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SOCIAL SUPPORT, SELF EFFICACY AND GENDER AS PREDICTORS OF REPORTED STRESS AMONG INPATIENT CAREGIVERS

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CHAPTER ONE

INTRODUCTION

Human beings are social animals known to care for one another, often the sick or disabled ones more especially their family members living in the community.  Often times, it is of great cost to them and/or great benefit to their relatives and society as a whole.  Caregiving typically involves a significant expenditure of time, energy and money over potentially long periods of time and also tasks that may be unpleasant and uncomfortable that could be psychologically stressful and physically exhausting. Caregiving is not a new phenomenon. Previously family members were the primary and often only source of support for sick/disabled persons. What has changed in the last century is the number of individuals involved in caregiving tasks (Schulz, 2000).  Because of increase in life expectancy and the aging of the population, the shift from acute to chronic diseases and their associated disabilities, changes in healthcare reimbursement and advances in medical technology, thus making caregiving to become commonplace (Biegel, Sales & Schulz, 1991).

The dominant conceptual model for caregiving assumes that the onset and progression of chronic illness and functional decline is stressful for both patients and caregiver, and as such, can be studied within the frame work of traditional stress/health models. Indeed, some researchers have likened caregiving to being exposed to a severe long term chronic stressor. Within this framework, objective stressor includes: Measures of patient physical disability, cognitive impairment and problem behaviours as well as the type and intensity of caregiving provided. The effects of caregiving are typically measured in terms of psychological distress and burden and psychiatric and physical morbidity as well as in economic impacts such as reduced work-hours or in caregivers quitting from the job (Biegel, Sale & Schulz, 1991; Schulz, 2000). Although the literature consistently reports a moderate relationship between level of patient’s disability and caregiver psychological distress, there is considerable variability in caregiver outcomes, which is though to be mediated and/or moderated by a variety of factors, including caregivers’ economic status, and the availability of social support resources and a host of individual difference factors such as gender, personality attributes,  optimism, self-esteem, self-mastery,  coping strategies used and the quality of the relationship between caregiver and care-recipient (Haley, Roth, Coleton & Hoffman, 1996).

Caregivers perform an important service for society and their relatives; they do so at considerable cost to their own well-being. There is strong consensus that caring for an elderly individual with disability is burdensome and stressful to many family members and contributes to psychiatric morbidity in the form of higher prevalence and incidence of depressive and anxiety disorders (Schulz, Brien & Bookwala, 1995). Studies have also suggested that the combination of loss, prolonged distress, and physical demands of caregivers may compromise their physiological functioning and increase their risk for physical health problems. Support for this hypothesis is shown in studies revealing that caregivers are less likely to engage in preventive health behaviours (Schulz, Newsom MittleMark, & Decamp 1997), that they show evidence of decrements in immunity measures (Glaser & Kiecolt-Glaser, 1997); exhibit greater cardiovascular reactivity (King, Oka & Young, 1994) and slowing of wound healing (Kiecolt-Glaser, Marucha & Malarkey, 1995).

Actually, providing care to someone especially the elderly sick whether full time, part time, formal, informal or long distance takes a huge toll, both physically and emotionally. Few people are prepared for the responsibilities and tasks involved in caring for the aged because of the stress involved in it. Caregivers provide many kinds of help to the care receivers ranging from assistance with shopping to help with daily task such as bathing, dressing, feeding, lifting, turning him or her in bed, cooking, paying of  bills, running errands, giving medicine, keeping him or her company, providing emotional support and so many others things (Vitaliano, Zhang & Scanlon, 2003; Lecovich, 2008). All these help rendered by caregivers can be time consuming and emotionally, physically and psychological draining. This, then contributes a lot of stress on the caregivers (Chieon & Chen, 2009; Edward & Higgins, 2009; Son, Erno, Shea,  Femia, Zarit & Stephens  2007; Vitaliano, Zhang & Scanlon, 2003).

Caregivers seems to be at a greater health risk than the receivers because when the caregivers devote themselves to the needs of someone else, they tend to neglect their own needs.  Studies have indicated that one reason for elder abuse and neglect is caregiver stress (Gupta & Chandhuri, 2008).  Apart from health concerns brought about by stress, scholars are of the view that it is common for caregivers to feel anger, frustration, guilt, isolation, unhappiness in marriage, anxiety, depression, a diminished social life, loss of self-esteem from time to time and dissatisfaction with life (Macneil, Kosberg,  Durkin  Dooley, Dewster & Williamson, 2010; Gonyea, Paris & De-Saxe-Zerden, 2008). Caregivers begin to feel guilty about all things they are not able to do for his/her elderly/sick ones and responding to this, they start again giving more than they should just to know if they could effect change. Guilt therefore, may be a cardinal feature of the caregiving experience.

Frustration, though a normal and valid emotional response, is one of the feelings that could arise as a result of being a caregiver to the sick ones. This arises out of trying to change an uncontrollable circumstance in taking care of the sick ones, especially those with Alzheimer’s disease or other kinds of dementia (Walker, Martin & Jones, 1992). Stoller and Pugliesi (1989) reported that caregivers who are home bound tend to be isolated from normal daily contacts. Isolation may lead to depression and anxiety, which in turn increases the stress.

Feelings of depression can become a serious problem for some caregivers. Many caregivers tend to develop negative health behaviours such as smoking, over eating, not exercising and even neglect taking care of themselves which results to high mortality rate of the caregiver and the care receivers. Caregivers are also stressed by restrictions on their social life especially those taking care of an Alzheimer patient (Losada, Perez-Penaranda, Rodriguez-Sanchez, Gomez-Marcos, Ballesteros-Rios, Ramos Carrera, Compode, Torre, & Garcia, 2009). The caregivers here, have fewer visits to friends and family, spend less times chatting, spend less time in their house of worship and spend less time with their hobbies (Losada et al., 2009). Marriages can also be affected by caregiving responsibilities. Caregiving can reduce the time husband, wife and children (if any) have for themselves.

Caregiving can also create positive feeling. As a positive influence, stress can compel one to action, which can result in a new awareness and an exciting new perspective. Even though caregiving can be quite demanding and is linked to serious stress and health problem, being a caregiver can also be rewarding (Walker, Pratt & Eddy, 1995). According to Walker, Shin and Bird (1990) providing for the needs of someone you care about can be very satisfying. It enables people to be useful, needed, appreciated and important. The experience of caregiving can also bring families together and cause people to appreciate life more (Haley, Allen, Grant, Olivio, Clay, Perkins & Roth (2009). Reece, Walz and Hageboeck (1983) asserted that adult children who are caregivers to the elderly parents find caregiving gratifying because they can pay back the care, which their parents provided to them when they were young.

Scholars have opined that behaviours and attitudes expressed by the power, pressure, influence or control in ways destructive to their relationship with the caregivers (Snyder, 2000; Geister, 2005). To some extent, the elderly patient’s behaviour can be self-centered and not noticing other people’s feelings and not realizing when they are upset or when something you do upset them. Occasionally, the patient develops abusive behaviour in this regard, they complain bitterly about unavoidable situations, finding faults with almost everything blaming others for problems caused by themselves, refusing advice that would ease care tasks because they think that they know better and their ideas should be carried, prolonging conversations through repetition and demanding help beyond the caregiver’s capacity (Baronet, 1999). This invariably many induce stress for instance; caregivers who attribute patients troubling behaviours to the patient’s illness are less burdened than caregivers who attribute the patient’s behaviour to the patient’s willfulness. Caregivers who see the patients as emotionally demanding or dependent feel a higher sense of burden than those who see the patient as disturbing or disabled (Snyder, 2000; Geister, 2005).  Pearlin, Mullan, Semple and Skaff (1990) distinguished between caring, the affective component of one’s commitment to the welfare of another, and “caregiving” the behavioural expression of this commitment. They further note that, under the demands of constant care, caregiving expands to encompass the entirety of the caregiver care recipient relationship. Financial, health and emotional costs to caregivers have been well documented (Pearlin, 1994). Caregivers find it necessary both to relinquish outside employment and to increase expenditures for service, and they experience declines in physical as well as mental health.

Patient caregiving has been linked to reported stress or burden, consequent upon placing the needs of care recipients before the needs of the caregiver (Baronet, 1999). A distinction is made between objective burden, including the negative effects on the household due to caregiving and subjective burden or personal appraisals of the caregiving situation and its consequences for the caregiver (Hoenig & Hamilton, 1966). Objective burden, has been found to be greatest in relation to assistance with activities of daily living, or personal care, whereas subjective burden has been found to be greatest with supervision (Baronet, 1999) and is most acute and sustained when dementia is present (Connell, Janevic &  Gallant, 2001). Rabins (1998) noted that Alzheimer’s care providers experience rates of emotional morbidity three times greater than do their same-aged non-caregiving age peers. The negative consequences of caregiving on mental health of the caregiver include increased distress, depression, demoralization and anxiety and psychiatric symptomatology such as insomnia, headaches and excessive irritability (Schulz, 2000).

In this study three independent variables are studied: Social support, self- efficacy and gender.  It appears that caregiving stress can be mediated by physical, psychological and environmental resources of caregivers (Baronet, 1999) but social support has emerged as the greatest moderator of the effect of caregiver stress (Logsden & Robinson, 2000).  Social support has been shown to serve as a buffer against the negative effect that is associated with caregiving (Honde, 1998; Palmer & Glass, 2003).  A number of studies have examined the role of social support on caregiving stress (Chang, Brecht & Carter, 2001).  A wide variety of researchers including anthropologists, physicians, psychologists and sociologists express interests to study social support and the focus of their studies vary widely. The unit of analysis might be individual, family, community or society. Furthermore, social support has been defined in a variety of ways, but none is unified (Chappell, 1985; Chak, 1996). Yuen-Tsang (1997) summarized the concept of social support and distinguished it into five aspects; functional, structural, subjective, interactional and the synthetic definition. Several researchers (Oxman & Hull, 1997; Chen & Silverstein, 2000) regarded social support as consisting of structural, functional and appraisal support although there are many ways to operationalize this construct. The structural dimension of social support is the composition of the social network and the availability of people to help the individual; the functional dimension represents the amount of instrumental, emotional and financial backing, the appraisal dimension denotes subjective evaluation of the extent of satisfaction with the support.

Tardy (1988) identified five distinct factors in defining the concept at the operational level including; direction, that is social support can be either to other people or it can received; secondly, disposition, that means differentiation between perceived support and received support; thirdly; description/evaluation, that is a focus on the characteristics of supportive behaviours; the evaluation of social support concerns people’s subjective appraisal of what they have received; fourthly, network. According to Krause (2001), social support is best defined as a measure of social embeddednes (indicators, assessing the frequency of contact with others), received support (measures of the amount of tangible help actually provided by social network members), and perceived support (subjective evaluation of supportive exchange).

Social support is widely regarded as a valuable resource comprising tangible and intangible forms of assistance that individuals receive from family and friends. Studies of types of social support (House & Kahn, 1985; Cutrona & Russell, 1990; Wellman & Wortley, 1990) suggested one or more of the following forms informational support, tangible assistance, emotional support, esteem support and social integration. Informational support refers to the guidance and advice from others which help the family caregiver to understand and manage stressful situations. Tangible assistance is the instrumental behaviours and goods which directly subsidize the primary caregiver’s caregiving responsibilities, the emotional support that caregivers receive refers to the behaviours of others that promote the primary caregiver’s feelings of comfort, ease and security. Some researchers (Streeter & Franklin, 1992; Bass & Noelker, 1997) distinguished between formal and informal social support. The former consist of caregivers relationships with family members, relatives, friends, neighbours and other associations who interact with the caregivers (Unger & Powell, 1980). Formal social support includes respite services like day-care centre, day hospital, old-age centre and residential services (Kane & Penrod, 1995).

Family support is composed of emotional support and instrumental support. Thompson, Futterman Gallagher-Thompson, Rose and Lovett (1993) opined that family support is the key-point of decrease of all kinds of negative outline. Most people acquire major portion of social support from their family, especially in the aspects of material and care activities of daily living (Hermalin, Chang, Lin, Lee & Ofstedal, 1993). Social support is the attachments among individuals that provide a sense of being assisted and supported by others (Turner, 1981) and is regarded as one of the moderating factors which can potentially reduce caregiver stress and depression. It is essential for maintaining mental health, particularly in chronic stressors. Other scholars point out that social support can prevent stress; increase problem solving abilities improve healthy actions, and increase well being (Wright, Clipp & George, 1993; Bass, Noelker & Rechlin, 1996).

Tardy (1985) viewed social support as either perceived social support that the focus is on the recipient’s subjective appraisal of the acts performed by others that are either helpful or intended to be helpful, or receive social support that others intend to assist a particular person. Kahn and Antonucci (1980) defined perceived social support as the perception of the individual of the amount and quality of support received from his/her social network. Hermalin and colleagues (1993) defined received social support as objective quantification of the help and aid people receive from their social network. Antonucci (1990) demonstrated that perceived social support has stronger predicting power for the effects of social support on adaptation than the measure of received social support but Hermalin Chang, Lin, Lee and Ofstedal (1993) claimed that the measure of received social support provides good information for assessment of policy implications. Theorists (Dunkel-Schetter & Bennett, 1990; Thoits, 1995) have argued that perceived social support is conceptually distinct from received social support. Perceived social support generally represents moderately stable cognitive appraisal that support from others will be available when needed or that connections to others are secure. In contrast to perceived social support received social support generally refers to actual administered aid or the behaviour of engaging in positive interpersonal social exchanges (Dunkel-Schetter & Bennett, 1990).

Studies have shown that self-efficacy is implicated in caregivers stress.  Caregivers who cope well with stress may possess high level of self-efficacy (Morwat & Laschinger, 1994).  So the construct of self-efficacy has been widely used among researchers to help explain a variety of reactions to long-standing, stressful experiences (Cozzarelli, 1993; Resnick, 1998). Self–efficacy has been conceptualized as a person’s belief about his or her ability to organize and execute courses of action to manage given situations (Bandura, 1997). Self-efficacy beliefs have diverse effects on psychosocial functioning. They: (a) determine whether coping behaviours will be initiated, how much effort will be expended, and how long effort will be sustained in the face of obstacles and aversive experiences and (b) affect vulnerability to emotional distress and depression (Bandura, 1997).

Gerontologists have used self-efficacy to predict different aspects of functioning in older adults, including active grand parenting (King & Elder, 1998), intellectual functioning (Berry, West & Dennehey, 1989), functional status following a decrease in physical capacity (Mendes-de, Wop, De-Swart, Bar & Appels, 1996), physical activity in osteoarthritis patients (Rejeski, Craven, Ettinger, McFarlane & Schumateer, 1996) and adherence to exercise following a structured exercise programme (McAuley, Lox & Duncan, 1993). Despite the fact that self-efficacy model has been widely used in research on chronic stress and coping, this construct has only recently been applied to help explain the experiences of family caregivers of persons with dementia (Gignac & Gottlieb, 1996). Caregiver’s self-efficacy is another variable that has been studied in caregiving research as a potential moderator in the relationship between stressors and distress, with research consistently showing the positive effects that this variable has on caregiver’s distress (Marquez-Gonzalez, Losada & Penacoba, 2009). Traditionally, self-efficacy has been defined as the conviction that one can successfully execute the behaviours required to produce certain outcomes (Bandura, Adams & Beyer, 1977). In the dementia caregiving context, self-efficacy has been conceptualized as the belief in the ability to carry out different activities related to caregiving (Steffen, Mckibbin, Zeiss Gallagher-Thompson & Bandura 2002).

            Apparently, gender seems to play a crucial role in reported stress among inpatient caregivers.   It is also likely that males and females may approach their caregiving differently. Women reports more stress resulting from caregiving duties than their male counterparts (Miller, 1990; Montgamer, 1992).it could also be based on socialization processes. This is because men and women think differently; their expectations also are different (Loscalzo, 2010). Men seem to consider it more as a task, whereas women may take it more comprehensively (Baker & Robertson, 2008; Russell, 2001; Calasanti & King, 2007). Loscalzo (2010) also noted that gender is so powerful, but it is often ignored. Because women are more “in tune” with sickness and suffering of others, they will experience a greater increase in their own distress when exposed to the distress of others (Graham, 1983). Women experience more burden, stress, lower life satisfaction, and depression than men as a result of their responsibilities (Yee & Schulz, 2000). Females usually take more responsibility of the well-being of the family from childbearing to care older family members. Considering the usually high emotional responsibility by female nature, it is quite understandable that they have more emotional stress when facing the situation.  Cultural aspects also have a great impact on caregiving, possibly females are expected to be more altruistic and more suitable for caregiving than males (Collins & Jones, 1997). Studies also noted that male caregivers are not as likely as women to be aware of or to use community services (Stommel, Collins, Given & Given, 1999). In addition, they may perceive that by accepting community services they admit being weak and losing control (Kaye & Applegate, 1993). Stommel and colleagues (1999) suggested that males do not take caregiver’s role similarly to females as their coping strategies are different. Males may prefer family independence.

Statement of the problem

            The mainstream of this study emanated from the fact that caregivers experience stress which they cannot run away from. This stress poses a big threat to them because it causes psychological disturbance such as anxiety and depression (Macneil, Kosberg,  Durkin  Dooley, Dewster & Williamson, 2010; Gonyea, Paris & De-Saxe-Zerden, 2008).  It is out of this fall-out that the researcher felt a need to study and to provide answers the following questions:

  • Would social support significantly predict inpatients’ caregivers stress?
  • Would self efficacy significantly predict inpatients ‘caregivers stress?
  • Would gender differences significantly predict inpatients’ caregivers stress?

Purpose of the study

            The purpose of the study is to investigate and establish whether social support, self-efficacy and gender will significantly influence caregiving stress among caregivers in selected hospital in Nsukka urban. More specifically, the objective of the study is to investigate whether:

 

  • Social support would significantly predict inpatients’ caregivers stress.
  • Self-efficacy would significantly predict inpatients’ caregivers stress.
  • Gender would significantly predict inpatients’ caregivers stress.

Operational Definition of Terms

Caregivers stress; refers to the unpleasant situation or burdens a caregiver experiences when taking care of a sick one as measured by Perceived Stress Scale (Gonzalez & Landero, 2005).

Caregiver; refers to a person who takes care of sick /elderly person in the hospital.

Social Support; refers to the assistant rendered by a potential provider to the individual inform of money, love, empathy, security, caring and advice in situation of need, as measured by the Multidimensional scale of Perceived Social Support (MSPS) (Zimet, Dehelm, Zimet & Farly, 1988).

Self-efficacy entails the perceived confidence or competent to accomplish a task, as measured by New General Self-efficacy Scale (Chen, Gully & Eden, 2005).

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