = 85). Variable
%
N
Care receiver’s age Care receiver’s gender Male Female Caregiver’s age Caregiver’s gender Male Female Income (in US$)
urnal of Applied Gerontology
JAG32410.1177/0733464811431163L
Article
Korean American Dementia Caregivers’ Attitudes Toward Caregiving: The Role of Social Network Versus Satisfaction With Social Support
Journal of Applied Gerontology 32(4) 422–442 © The Author(s) 2012 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464811431163 jag.sagepub.com
Youjung Lee1 and Sunha Choi2
Abstract The purpose of this study was to explore how Korean American family caregivers view the services they offer to patients with dementia. It also investigated the roles of social networks and satisfaction with social support on attitudes toward caregiving. Social network, satisfaction with social support, demographic characteristics, caregiving-related stress factors, and cultural factors were examined. We used a convenience sample of 85 Korean American dementia caregivers. The results from hierarchical multiple regression models show that the level of satisfaction with social support significantly contributed to Korean American caregivers’ attitudes toward working with patients with dementia, while no statistically significant associate was found for social network. Higher levels of satisfaction with social support were associated with greater positive attitudes toward caregiving among Korean American caregivers (b = 0.26, p = .024). The implications for mental health professionals and policy makers are discussed.
Manuscript received: December 1, 2010; final revision received: September 27, 2011; accepted: November 4, 2011 1
Binghamton University, Binghamton, NY, USA University of Tennessee, Knoxville, TN
2
Corresponding Author: Youjung Lee, Binghamton University, College of Community and Public Affairs, Binghamton, NY 13902, USA. Email: [email protected]
Downloaded from jag.sagepub.com at The University of Iowa Libraries on June 7, 2015
423
Lee and Choi Keywords
Korean American, caregiving of persons with dementia, culture, social networks, satisfaction with social support
Introduction Approximately 3.4 million people are affected by dementia in the United States (Plassman et al., 2007), and almost 10 million Americans provide unpaid care for a person with dementia (Alzheimer’s Association, 2009). In minority groups in the United States, including Korean Americans, family members often serve as caregivers for loved ones with dementia. These caregivers make up a large portion of the unpaid backbone of the national health care system. According to the 2000 U. S. Census, there were 1,076,872 Koreans in the United States, making Koreans the fourth-largest Asian group in the United States (U.S. Census Bureau, 2002). Among them, 66,254 (6.15%) were older than 65. As the population of older Koreans in the United States grows, the number of older Korean adults suffering from dementia will increase as well, causing the number of family caregivers to increase. Despite the growth of this population in the United States, relatively little is known regarding the effect of dementia caregiving on caregivers in the Korean American community, especially in relation to the positive aspects of caregiving and the impact of social support. To address this gap in the literature, this study focused on the degree to which Korean American dementia caregivers positively perceive their caregiving experiences and the relative roles of social support and social networks as factors that affect these positive attitudes toward caregiving. Korean American dementia caregivers are expected to be different from American caregivers with respect to its collectivistic family culture and expected caregiving roles in the culture. Korean culture is significantly influenced by Confucianism, which emphasizes family cohesion and continuity for sustaining community and state (Park, & Cho, 1995). Korean and Korean American caregivers, therefore, tend to have higher familism compared to White caregivers (Chun, Knight, & Youn, 2007) even though they have been exposed to the Western culture. Caregiving-related decisions (i.e., institutionalization of dementia patients) that Korean and Korean American caregivers make are based on cultural expectations in the collective culture. Moreover, the decisions can be influenced by the unique situation of care receivers who immigrate at the age of 55 and older for family reunion. The older adults, who are mainly expected to rear grandchildren and help housework, have had limited access to the U.S. systems. Therefore, care receivers’ unfamiliarity with the social and health system of the United States affects the caregiving-related decision making; Korean American dementia patients may want to use only senior centers or nursing
Downloaded from jag.sagepub.com at The University of Iowa Libraries on June 7, 2015
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homes that provide Korean meals and Korean staff. This phenomenon limits possible social services the caregiving families can utilize and eventually limits the service utilization. Even though there are psychosomatic and other negative outcomes associated with dementia caregiving (Pinquart & Sorenson, 2007), caregivers also report that dementia caregiving involves positive outcomes (Schultz & Sherwood, 2008) such as a sense of self-worth and mastery, greater family cohesion, marital satisfaction (Martire, Stephens, & Atienza, 1997), an appreciation from family members (Cummings & MacNeil, 2008), and having an opportunity to give back and finding personal strengths (Peacock et al., 2011). The caregiving research paradigm has shifted its focus toward the positive aspects of dementia caregiving (Boerner, Schulz, & Horowitz, 2004). Dementia caregivers report that “caregiving made [the participants] feel needed, useful, and good about themselves” (Tarlow et al. 2004, p. 446). In a study of caregivers of older adults with severe mental illnesses, Cummings and MacNeil (2008) found that caregivers enjoyed their involvement with their relatives and felt appreciated because they were providing such care. In the dementia caregiving setting, social support is an important determinant of a dementia caregiver’s well-being (Chappell & Reid, 2002). The components of high levels of social support include large social networks and frequent social interactions. A lack of informal social support is significantly related to worse physical health (Pinquart, & Sorensen, 2007), and aid from friends and relatives of caregivers is known to decrease the severity of depressive symptoms (Sorenson, Duberstein, Gill, & Pinquart, 2006). The positive role of social support can be found in Korean and Korean American culture as well; informal social support significantly reduces the perception of caregiving-related stressors among Korean caregivers (Lee, Yoon, & Kropf, 2007). Yong and McCallion (2003) argue that culturally appropriate social support can buffer the negative impact of dementia caregiving on the well-being of Korean American dementia caregivers. In their qualitative study, dementia caregivers articulated the importance of having quality social support in the caregiving process. The narrative analysis confirmed the positive influence of social support from family members on the caregiver’s mental health. Considering the limited resources and cultural barriers the immigrant dementia caregivers face (Janevic, & Connell, 2001), having adequate social support in the dementia caregiving process is a crucial factor for the maintenance of the well-being of immigrant caregivers and their family members.
Conceptual Framework: Role of Satisfaction With Social Support This study was developed based on the Alzheimer Caregivers’ Stress Model that Pearlin, Mullan, Semple, and Skaff (1990) presented. According to them, family
Downloaded from jag.sagepub.com at The University of Iowa Libraries on June 7, 2015
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Satisfaction with Social Support
Demographic Factors Age, Gender, Income, Education, Relationship Cultural Factors Acculturation Familism
Stressor Factors Amount of caregiving, Duration of caregiving Problem behavior of care receiver
Attitude toward Caregiving
Social Network
Figure 1. Conceptual framework.
caregiving experiences contain the following factors: (a) contextual variables, such as gender, age, relationship to the care receiver, (b) stress variables, such as the care receiver’s problem behaviors, and amount of caregiving, (c) a caregiver’s appraisal of the caregiving situation as demanding or satisfying, (d) potential mediators, such as social support and coping styles, and (e) the outcome from the caregiving, such as emotional distress, psychological and physical well-being. Recognizing the role of social support as a potential mediator, Pearlin and associates describe two types of social support: availability of instrumental support and perceived availability of support. Using the Alzheimer Caregivers’ Stress Model as a reference, a modified conceptual framework (Figure 1) is proposed to examine the relationship among satisfaction with social support and social network on dementia caregivers’ attitudes toward caregiving. As Pearlin and associate explain, it is important to investigate the size of the social network (i.e., the quantity of social support) and satisfaction with social support (i.e., the quality of the social support) independently. Clay, Roth, Wadley, and Haley (2008) found that satisfaction with social support is a more significant indicator of life satisfaction than the amount of available social support. Stuckey and Smyth (1997) also argued that social ties are conceptually distinct from social support. Their research with 203 dementia caregivers found not only that social ties and social support are separate constructs but also that a caregiver’s subjective awareness of the adequacy of their social ties is a stronger predictor of positive health outcomes than their objective level of social ties. The importance of quality social support in caregivers’ health generally is consistent with findings from Korean American caregivers. In Kim and Knight’s (2008) research, caregivers with lower quality instrumental social support presented with greater physiological distress. The quantity of informational social support was not found
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to mediate the relationship to caregivers’ health (Kim & Knight, 2008). The importance of the quality of social support in the caregiver population has also been recognized in other Asian cultures; Chiou, Chang, Chen, and Wang (2009) found that perceived social support predicts a caregiver’s experience of burden better than received social support among Taiwanese caregivers.
Research Hypotheses On the basis of the previous literature, three hypotheses were tested in this study: Hypothesis 1: There is a positive relationship between the availability of social support and the level of positive attitudes toward caregiving among Korean American dementia caregivers. Hypothesis 2: There is a positive relationship between the level of satisfaction with social support and the level of positive attitudes toward caregiving among Korean American dementia caregivers. Hypothesis 3: The level of satisfaction with social support has a greater impact on increasing the level of positive attitudes toward caregiving than the availability of social support among Korean American dementia caregivers. These hypotheses were tested after controlling for the impact of age, income, education, relationship to care receiver, acculturation, and familism on positive attitudes toward caregiving.
Method Sample and Data Collection For the purposes of this study, a “Korean American dementia caregiver” was defined as a Korean individual responsible for a community-dwelling spouse, parent, or other family member who had been diagnosed with dementia. Participants reported their care receiver’s health status regarding diagnosis of dementia. Based on caregivers’ reports, differential diagnoses of dementia were provided by a variety of community service providers. Because of practical limitations, a convenience sample of Korean American dementia caregivers was obtained from various Korean American organizations, including the Korean Adults Health and Day Care Centers (ADHC) in Los Angeles and Chicago and from Korean churches in Houston. The data were collected by mail and personal visits between December 2006 and May 2007. A total of 85 Korean American
Downloaded from jag.sagepub.com at The University of Iowa Libraries on June 7, 2015
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dementia caregivers were recruited in the parent study (Lee, 2007). This study was approved by the Institutional Review Board of the University of Texas at Austin. All participants provided written informed consent. The study aimed to recruit at least 60 caregivers to test the hypotheses outlined above and to perform multivariate tests with 12 predictors; multiple regression requires the minimum ratio of cases to predictor to be at least 5:1 (Hair, Anderson, Tatham, & Black, 1998). Because of missing responses in certain variables, sample size varied between 83 and 85 depending on the variable used for a statistical test (e.g., 2 missing responses for the amount of care the respondents provide daily). No pattern was found in the missing data.
Measures All measurements were translated into Korean by the principal investigator and back-translated into English by another Korean doctoral student specializing in gerontology. A Korean-speaking social worker and a native Korean speaker from outside the social work discipline reviewed the translation of the measurements. Items were modified by the reviewers for conceptual equivalence and metric equivalence. Dependent variable: Attitude toward caregiving. The attitude toward caregiving was conceptually defined as a caregiver’s perception of the experience of caring for a relative. This variable was measured using Farren’s Finding Meaning Through Caregiving Scale (FMTCS; Farren, Miller, Kaufman, Donner, & Fogg, 1999). The FMTCS has strong reliability (α = .84) and convergent and discriminant validity (Farren et al., 1999). This measurement consists of 43 Likert-type scale items that are measured on a scale of 0 (strongly disagree) to 4 (strongly agree). Possible scores ranged from 0 to 172, with higher scores reflecting more positive attitudes toward caregiving. Cronbach’s alpha for the FMTCS among the current study participants was .87. Independent variables: Social network and satisfaction with social support. The social network was measured using the short form of the Lubben Social Network Scale (LSNS; Lubben, 1988), which was originally composed of questions related to family networks, friend networks, confidant relationships, helping others, and living arrangements (e.g., “How many relatives do you see or hear from at least once a month?”). For the sake of parsimony, only family networks, friend networks, and confidant relationships were utilized in this study. The response options for the social network ranged from 0 (none) to 5 (nine or more), corresponding to the number of people in one’s own network, and 0 (less than monthly) to 5 (daily), corresponding to the frequency of contact with one’s social network. Possible scores ranged from 0 to 40, with higher scores reflecting a greater
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amount of social support. Satisfaction with social support was measured by three questions that were designed to measure tangible, emotional, and informational social support (Krause & Markides, 1990) (e.g., “Overall, how satisfied in the last month have you been with the suggestions, clarifications, and sharing of similar experiences you have received from others?”). Response options for satisfaction with social support ranged from 0 (not at all) to 3 (very). The possible score ranged from 0 to 9, with higher scores reflecting more satisfaction with social support. Two expert reviewers with extensive research backgrounds related to social support and caregiving reviewed the validity of the measurements. Both experts agreed that the modified instruments measured the social network and satisfaction with social support. The reliabilities of the measurements were then tested with 20 Korean American seniors at the Houston Korean American Senior Center (Lee, 2007). Most of the participants were born in Korea, and some were caregivers to their spouses or grandchildren. The average age of these participants was 65. Cronbach’s alphas for the modified social support measurement on the social network and satisfaction with social support were .81 and .83, respectively. With the current study sample, the alphas were .80 and .86, respectively. Control variables. Demographic factors included the caregiver’s age (in years), gender, education, relationship to a care receiver (0 = nonspouse, 1 = spouse), and annual household income. To increase the response rate, income was collected as an ordinal variable rather than an actual amount; this particular group of minority respondents tends to be uncomfortable with disclosure of financial information. Ages of caregivers and care receivers were measured in years. Caregiving-related stress factors included a care receiver’s problem behaviors, the amount of care provided, and the duration of caregiving. A care receiver’s problem behaviors were measured using the 24-item Revised Memory and Behavior Problems Checklist (RMBPC; Teri et al., 1992). The amount of care provided was measured by asking how many hours of direct care or supervision were offered per day. Duration of caregiving was measured by asking participants to indicate how many years he or she had provided care. Cultural factors included two variables: level of acculturation and level of familism. Acculturation is conceptually defined as a process that involves adopting or acquiring the language, customs, values, and so forth of a dominant or alternative culture (Skinner, 2002) while maintaining one’s original culture. Because of the complexity and the multidimensionality of acculturation, current measurements of acculturation created by other researchers did not meet the specific needs of this research. For example, the Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA; Suinn, Richard-Figueroa, Lew, & Vigil, 1987) measures several important constructs of acculturation, such as language and
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food preferences. However, the scale includes several redundant questions on the same construct. Moreover, it was developed to measure Asian students’ acculturation, so some questions are not relevant to adult caregivers. The Short Acculturation Scale for Hispanics (SASH; Marin, Sabogal, & Marin, 1987) measures acculturation succinctly compared with the Suinn-Lew Asian Self-Identity Acculturation Scale. However, it misses an important question regarding the respondent’s self-evaluation of his or her acculturation level. Therefore, for this study, four major questions from the two measurements were selected to measure the level of acculturation of Korean American dementia caregivers. The possible score ranged from 4 to 20, with higher scores reflecting more acculturation. Two expert reviewers with extensive research backgrounds in culturally sensitive social work reviewed the validity of the acculturation measurement. Both agreed that, conceptually, the instrument measured the acculturation of Korean dementia caregivers. The modified acculturation scale was found to have moderate reliability with Cronbach’s alpha of .7 when tested with Korean American older adults (Lee, 2007). For the current study sample, the alpha was .77. Familism was defined as the perceived strength of family bonds and sense of commitment to family (Luna et al., 1997). Familism was assessed using the Familism Scale (Bardis, 1959a), a 16-item scale designed to measure ideal and typical familism that includes evaluations of feeling related to group feelings, emphasis on family goals, common property, mutual support, and the desire to pursue the perpetuation of the family (Bardis, 1959b). This measurement consists of 16 Likert-type scale items that are measured on a scale of 0 (strongly disagree) to 4 (strongly agree). The possible score ranged from 0 to 64, with higher scores reflecting a more positive attitude toward familism. The familism scale had good discriminant validity and reliability (α = .84; Bardis, 1959a, 1959b). For the study sample, the alpha was .75.
Statistical Analyses Bivariate correlations among study variables were calculated to understand the relationships among the study variables and to identify factors related to the attitude toward caregiving at the bivariate level. Hierarchical multiple regression was employed to determine the relative influence of social network and satisfaction with social support on the attitudes of the caregivers toward caregiving. To achieve parsimony, the first step of the analysis included only control variables (i.e., age, income, education, relationship to care receiver, acculturation, and familism) that were significant (p < .1) in the bivariate correlations. Then, social network was entered as a second block, followed by the level of satisfaction with social support as a third block. The order of the entry of the blocks was based on
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theoretical considerations that are described in the literature on the role of social support in dementia caregiving (Clay et al., 2008; Stuckey & Smyth, 1997). The omitted variables, caregiver’s gender (Andren & Elmstahl, 2008), care receivers’ problem behaviors (Campbell et al., 2008), amount of care (Pinquart & Sorenson, 2007), and duration of care (Pinquart & Sorenson, 2003) have shown weaker or not-significant associations with caregiving outcomes in other caregiving research. Tolerance values were examined to assess the degree of multicollinearity among the prediction variables included in the final hierarchical regression model. The values ranged from .46 (age) and .49 (relationship with care receiver) to 0.91 (familism). Because all tolerance values were above the widely used cutoff of .25 (Fox, 1991), multicollinearity was not regarded as an issue.
Results Sample Description The caregivers’ mean age was 62.56 (SD = 13.23). Consistent with previous studies, the majority (77.6%) of the caregivers were female; the largest groups were spouse caregivers (38.8.0%), followed by daughters (25.9%), daughters-inlaw (10.6%), and sons (9.4%) (Table 1).
Bivariate Findings Dementia caregiver attitudes toward caregiving were significantly associated with their satisfaction with social support (r = .406, p < .001), level of acculturation (r = .304, p < .01), income (r = .302, p < .01), familism (r = .297, p < .01), social network (r = .289, p < .01), relation to care receiver (r = –.281, p < .01), and education (r = .256, p < .05) (Table 2).
Multivariate Findings The multivariate hypotheses were tested using hierarchical multiple regression analyses (Table 3). With all predictors in the equation (Step 3), the model accounted for 28.3% of the variance in the attitudes of Korean American dementia caregivers toward caregiving (R2 = .283; adjusted R2 = .208). Caregiver’s age, income, education, relationship to care receiver, acculturation, and familism were included in Step 1 as control variables. The control variables explained 21.7% of the variance in the attitudes of Korean American dementia caregivers toward caregiving (R2 = .217; adjusted R2 = .157).
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Lee and Choi Table 1. Demographic Characteristics of the Study Participants (N = 85). Variable
%
N
Care receiver’s age Care receiver’s gender Male Female Caregiver’s age Caregiver’s gender Male Female Income (in US$)
