Associations Between Secondary Caregivers

The Gerontologist Advance Access published December 23, 2013 The Gerontologist Cite journal as: The Gerontologist doi:10.1093/geront/gnt156

© The Author 2013. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].

Associations Between Secondary Caregivers’ Supportive Behavior and Psychological Distress of Primary Spousal Caregivers of Cognitively Intact and Impaired Elders

1

Department of Social Work & Social Administration, Sau Po Centre on Ageing, University of Hong Kong. 2 Department of Statistics and Actuarial Science, University of Hong Kong. 3 Department of Applied Social Studies, City University of Hong Kong. 4 School of Social Work, University of Southern California.

*Address correspondence to Vivian W. Q. Lou, MSW, PhD, Department of Social Work & Social Administration, University of Hong Kong, Pokfulam Road, Hong Kong. E-mail: [email protected] Received June 19, 2013; Accepted November 6, 2013 Decision Editor: Rachel Pruchno, PhD

Purpose of the Study: This study examined associations between the availability and types of supportive behavior provided by secondary caregivers and the psychological distress of primary spousal caregivers of cognitively intact and impaired elders. Design and Methods: A sample of 8,087 assessments using the validated Chinese version of the Minimum Data Set– Home Care of individuals applying for governmentsubsidized long-term care services from 2006 to 2009 in Hong Kong were selected based on inclusion criteria. Results: More than 70% of primary caregivers had secondary caregivers; the rate was slightly lower for those caring for moderately or severely cognitively impaired spouses. More than half of the primary spousal caregivers had secondary caregivers who provided both emotional and instrumental support. Emotional support provided by secondary caregivers had a negative association with primary caregivers’ psychological distress when their care recipients were cognitively intact. When secondary caregivers provided both instrumental and emotional support, primary caregivers had a higher likelihood of psychological distress when care recipients had greater negative mood symptoms as compared to those who had less negative mood symptoms. Implications: This is the

first study that examined the association between availability and types of supportive behavior provided by secondary caregivers and the psychological distress of primary spousal caregivers of cognitively intact and impaired elders. The findings suggest a need to provide services that enhance the provision of emotional support from both secondary and primary caregivers to cognitively intact elders and support primary spousal caregivers to seek appropriate help according to the mood of care recipients. Key Words: Spousal primary caregivers, Secondary caregivers’ supportive behavior, Psychological distress, Cognitively intact and impaired spouses

Family caregivers play important roles in longterm care systems in all societies (Organisation for Economic Co-operation and Development, 2005). They not only provide care to those with continuous needs related to daily living, but also enable frail elders to age in place (Gaugler, Duval, Anderson, & Kane, 2007). In countries with less-developed long-term care systems, family caregivers may be the only support that frail older adults can rely on

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Vivian W. Q. Lou, MSW, PhD,*,1 Chi Wai Kwan, PhD,2 Ming Lin Alice Chong, PhD,3 and Iris Chi, DSW4

in extended families (e.g., Silverstein, Cong, & Li, 2006; Xu, Xie, Liu, Xia, & Liu, 2007). Therefore, it is culturally relevant and crucial to explore the role of secondary caregivers in the Chinese context. This study aimed to fill this gap by examining the effects of supportive behavior provided by secondary caregivers to care recipients on the psychological distress of spousal primary caregivers who care for cognitively impaired and intact elders. As described by the stress process of caregiving, care needs of care recipients trigger the process of stress, coping, and adaptation (Pearlin, Mullan, Semple, & Skaff, 1990), which indicates two possible mechanisms of influencing the psychological well-being of primary caregivers. One focuses on reducing care needs and the other targets increasing coping resources so that stress triggered by care needs could be perceived as more controllable. Social support has been found to contribute directly to well-being outcomes and also serve as a coping resource that influences the relationship between stress and psychological distress, most often as a moderator (Etters, Goodall, & Harrison, 2008; Haley, Levine, Brown, & Bartolucci, 1987; Kaufman, Kosberg, Leeper, & Tang, 2010; Wilks & Croom, 2008). Family caregivers provide supportive behavior to help older adults with dementia achieve daily functionality according to individual needs. Among all types of support, instrumental and emotional support have been viewed as the two main forms of support (Pierce, Sarason, Sarason, & Joseph, 1996). Although exploration of the role of social support in human adaptation to stress can be traced to earlier scholars such as Cohen, Cassel, and Lazarus, studies on social support and caregiving for elders with dementia suggested that the role played by social support varies with respect to sources of support, types of support, and how support is provided and received—factors that are embedded in the context of cultural traditions and practices (Knight & Sayegh, 2010; Pruchno, 2012; Sun, Ong, & Burnette, 2012). Two theoretical models provide invaluable insights to conceptualize the relationship between supportive behavior provided by secondary caregivers and well-being of spousal primary caregivers in a Chinese context (Figure 1). The compensation hypothesis argues that multiple caregivers compensate for each other to fulfill care needs, particularly in terms of formal and informal caregiving (Litwin & Attias-Donfut, 2009). However, in the Chinese context, care and concern for ill family members are normative expectations among interpersonal

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(Brodsky, Habib, & Hirschfeld, 2002; Feng, Liu, Guan, & Mor, 2012; Liu & Lou, 2012; Lou & Gui, 2012; Zhan, Feng, Chen, & Feng, 2011). Family caregiving is not free of negative consequences. During the past three decades, researchers found that family caregivers were more vulnerable to psychological distress when compared to family members who are not caregivers (e.g., Borg & Hallberg, 2006; Daire, Torres, & Edwards, 2009; Pruchno & Potashnik, 1989; Seltzer, 1992; Son et al., 2007). In particular, caregivers caring for spouses with dementia are at high risk of psychological distress due to high demands on care associated with communication challenges, safety concerns, and behavioral problems, highlighting the need for clinical intervention and policy response (Lou & Ng, 2013; Mioshi, Bristow, Cook, & Hodges, 2009; Pinquart & Sörensen, 2011; Torti, Gwyther, Reed, Friedman, & Schulman, 2004). However, taking care of frail older adults is often a responsibility shared with people inside or outside the family. According to U.S. statistics, approximately 50% of families had secondary caregivers (Wolff & Kasper, 2006); in Hong Kong, about 75% of families reported having secondary caregivers and 8.25% employed foreign domestic helpers (Sau Po Centre on Ageing and Department of Social Work & Social Administration, 2011). In particular, tasks of caring for family members with dementia were usually shared by several caregivers (Gaugler, Mendiondo, Smith, & Schmitt, 2003; Lou & Ng, 2013). Regardless of the fact that population-based statistics show that family caregiving is frequently shared by multiple caregivers, the majority of family caregiving studies have focused on one caregiver per family (e.g., the primary caregiver). This may be due to the common assumption that the primary caregiver takes on all caregiving roles (McCarty, Hendricks, Hendricks, & McCarty, 2008). The few existing studies on secondary caregivers of frail older adults focused more on who they were and what they did (Gonçalves-Pereira et al., 2010; Penrod, Kane, Kane, & Finch, 1995; Tennstedt, McKinlay, & Sullivan, 1989); few assessed the influence of supportive behavior provided by secondary caregivers on the well-being of primary caregivers. In the Chinese context, mutual help and support among family members are highly prescribed by traditional culture. Giving and taking behaviors are not only expected and experienced between spouses and partners, but also among parents, children, siblings, and family members

Care Needs of Elders -ADL need -IADL need -Mood problems -Behavior problems

Background Attributes -Care recipients -Primary caregivers

Support Provided by Secondary Caregivers -ADL support -IADL support -Emotional support

Caregiving Stress

Psychological Distress of Spousal Primary Caregivers

Figure 1. Theoretical framework of associations between caregiving stress, support provided by secondary caregivers, and psychological distress of primary spousal caregivers. Note. ADL = activities of daily living; IADL = instrumental activities of daily living.

networks, but providing personal care is regarded as a role for close kin such as spouses and daughters-in-laws. A study conducted in the United States also revealed that the amount and scope of supportive behavior provided by primary and secondary caregivers seemed to be independent (Penrod et al., 1995). These observations imply that types of supportive behavior provided by secondary caregivers may not always compensate for support provided by primary caregivers. In this regard, we assumed that the association between supportive behavior provided by secondary caregivers and the psychological distress of primary caregivers would vary by the availability and type of support. Moreover, the optimal fit model of social support further suggests that the intervening role of social support is often complicated by the type of stress triggered by care needs (e.g., needs related to functioning activities, emotional distress, or behavioral problems) and the type of support provided (e.g., instrumental vs. emotional support; Jarrott, Zarit, Stephens, Townsend, & Greene, 2005; Lopez Hartmann, Wens, Verhoeven, & Remmen, 2012; Thoits, 2011). Therefore, in the context of providing care to frail older spouses, we assumed that the moderating effect of supportive behaviors provided by secondary caregivers would be complicated by varying types of caregiving stress as reflected by the level of functional disabilities, emotional distress, or behavioral problems (Wolfs et al., 2012).

Thus, the present study tested two hypotheses: (a) the association between supportive behavior provided by secondary caregivers to care recipients and the psychological distress of spousal primary caregivers would vary by the type of support provided by secondary caregivers; and (b) the moderating effect of supportive behavior provided by secondary caregivers would vary by the care recipients’ care needs as reflected by level of functional disabilities, emotional distress, or behavioral problems. Findings of the study may inform clinical interventions and evidence-based policy responses to reduce psychological distress in family caregiving. Methods Data Sources This study was a secondary analysis using data from a study of the long-term care needs of older adults in Hong Kong as assessed by the validated Chinese version of the Minimum Data Set–Home Care (MDS-HC) beginning in 2000 (Kwan, Chi, Lam, Lam, & Chou, 2000). All assessments were conducted by trained accredited assessors based on direct communication with applicants and their family members as well as observations via home visit. The analytic sample of the present study included assessments conducted in 2006–2009, with the following five inclusion criterion: the care recipient was (a) 60 years old or older; (b) living

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Care Provision by Spousal Primary Caregivers -ADL support -IADL support -Emotional support

Measures Measures in the present study were derived from items assessed in the MDS-HC. In Hong Kong, the MDS-HC is a mandatory assessment adopted by the government to determine the eligibility of applicants for government-subsidized community or residential long-term care services. Each assessment lasted approximately 45–60 min, during which a trained and accredited assessor evaluated the living environment of the applicant and interviewed the applicant and family caregivers. Inter-rater reliability of the assessment was found to be satisfactory (Kwan et al., 2000). During the past 12 years, only 0.59% of the 238,874 applicants as of July 31, 2013, appealed the decision regarding their eligibility for care (Social Welfare Department, 2013). Dependent Variable.—Psychological distress of the primary caregiver was measured by a dichotomous item evaluating whether the primary caregiver shows signs of distress, anger, and/or depression while providing care to the older adult. Through close observation, active listening, and direct communication with the primary caregiver and the elderly applicant, the coding of this item was based on professional knowledge and judgment (Morris, Bernabei, & Ikegami, 2002; Sau Po Centre on Ageing, 2000).

(ADLs); (b) support for instrumental activities of daily living (IADLs); and (c) emotional support. For care recipients who were cognitively intact, assessments were conducted by interviewing care recipients; for cognitively impaired care recipients, assessments were conducted by asking their primary caregivers. Final codings of the three items were based on clinical knowledge and judgment following observations during home visits and informal communications with caregivers and elderly applicants (Morris et al., 2002; Sau Po Centre on Ageing, 2000). Care recipients were categorized into four groups: (a) no secondary caregivers or not receiving any ADL, IADL, or emotional support from secondary caregivers; (b) receiving only instrumental support (either ADL or IADL support) from secondary caregivers; (c) receiving only emotional support from secondary caregivers; and (d) receiving both emotional and instrumental support (either ADL or IADL support) from secondary caregivers. Covariates.—To test the study hypotheses, demographic variables and health needs of frail older adults, which have been found to significantly contribute to psychological distress among family caregivers (Daire et al., 2009; Lopez Hartmann et al., 2012; Pinquart & Sörensen, 2011), were treated as covariates. Demographic variables related to the care recipient were age (in years), gender (1 = female, 0 = male), and education (0 = primary school or less, 1 = more than primary school). We also examined co-residence of the care recipient and his/her primary and secondary caregivers (0 = no, 1 = yes) and hours of care provided by his/her primary caregiver per week. Five health status variables measured by the MDS-HC were selected as indicators of health needs: ADL impairment (range = 0–6; Morris, Fries, & Morris, 1999), IADL impairment (range = 0–48), cognitive impairment (range = 0–6; Morris et al., 1994), negative mood symptoms (range = 0–18; Leung, Leung, & Chi, 2012), and behavioral problems (range = 0–10; Perlman & Hirdes, 2008). Provision of ADL, IADL, and/or emotional support by primary caregivers was also included (0 = provided, 1 = not provided). Data Analyses

Independent Variables.—The availability and types of supportive behavior (emotional vs. instrumental) provided by secondary caregivers were calculated based on whether secondary caregivers provided (a) support for activities of daily living

Demographic variables, care recipient care needs, spousal caregivers’ psychological distress, and availability and type of support provided by secondary caregivers were calculated as frequencies and percentages. Logistic regression modeling was

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in the community; (c) being assessed for the first time during 2006–2009; (d) married and had a spousal primary caregiver; and (e) had at least one deficit in activities of daily living as indicated by the Activities of Daily Living Hierarchy Scale or cognitive impairment as indicated by the Cognitive Performance Scale (CPS). A total of 8,070 cases met the criteria and were included in the present analyses, representing 12.23% of those who applied for government-subsidized long-term care services in 2006–2009. According to CPS score, the samples were divided into three subgroups: cognitively intact (CPS = 0 or 1), mildly cognitively impaired (CPS = 2), and moderately/severely cognitively impaired (CPS > 2).

used to test hypotheses regarding the association between secondary caregivers’ supportive behavior and the psychological distress of spousal primary caregivers of cognitively intact and impaired elders among three groups. A logistic regression was applied to each of the three groups independently by simultaneously entering dependent variable and covariates. Odds ratios and 95% confidence intervals of the factors were calculated. SAS version 9.3 was used for the statistical analysis. Findings Profile of the Sample

Supportive Behavior Provided by Secondary Caregivers and Its Association With Psychological Distress Among Spousal Primary Caregivers More than 70% of the spousal primary caregivers had secondary caregivers; the percentage

Supportive Behavior Provided by Secondary Caregivers Moderates the Relationship Between Care Needs and Primary Caregivers’ Psychological Distress Logistic models showed that provision of both instrumental and emotional support by secondary caregivers moderated the relationship between care recipient care needs as measured by negative

Table 1. Profile of Study Sample: Care Recipients (N = 8,070) Mildly cognitively impaired

Cognitively intact n N Age 60–69 70–79 80–89 90+ Gender* Female Male Education Primary or less More than primary Care needs IADLs need** ADLs need** Negative mood symptoms* Behavioral problems**

%

n

3,464

%

4,298

N

%

308

578 1,592 1,116 128

16.69 45.96 33.66 3.70

664 2,037 1,449 148

15.45 47.39 33.71 3.44

62 148 92 6

20.13 48.05 29.87 1.95

991 2,473

28.61 71.39

1,118 3,180

26.01 73.99

81 227

26.30 73.70

2,043 1,421 M 18.23 0.71 0.71

58.98 41.02 SD 5.72 0.96 1.26

2,640 1,658 M 21.40 0.88 0.78

61.42 38.58 SD 5.08 1.06 1.31

180 128 M 25.26 2.79 0.70

58.44 41.56 SD 3.29 1.46 1.34

0.05

0.31

0.35

0.81

0.48

1.13

Notes: ADLs = activities of daily living; IADLs = instrumental activities of daily living. *p < .05. **p < .001.

Moderately/severely cognitively impaired

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A sample of 8,070 care recipients was included in the study (see Table 1), including 3,464 (42.9%) who were cognitively intact, 4,298 (53.5%) with mild cognitive impairment, and 308 (3.8%) with moderate or severe cognitive impairment. Approximately half of the participants were in their 70s. The proportion of men was higher in the cognitively impaired group than in the cognitively intact group.

was slightly lower among those caring for moderately or severely cognitively impaired spouses, but the difference was not statistically significant (Figure 2). More than half of the spousal primary caregivers had secondary caregivers who provided both emotional and instrumental support. Findings based on regression models revealed that the provision of emotional support by secondary caregivers to cognitively intact care recipients was significantly negatively associated with the psychological distress of primary spousal caregivers (odds ratio = 0.25, p < .05). No significant associations were found between provision of emotional support by secondary caregivers and psychological distress of primary caregivers among the two cognitively impaired groups, or between provision of instrumental support by secondary caregivers and psychological distress of primary caregivers regardless of the cognitive status of care recipients (Table 2).

62.962 62.983

60

58.442

%

40

27.273 23.034

20

9.3822 9.6091 6.8182

7.4675

4.1859 4.3741

0 No Secondary Caregivers/No Support ADL or IADL Support

Cognitively Intact

Emotional Support Both Types of Support

Mildly Cognitively Impaired

Moderately/Severely Cognitively Impaired

Figure 2. Availability of primary and secondary caregivers and types of care provided.

mood symptoms and primary caregivers’ psychological well-being across all three subgroups (Table 2). No significant interaction effects were identified between ADL support needs, IADL support needs, and supportive behavior provided by secondary caregivers, or between behavioral problem needs and supportive behavior provided by secondary caregivers. Further analyses showed that when care recipients had more negative mood symptoms, the likelihood of primary caregivers having psychological distress increased when secondary caregivers provided both instrumental and emotional support than when the secondary caregiver provided no support (Figure 3). In other words, an increase in negative mood symptoms had a greater impact and led to a greater increase in the likelihood (+14%, +26%, +32%) of primary caregivers’ psychological distress in the former group (e.g., secondary caregivers provided both instrumental and emotional support) than that in the latter group (+10%, +13%, +17%) (e.g., secondary caregivers provided no support.

In addition to these findings, the present study also found significant associations between care needs and supportive behavior provided by primary caregivers. Greater negative mood symptoms assessed among care recipients was associated with a higher likelihood of primary caregivers’ psychological distress in the mildly cognitively impaired subsample. Emotional support provided by primary caregivers was associated with a lower likelihood of psychological distress in the cognitively intact subsample. In addition, instrumental support provided by primary caregivers was associated with a higher likelihood of psychological distress in the cognitively intact and mildly cognitively impaired subsamples (Table 2). Discussion Findings of the present study showed that the majority of the older adults who applied for government-subsidized long-term care in Hong Kong received care from both spousal primary caregivers and secondary caregivers. In addition, the majority

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23.47

Table 2. Logistic Regression of Spousal Primary Caregiver Distress by Three Care Recipient Groups

Cognitively intact (N = 3,464) OR

Mildly cognitively impaired (N = 4,298)

95% CI

OR

95% CI

OR

95% CI

1.06 1.44 0.77 2.15

0.87, 1.31 0.89, 2.32 0.48, 1.22 1.15, 4.01

3.24 2.48 1.47

0.81, 12.96 0.48, 12.95 0.19, 11.70

1.00 187.11 181.70 1.15

0.00, —a 0.02, —a 0.00, —a

1.00 0.22

0.04, 1.17

0.59 0.88

0.21, 1.61 0.51, 1.52

1.00 1.06

0.52, 2.16

0.86

0.56, 1.31

1.01

0.78, 1.32

1.00 0.44 5.71 2.18 1.00 0.44

0.08, 2.57 0.72, 45.20 1.24, 3.82 0.01, 21.82

0.61

0.22, 1.65

0.70

0.34, 1.45

Notes: Covariates were age, gender, marital status, education, coresidence, and duration of care provision. Bolded figures = significant effect. ADL = activities of daily living; IADL = instrumental activities of daily living. a Very large.

of applicants received both instrumental and emotional support from secondary caregivers. However, the study also revealed that the roles played by secondary caregivers were not always associated with constructive benefits for primary caregivers, indicating the need for further in-depth studies that take into account the ecology of family caregiving. First, the present study showed that only emotional support but not instrumental support

provided by secondary caregivers had a significant and negative association with psychological distress among primary spousal caregivers of cognitively intact care recipients. Similar results were found for primary caregivers, suggesting that complimentary theory of emotional support applies to cognitively intact frail family members in the Chinese context. That is, showing care and concern to ill family members results in benefits for informal

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Caregiving stress IADL care need 0.98 0.95, 1.01 1.00 0.97, 1.03 ADL care need 1.05 0.88, 1.26 1.13 0.97, 1.30 Negative mood symptoms (mood) 1.07 0.96, 1.18 1.23 1.11, 1.36 Behavior problems 1.59 1.05, 2.41 1.01 0.86, 1.20 Supportive behavior by primary caregivers ADL support 2.04 1.60, 2.61 1.55 1.24, 1.95 IADL support 1.68 1.01, 2.80 1.71 1.08, 2.70 Emotional support 0.42 0.25, 0.71 0.80 0.51, 1.27 Supportive behavior by secondary caregivers No support 1.00 1.00 IADL or ADL support 0.24 0.04, 1.37 1.26 0.23, 6.86 Emotional support 0.25 0.09, 0.68 1.23 0.48, 3.17 Both types of support 0.59 0.32, 1.06 1.13 0.57, 2.24 Interactions between caregiving stress and supportive behavior by secondary caregivers ADL care need × no support 1.00 1.00 ADL care need × IADL or ADL 0.86 0.59, 1.26 0.82 0.59, 1.16 support ADL care need × emotional support 1.34 0.95, 1.89 0.80 0.62, 1.04 ADL care need × both types of 0.92 0.75, 1.13 0.92 0.78, 1.09 support IADL care need × no support 1.00 1.00 IADL care need × IADL or ADL 1.08 0.98, 1.18 1.01 0.94, 1.10 support IADL care need × emotional 1.04 0.99, 1.10 1.01 0.96, 1.06 support IADL care need × both types of 1.02 0.98, 1.05 1.00 0.96, 1.03 support Mood × no support 1.00 1.00 Mood × IADL or ADL support 1.14 0.87, 1.49 0.82 0.64, 1.04 Mood × emotional support 1.25 0.98, 1.59 0.88 0.74, 1.04 Mood × both types of support 1.35 1.18, 1.54 1.22 1.08, 1.39 Behavior problem × no support 1.00 1.00 Behavior problem × IADL or ADL 1.18 0.17, 8.01 1.78 1.08, 2.93 support Behavior problem × emotional 0.75 0.29, 1.98 1.06 0.78, 1.44 support Behavior problem × both types of 0.64 0.37, 1.10 1.06 0.87, 1.28 support

Moderately/severely cognitively impaired (N = 308)


Figure 3. Associations between negative mood symptoms, support provided by secondary caregivers, and psychological distress of primary caregivers among three groups.

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A study on mental illness patients and their family caregivers revealed that when Chinese people failed to fulfill socially expected salient roles, they would feel shame and guilt (Hsiao, Klimidis, Minas, & Tan, 2006). Therefore, not only did both instrumental and emotional support from secondary caregivers fail to buffer spousal caregivers’ psychological distress, it accelerated the level of distress among spousal caregivers. This finding is new and enriches the cultural and contextual understanding of the stress and support relationship (Reblin, Uchino, & Smith, 2010). Mediating effects were also tested and found to be not significant for all three types of caregiving stress across three subgroups. These findings supported our discussion that providing care and concern for family members in ill health is highly expected in Chinese context, which may not be necessarily directly associated with expressed needs of care receivers. Therefore, it supported the assumption that support provided by secondary caregivers plays a moderating rather than mediating role. Limitations This study has several limitations. First, the present study was based on secondary data, which restricted available information. For example, the amount and intensity of care provided by secondary caregivers was not available. The cross-sectional nature of the data prevented testing of causality among caregiving stress, support provided by secondary caregivers, and the psychological wellbeing of primary spousal caregivers. A longitudinal study design is needed to explore these factors over time. Second, only spousal primary caregivers were included in the present study. Future research may focus on comparing spousal and adult child primary caregivers. Third, the present study combined assessments conducted from 2006 to 2009 without considering the possible influences of time and cohort, given potential changes in societal and cultural factors. Conclusion and Implications In summary, the findings of the present study enhanced a contextualized understanding of social support and primary spousal caregiving for elders in Chinese culture by identifying two factors. First, there is a need to differentiate between the influence of instrumental and emotional support provided by secondary caregivers on primary spousal caregivers’ psychological well-being while taking

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care providers because these behaviors fulfill sociocultural expectation. However, this relationship only occurred among cognitively intact care recipients. One possible explanation is that reinforcement of sociocultural expected behavior by care recipients contributes to a positive and warm family caregiving atmosphere that has psychological benefits for primary caregivers, which is in line with discussions of social support in the family literature (Lee, Santoro, Paul, & Rosenbaum, 1996; Ory, Yee, Tennstedt, & Schulz, 2000; Silverstein & Giarrusso, 2010). In contrast, when care recipients are cognitively impaired, positive responses to emotional support may be limited by communication difficulties, leading to frustration and disappointment in the family context (Savla, Roberto, Blieszner, Cox, & Gwazdauskas, 2011). The lack of a significant association between instrumental support from secondary caregivers and primary spousal caregivers’ psychological well-being implied neither a compensatory nor complimentary role of instrumental support provided by secondary caregivers. Further studies are needed to examine potential mechanisms. However, this finding is new and enriches the cultural and contextual understanding of the differing effects of instrumental and emotional support in the context of multiple sources of informal support. Second, the present study revealed that when care recipients exhibited negative mood symptoms, significant interactions occurred between secondary caregivers providing both instrumental and emotional support and primary spousal caregivers’ psychological distress. This finding was consistent among cognitively intact and impaired care recipients. One possible explanation may be that the caregiving context (e.g., taking care of elders with mood distress who receive support from both primary and secondary caregivers) put spousal caregivers into a negative interlocking cycle. According to the health concordance hypothesis, which involves the likelihood of older couples concurrently experiencing depressive symptoms, primary caregivers are more likely to be influenced by negative mood symptoms exhibited by their spouses (Butterworth & Rodgers, 2006; Meyler, Stimpson, & Peek, 2007). In addition, receiving instrumental and emotional support by secondary caregivers might imply that the primary caregivers fail to fully fulfill their caregiving responsibilities, which is considered as salient for spouse caregivers (Miller & Guo, 2000).

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