Aging & Mental Health, January 2007; 11(1): 3–13
ORIGINAL ARTICLE
The socio-cultural context of family caregiving and psychological distress: A comparison of immigrant and non-immigrant caregivers in Israel
V. SOSKOLNE1,2, S. HALEVY-LEVIN3,4, & A. COHEN3 1
School of Social Work, Bar-Ilan University, Ramat-Gan, 2Braun School of Public Health, Hadassah-Hebrew University Medical Center, Jerusalem, 3Department of Social Work Services, Hadassah-Hebrew University Medical Center, Jerusalem, and 4The Geriatric Unit, Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
(Received 12 September 2005; accepted 22 January 2006) Abstract The study aimed to examine the differences in caregiving context and psychological distress outcome between non-immigrant and immigrant caregivers; to investigate these differences by relationship type; and to examine the factors related to psychological distress. Spouse or adult child caregivers (213 non-immigrants and 206 immigrants from the Former Soviet Union) were interviewed. Based on stress and appraisal conceptual framework, caregiving stressors, primary appraisal, psychosocial resources, secondary appraisal and psychological distress were measured. A series of two-way MANOVA, followed by ANOVA, was used to examine the differences by immigration status, by relationship type and their interaction. Hierarchical multiple linear regression was conducted to examine variables associated with psychological distress. Negligible differences in caregiving stressors, but significant differences in caregiving primary and secondary appraisal, psychosocial resources and psychological distress were found by immigration status and by relationship type, and significant interactions only in caregiving primary appraisal. The regression models showed that the differences in psychological distress by immigration status and by relationship type were fully explained by caregiving stressors (care recipient’s problem behavior), psychosocial resources (mastery) and caregiving secondary appraisal (role overload, captivity, economic difficulties). The results suggest that socio-cultural background and role relationship shape caregiving appraisal and psychosocial resources, and that these factors explain psychological distress outcomes.
Introduction With the increased aging in many populations, the number of frail and disabled elderly in need of assistance in the activities of daily living (ADL) is steadily growing. The majority of these elderly live in the community and are cared for by family members. Caregiving demands are often high, with subsequent burden, strain, depression or psychological distress (Tennstedt, 1999; Yates, Tennstedt, & Chang, 1999) that vary between sub-groups of the population. Ethnic and cultural background are important factors determining caregiving stress and health outcomes, yet relatively little is known about the distinct experiences of various ethnic/cultural groups (Dilworth-Anderson, Williams, & Gibson, 2002). The majority of the studies have focused primarily on the differences between White and Black caregivers (e.g., Farran, Miller, Kaufman, & Davis, 1997; Haley et al., 1996; Lawton, Rajagopal, Brody, & Kleban, 1992; Miller, Campbell, Farran,
Kaufman, & Davis, 1995; White, Townsend, & Stephens, 2000), or other ethnic groups, such as Hispanic or Asian caregivers (Aranda & Knight, 1997; Patterson et al., 1998; Youn, Knight, Jeong, & Benton, 1999). In Israel, a multi-ethnic, multi-cultural society, little is known about ethnic and cultural variations in family caregiving and its health outcomes. Such research is particularly needed in relation to recent immigrants from the former Soviet Union (FSU), among whom a higher proportion (17%) compared to the general Israeli population (10%) are elderly (Brodsky, Shnoor, & Be’er, 2002). The relevance of such research is particularly important as we adopt the sociological distinction between definitions of ethnic groups as ‘those characterized by a subjective belief in their common descent’, and of culture as ‘ordered systems of symbols that guide social action and are internalized components of the personalities of individual actors’ (Quah, 2001).
Correspondence: Varda Soskolne, PhD, School of Social Work, Bar-Ilan University, Ramat-Gan 52900, Israel. Tel: þ 972 3 5317806. Fax: þ 972 3 5347228. E-mail:
[email protected] ISSN 1360-7863 print/ISSN 1364-6915 online/07/010003–13 ß 2007 Taylor & Francis DOI: 10.1080/13607860600641127
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Cultural differences are often associated with socio-economic factors, which together shape the specific socio-cultural contexts of sub-populations. This may be particularly pertinent to immigrants who are ethnically similar to the general population in the new country, as are the immigrants from the FSU to Israel, but still carry cultural views from the old country, and also differ in their socio-economic status post-immigration (Shuval, 2001). These conditions also determine the socio-cultural context of caregiving: the social conditions and cultural beliefs that influence and shape willingness to give care, the provision of caregiving within the family, and responses to feelings of caregiving burden (Dilworth-Anderson, 2001). In this context, the type of relationship (kinship) between the care recipient and the caregiver is an important factor. Therefore, the focus in this study is on differences in the socio-cultural context of caregiving. The study examines spouse and adult offspring caregivers, and compares between recent immigrants from the FSU, who are predominantly of a Jewish descent, and other Jewish caregivers, Israeli-born or long-time inhabitants (hereafter referred to as ‘non-immigrants’). Caregiving stress model and health Family caregiving is the behavioral expression of one’s commitment to the welfare of another family member (Pearlin, Mullan, Semple, & Skaff, 1990). The prolonged need for the provision of care at home for patients with disability or dementia leads to elevated levels of distress and depression (Braithwaite, 1996; Yates et al., 1999). Based on the general theoretical model of stress, coping and health (Lazarus & Folkman, 1984), many studies have shown that cognitive appraisal of the stressors and the caregiver’s psychosocial resources mediate the association between caregiving stressors and psychological distress outcomes (Bookwala & Schulz, 1998; Haley et al., 1996; Li, Seltzer, & Greenberg, 1997; Patterson et al., 1998). Two main conceptual frameworks that have emerged in caregiving research emphasize different components of this model. The ‘caregiving stress model’, outlined by Pearlin and his colleagues (1990), makes a distinction between primary stressors—those that stem directly from the needs of the patient, and secondary stressors or strains that stem from this condition (such as ‘overload’). In the ‘appraisal model’ (Lawton, Kleban, Moss, Rovine, & Glicksman, 1989), objective and subjective strains are conceptualized as cognitive appraisal of the caregiving role. Yates et al. (1999) proposed an integrated framework, built on the strengths of both models. They incorporated the concept of appraisal into the model by Pearlin et al. (1990) and suggested separating the variables conceptualized as
primary stressors. In their framework (Yates et al., 1999), caregiving assistance (e.g., hours of informal care) and overload are not considered stressors, but rather as responses of the caregiver to the stressor. Caregiving assistance is considered a primary appraisal, representing the caregiver’s appraisal of care needed in response to the objective levels of care recipients’ disability (stressors). Overload is considered a secondary appraisal: having assessed their own situation, the caregivers determine their resulting feeling of overload. This conceptual model guided the current study and was expanded by inclusion of additional aspects of caregiving secondary appraisal. The model thus links caregiving stressors (the objective status of the care recipient and duration of caregiving), caregiving primary appraisal (caregiving assistance), psychosocial resources, and caregiving secondary appraisal (negative aspects and economic strains due to caregiving) to psychological distress. Incorporation of cultural backgrounds into this integrated model links it to the socio-cultural perspective of family caregiving (Aranda & Knight, 1997). This approach contends that, beyond the influence of socio-economic background, cultural values and beliefs affect the type of care provided, shape the appraisal of caregiving, the available resources and the psychological health outcomes (Dilworth-Anderson et al., 2002; Knight, Silverstein, McCallum, & Fox, 2000). Thus, sociocultural context determines who and how care is provided in the family (Dilworth-Anderson, 2001). The synthesis of pragmatic circumstances and social norms influences who is the caregiver, and this role relationship (whether spouse or adult child) shapes the caregiving tasks and the impact of caregiving (Montgomery & Williams, 2001). Spouse caregivers differ from children in the type of care they provide (Tennstedt, 1999), in their overload appraisal (Yates et al., 1999), social support (Li et al., 1997) and psychological outcomes. Spouses report greater psychological distress than do adult child caregivers (Li et al., 1997; Pot, Deeg, Van Dyck, & Jonker, 1998). The role of another factor, the caregiver’s physical health status, is not consistently conceptualized in the socio-cultural model of family caregiving, although it is particularly important when the health of one group is likely to be poorer (Haley et al., 1996). Physical health is measured as an outcome of caregiving (Aranda & Knight, 1997), or as a background factor or a resource of the caregiver, associated with appraisal and psychological health (Lawton et al., 1992). Caregiving in Israel among non-immigrants and immigrants In Israel, the majority of the disabled patients are eligible for formal homecare services under
Immigration, family caregiving, and psychological distress the Community Long-term Care Insurance Law. Yet, these services do not meet all the needs and family members provide the bulk of assistance needed at home (Brodsky, 1998). Despite variations within the Jewish society in Israel, such as those between Sephardic and Ashkenazi Jews, between Israeli-born and those who arrived in past waves of immigration two or more decades ago, the society at large is characterized by strong family ties (Walter-Ginzburg, Guralnik, Blumstein, Gindin, & Modan, 2001) and cultural values of filial responsibility for the elderly (Litwin, 1994). During the years 1989–1995 close to one million people arrived in Israel from the FSU. These immigrants are marked by a very distinct cultural background, and by the longstanding experience of an authoritative, closed society; features that distinguish them from the general Israeli population (Ben-Rafael, Olshtain, & Geijst, 1997). In their transition to a Western democratic, more open society, new immigrants from FSU tend to cling to their familiar mores and traditions, in particular during times of ongoing crisis such as caring for the chronically ill. Some of the social conditions and cultural norms of the FSU immigrants distinguish them from their non-immigrant counterparts and may influence their caregiving context. In FSU almost all caregiving was extended from within the family setting (Remennick, 1999). The limited social services that did exist were directed mainly to the provision of social benefits and institutionalization. However, these services were poor and institutions were badly managed. This gave way to the development of a strong moral and cultural norm that the frail elderly should be supported within the family framework (Remennick, 2001). These norms were common among Jewish families who, in particular, were characterized by strong intergenerational ties, and often shared households with the elderly. Following immigration to Israel, sharing household has become more prevalent, due to the social and economic constraints that forced many sick or disabled elderly to become more dependent on younger family members (Remennick, 2001). These conditions were also reflected in the limited social networks of elderly immigrants, composed mainly of other immigrants (Litwin, 1995), and in lower utilization of health services in the first years after immigration compared to the general population (Habib et al., 1998). In comparison, nonimmigrant families, already well established in the country and diverse networks, are more able to provide a varied support system to the elderly. They are acculturated to Western standards, expect more assistance from sources other than the family and do not hesitate to use formal services. There is also accumulating evidence regarding differences in health status between the immigrant and non-immigrant populations. Previous surveys
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showed a higher proportion of elderly immigrants with disabilities and chronic disease (Habib et al., 1998), poorer self-assessed health (Baron-Epel & Kaplan, 2001) and higher levels of psychological distress (Zilber & Lerner, 1996). Consequently, those who are family caregivers may also suffer from health problems that limit their ability to care, and thus feel burdened. These economic, social, and health difficulties, experienced less by nonimmigrant caregivers, may contribute to greater caregiving stressors and psychological distress outcomes among the immigrants. While it may be difficult to distinguish cultural norms from the life context of the immigrants, research on differences between these groups can provide important information. So far, the few studies on family caregiving in Israel showed that psychological distress or depressive mood varied by relationship with the care recipient. Spouses of cancer patients reported higher burden and strain than adult children (Lowenstein & Gilbar, 2000), and wives caring for disabled spouses reported a higher rate of strain than did daughter caregivers (Gross, BrammliGreenberg, & Bentur, 2003). One study highlighted the parental caregiving experiences of immigrant women (Remennick, 2001). However, data on the socio-cultural context of caregiving stressors, appraisal, resources and psychological health outcomes are not available. The aims of this study, using Yates et al. (1999) conceptual framework, were to: (a) examine the differences in caregiving stressors, primary appraisal, psychosocial resources, secondary appraisal, and in psychological distress outcomes between nonimmigrant and immigrant caregivers; (b) explore these differences by relationship type; and (c) examine the independent contribution of immigration group, relationship type, caregiving stressors, appraisal and psychosocial resources to psychological distress.
Methods Sample The participants for this cross-sectional comparative study were recruited during the year 2001–2002 from the home-care units of the four Health Maintenance Organizations in Jerusalem, and from three ambulatory units of the Hadassah Hospitals (the Geriatric Unit, Hospice Home Care Unit and the Retired Personnel Services). Inclusion criteria: (a) For care recipient: aged 55 years or older, in need of assistance with two or more activities of daily living (ADL), or three or more instrumental ADL (IADL), or in need of constant supervision. (b) For primary family caregivers: first-kin family caregivers (spouses, children, children-in-law), 25 years of age or older, independent in ADL and IADL, provide
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care on a regular basis for at least five weekly hours and over two months or more, non-immigrants (Israeli-born or inhabitants in Israel for 20 years or more) or recent immigrants from the FSU (in Israel for ten years or less). It is important to note here that immigration status and cultural background were not separated in the selection of our groups. Moreover, there is cultural variability in the non-immigrant group, reflecting the existing structure of the general Jewish population of Israel (e.g., Ashkenazi and Sephardic Jews, Israeli-born and others who immigrated to Israel long ago) as well as within the immigrant group (e.g., by region of origin in the FSU). Further stratification would have resulted in small samples, and selection of a comparison group comprised only of long-term Soviet immigrants (420 years since immigration) from the lists of the participating services was not feasible. Therefore, we opted to retain all the non-immigrant caregivers in the comparison group in order to have a better representation of the general population of caregivers. Additionally, the inclusion of care recipients from age 55 was chosen in order to capture younger spouse caregivers. Procedures The Human Subjects Ethical Committees of the participating services approved the study. Names of caregivers were selected from lists of eligible patients being cared for by each service. The number of family members involved in caregiving at each service was established following initial contact. In two services (the Hospice Home Care and the Hadassah Retired Personnel Unit), all the eligible caregivers were included. In the other services, consecutive samples of Israeli or immigrant caregivers were selected until we obtained approximately 15–30% of the potential populations. Having signed an informed consent form, the participants were interviewed at home in Hebrew or Russian by trained interviewers. A total of 588 eligible family members were approached, of whom 419 (71%) were interviewed, 213 (66%) non-immigrant and 206 (79%) immigrant caregivers. Reasons for non-response were mainly refusal (19%) and lack of time (9%). The non-participants differed from the participants in their relationship to the care recipient (56% and 42%, respectively, were spouses), but not in age or gender. Measures To assure linguistic equivalences, the questionnaire was translated from Hebrew to Russian, examined by another expert and translated back to Hebrew. Some of the scales were already available in both languages.
. Background variables (a) Caregiver demographics included the relationship to the care recipient, age, gender, marital status (for adult child caregivers), education, average family income, employment, years in Israel and living arrangement (whether residing with the care recipient). Care recipient demographics included age and gender. (b) Physical health. Two global indicators of morbidity were selected: (i) limiting longstanding illness, a dichotomous single item measure of functional limitation that focuses on chronic conditions that limit an individual’s activity (Manor, Power, & Matthews, 2001); and (ii) self- assessed health, a single five-point item that has been proven a reliable indicator of morbidity in many studies (Idler & Benyamini, 1997). It was further collapsed into three categories of good, fair and bad health. . Caregiving stressors The scales selected for the study have been used widely in previous caregiving research and are considered valid and reliable. Measures of internal consistency (Cronbach’s alpha) were computed for each group in our sample. (a) Care recipient status was measured by four scales. Functional status was measured by the fiveitem Activities of Daily Living (ADL) scale and a five-item Instrumental Activities of Daily Living (IADL) scale (Fillenbaum, 1985). Four of the items of the ADL scale range from 0–2 and one item from 0–3, resulting in a mean score ranging from 0–2.2. Higher scores represent greater disability, with Cronbach’s alpha of 0.83, similar in both groups. The dichotomous responses to having problems with IADL items were summed to form a scale ranging from 0–5 (needing assistance in all IADL). Cognitive impairment was measured by an eight-item scale, with higher scores representing greater impairment (Pearlin et al., 1990). Cronbach’s alpha was 0.94 and was similar in both groups. Problem behavior was measured by responses to the frequency of five behaviors (wandering, yelling or cursing, hitting, acting inappropriately, or accusing others of stealing), each ranging from 0 ‘never’ to 4 ‘very often’ (Yates et al., 1999). Due to the skewed distribution of the summative scale, it was further dichotomized to 0 ‘none’ and 1 ‘any problem behavior’. (b) Caregiving primary appraisal. Caregiving assistance included four variables: Intensity (the number of weekly hours of caregiving) was measured by one question. Caregiving tasks were constructed specifically for the study as the mean value of the frequency of assistance
Immigration, family caregiving, and psychological distress in each of the ADL or IADL items, ranging from 1 ‘not at all’ to 4 ‘all the time’. Cronbach’s alphas were 0.76 and 0.78 respectively, and were similar in both groups. . Psychosocial resources (a) Mastery. A seven-item scale that measures the sense of control over issues in a person’s life (Pearlin & Schooler, 1978). Each item ranges from ‘1’ to ‘4’ (high mastery). Cronbach’s alpha was 0.71 and similar in both groups. (b) Social support was measured by the Medical Outcome Study (MOS) Social Support Scale, a 19-item scale tapping emotional, instrumental, tangible or affective support (SherbourneDonald & Stewart, 1991). The total score was used for the current analysis with higher scores representing greater support. Cronbach’s alpha was 0.96 and similar in both groups. . Caregiving secondary appraisal (a) Role overload. A four-item scale which indicates how much an individual feels overwhelmed by the tasks of caregiving (Pearlin et al., 1990). Cronbach’s alpha was 0.80 and was similar in both groups. (b) Role captivity. A three-item scale that indicates the perception of being captive in the caregiving role (Pearlin et al., 1990). Cronbach’s alpha was 0.78 and similar in both groups. Higher scores on both scales represent more negative appraisal. (c) Economic difficulties resulting from their family caregiving, was measured by a four-point single question, but based on its distribution it was further dichotomized into 0 ‘no’ and 1 ‘yes’. . Psychological distress (a) The 24-item Talbieh Brief Distress Inventory (TBDI; Ritsner, Rabinowitz, & Slyuzberg, 1995) was used. The total Distress Index, a mean of all items, ranging from 0–4 (high) was used. Cronbach’s alpha was 0.91 and was similar in both groups. This scale was preferred over others because of its frequent use in studies of immigrants from the FSU in Israel. Statistical analysis Each group was stratified by relationship to care recipient: spouses versus adult children, including children-in-law (who comprised 8% of the nonimmigrant and 17% of immigrant samples). Exclusion of children-in-law did not change the results, thus they were retained in the analysis. To examine the differences by immigration status and by relationship type we conducted a series of twoway multivariate analysis of variance (MANOVA) on four sets of variables (caregiving stressors, caregiving
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primary appraisal, psychosocial resources, and caregiving secondary appraisal). In each set, the main effect of group (non-immigrants vs. immigrants) and the main effect of relationship type (spouses versus adult children) were examined as the betweensubjects variables to test the first aim, and their interaction (group relationship type) was examined to evaluate whether the differences between the non-immigrant and the immigrants varied by relationship type (the second aim). Eta2 parameter that represents the effect size of F ratio (range 0–1) (Aron & Aron, 1994: pp 328–329) is presented for each significant factor in the MANOVA. Univariate analyses of variance (ANOVA) followed MANOVA to examine the differences separately for each variable in the four sets, as well as in psychological distress (the single dependent variable). Analyses were performed using SPSS, version 11 (SPSS, Inc.) computer program. Multivariate analyses, using hierarchical multiple linear regression models were conducted to examine the independent associations of group affiliation and relationship type with psychological distress once other factors are included. In order to build more parsimonious models, the associations between variables of each block were examined; if highly correlated only one variable was retained in this block. Group affiliation and relationship type were entered first, together with control background variables and caregiving stressors, followed by three blocks of explanatory variables (caregiving primary appraisal, psychosocial resources and caregiving secondary appraisal). In the final stage, interaction terms of group affiliation or relationship type with the predictor variables were entered. In order to detect only the most significant interactions, this stage was performed using a forward stepwise mode, with significance level set at p50.05 for inclusion and at p40.10 for exclusion.
Results Study population Minor differences in demographic characteristics— age, gender, marital status, and employment status, were found between the non-immigrant and immigrant caregivers. Significant differences were noted in levels of education and family income; the immigrant caregivers had significantly higher education and lower levels of family income (Table I). In addition, more than twice as many immigrants than non-immigrant adult children were living with the care recipient and caring for older care recipients. The majority of the immigrant caregivers (67%) had arrived in the early stages of this wave of immigration and had been living in Israel for 8–10 years (data not shown). The immigrant adult
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Table I. Background characteristics of the immigrant and non-immigrant caregivers. Spouse caregivers
Caregiver characteristics Age (mean, SD) Gender: (women) Marital status (married) Education (4high school) Employment (yes) Family monthly income (5IS4500) Lives with the care recipient (yes) Care recipient’s characteristics Age (mean, SD) Gender (women) Caregiver physical health Any longstanding illness (yes) Self-assessed health (yes) Very good/good Fair Bad/very bad
Adult child caregivers
Nonimmigrant (n ¼ 108)
Immigrant (n ¼ 66)
Nonimmigrant (n ¼ 105)
Immigrant (n ¼ 140)
69.7 (10.9) 75% – 20% 16% 31% 100%
71.0 (9.5) 61% – 65%*** 11% 85%*** 100%
51.3 (9.7) 83% 68% 47% 62 25% 42%
54.0 (10.6)* 84% 64% 76%*** 67 39%** 91%***
73.5 (10.7) 25%
73.2 (8.7) 39%
81.6 (8.6) 79%
84.3 (7.7)* 83%
42%
70%***
22%
40%***
40% 45% 15%
8% 51% 41%***
68% 27% 5%
30% 50% 20%***
IS, Israeli Shekels (Equivalent to $1100 at the time of the study). Statistical significance for differences by immigration status (Fisher’s chi-square test; t-test). *p50.05; **p50.01; ***p50.001.
children were caring for slightly older parents (Table I). The age of the care recipients in the study ranged from 55–100 years, but the majority (94%) were over 65 years of age. Both spouse and adult child immigrant caregivers reported significantly poorer health status (Table I). Approximately two to three times as many immigrant caregivers than non-immigrant spouse or adult child caregivers reported they were suffering from a chronic condition, and assessed their health to be bad or very bad. It is important to note that family caregivers who were seriously ill were excluded from the study. The majority of the participants reported that their health conditions existed prior to caregiving. Comparison of caregiving stressors, appraisal, and psychosocial resources The results of the MANOVA for each set of variables are reported in the text and the results of the univariate ANOVA for each variable are presented in Table II. Caregiving stressors. The MANOVA yielded a significant main effect for immigration group (F (4, 412) ¼ 3.68, p ¼ 0.006, Eta2 ¼ 0.035), but no significant main effect of relationship type (F (4, 412) ¼ 1.76, p ¼ 0.14). Inspection of the univariate analyses (see Table IIa) indicates only a significant difference in ADL between the groups: the non-immigrant caregivers were caring for elderly who were more limited in ADL (Eta2 ¼ 0.025). In addition, the MANOVA shows
a significant group by relationship type interaction (F (4, 412) ¼ 2.83, p ¼ 0.024, Eta2 ¼ 0.027). Univariate ANOVA (Table IIa) shows that only the interaction in cognitive status of the care recipient was statistically significant (Eta2 ¼ 0.023); non-immigrant spouses were caring for elderly who had less cognitive problems than did the immigrant spouses, while the non-immigrant adult child caregivers were caring for parents with more cognitive problems. Caregiving primary appraisal. For these variables, MANOVA yielded a significant main effect for immigration group (F (3, 413) ¼ 20.40, p50.001, Eta2 ¼ 0.129). Inspection of univariate analyses (Table IIb) indicates that this was accounted for by the differences in providing assistance with ADL (Eta2 ¼ 0.056) and with IADL (Eta2 ¼ 0.124): the non-immigrant caregivers provided less assistance with ADL or IADL. The MANOVA showed that there was also a significant main effect of relationship type (F (3, 413) ¼ 17.02, p50.001, Eta2 ¼ 0.110). Univariate ANOVA (Table IIb) indicates that this was accounted for mainly by the differences in intensity (Eta2 ¼ 0.107): spouses devoted many more hours to caregiving than adult children. In addition, the MANOVA yielded a significant group by relationship type interaction (F (3, 413) ¼ 4.68, p ¼ 0.003, Eta2 ¼ 0.033). Table IIb shows that this was accounted for by interactions in all the three measures; the non-immigrant adult child caregivers provided significantly less assistance than immigrant adult
Immigration, family caregiving, and psychological distress Table II.
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ANOVA results for caregiving stressors, appraisal, psychosocial resources and psychological distress. Spouse caregivers
(n)
Nonimmigrant (108)
Immigrant (66)
Adult child caregivers Nonimmigrant (105)
Immigrant (140)
p-value Group Relation
Group
Relation
(0.62) (0.91) (1.25) (0.50)
0.001 0.689 0.503 0.082
0.913 0.278 0.302 0.028
0.232 0.534 0.002 0.765
Mean Standard deviation a. Caregiving stressors CR ADL CR IADL CR Cognitive status CR Problem behavior (1 ¼ yes) b. Caregiving primary appraisal Intensity (1 ¼416 hours/week) Care provided for ADL – total Care provided for IADL – total c. Psychosocial resources Mastery Perceived support d. Caregiving secondary appraisal Role overload Role captivity Economic difficulties (1 ¼ yes) e. Psychological distress
1.21 4.79 1.31 0.35
(0.67) (0.63) (1.37) (0.48)
0.93 4.86 0.84 0.42
(0.60) (0.46) (1.14) (0.50)
1.14 4.75 1.05 0.45
(0.63) (0.71) (1.11) (0.50)
1.01 4.74 1.36 0.55
0.92 (0.28) 2.52 (0.89) 3.22 (0.67)
0.89 (0.31) 2.69 (0.95) 3.58 (0.71)
0.53 (0.50) 2.09 (0.84) 2.87 (0.81)
0.69 (0.47) 2.82 (0.91) 3.64 (0.72)
0.122 50.001 50.001
50.001 0.092 0.051
0.037 0.002 0.005
2.44 (0.57) 69.5 (22.5)
2.65 (0.60) 56.5 (26.2)
2.81 (0.61) 80.2 (22.5)
2.77 (0.56) 66.8 (24.3)
0.186 50.001
50.001 50.001
0.039 0.946
0.001 50.001 0.038 0.030
50.001 0.860 50.001 0.001
0.937 0.023 0.881 0.742
2.75 2.19 0.65 1.02
(0.91) (1.02) (0.48) (0.64)
3.05 1.63 0.76 1.16
(0.85) (0.75) (0.43) (0.66)
2.28 1.99 0.48 0.80
(0.86) (0.91) (0.50) (0.68)
2.60 1.85 0.58 0.96
(0.87) (0.89) (0.50) (0.67)
CR, Care recipient; ADL, Activities of daily living; IADL, Instrumental ADL; Significant p-values (in bold) are based on F-test, Degrees of Freedom ¼ 1,415; aHigher scores of continuous variables represent higher level of each measure. Range: ADL, 0–2.2; IADL, 0–5; Cognitive status, 0–4; Caregiving primary and secondary appraisal, Mastery, 1–4; Social support, 0–100; Psychological distress, 0–4.
child caregivers while the differences between nonimmigrant and immigrant spouses were negligible. Psychosocial resources. The MANOVA yielded a significant main effect for immigration group (F (2, 414) ¼ 18.52, p50.001, Eta2 ¼ 0.081). Inspection of univariate analyses (Table IIc) indicates that this was accounted for by the differences in social support (Eta2 ¼ 0.067): the non-immigrant caregivers reported higher levels of social support than the immigrants. The MANOVA showed also a significant main effect of relationship type (F (2, 414) ¼ 14.68, p50.001, Eta2 ¼ 0.066), that was accounted for by differences in both mastery and social support (see Table IIc): spouses reported lower levels of mastery and of social support than did caregivers for their parents. The MANOVA showed a non-significant group by relationship type interaction (F (2, 414) ¼ 2.21, p ¼ 0.111). Caregiving secondary appraisal. The MANOVA yielded a significant main effect for immigration group (F (3, 411) ¼ 15.85, p50.001, Eta2 ¼ 0.104), accounted for by the differences in all the three measures, as revealed by the ANOVA (Table IId): the non-immigrant caregivers reported lower levels of role overload (Eta2 ¼ 0.028), and economic difficulties (Eta2 ¼ 0.010), but higher role captivity (Eta2 ¼ 0.033) than the immigrants. The MANOVA showed also a significant main effect of relationship type (F (3, 411) ¼ 13.13, p50.001, Eta2 ¼ 0.087), that was accounted for by differences in role overload (Eta2 ¼ 0.060) and economic difficulties (Eta2 ¼ 0.030): the spouses reported
higher levels than adult child caregivers. In addition, MANOVA showed a non-significant group by relationship type interaction (F (3, 411) ¼ 2.07, p ¼ 0.103). Psychological distress. The ANOVA showed significant main effects of group (Eta2 ¼ 0.011) and of relationship type (Eta2 ¼ 0.025) but no significant interaction (Table IIe). The non-immigrant caregivers had significantly lower levels of distress than immigrants, and spouses were more distressed than adult children. Multivariate analysis Hierarchical multivariate regression was used to examine the independent associations of group affiliation and relationship type with psychological distress once other factors in the conceptual model of the study are included. In order to decrease the number of variables in the analysis, variables that were not significantly different by immigration status or relationship type and were not associated with distress (IADL, care recipient’s cognitive status) were excluded. Secondly, based on intercorrelations of the variables within each block, variables highly correlated with one or two other variables were not retained. The excluded variables were caregiver’s self-rated health, caregiving intensity and care provided for IADL. Two sociodemographic variables, education and income, were used to control for significant differences between the two immigration groups. Age was excluded because of its association with relationship type.
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V. Soskolne et al. Table III. Standardized regression coefficients ( ) in hierarchical regression analysis of psychological distress. Variablea Group: Immigrants Relationship: Adult child Background variables Education Income: 5IS4500 A longstanding illness: yes Caregiving stressors ADL CR Problem behavior: yes Caregiving primary appraisal Assistance with ADL Psychosocial resources Mastery Social support Caregiving secondary appraisal Role overload Role captivity Economic difficulties (1 ¼ yes) R2 F df R2 change
Step 1
Step 2
Step 3
Step 4
0.05 0.07
0.01 0.05
0.02 0.02
0.02 0.01
0.14* 0.11* 0.15**
0.13* 0.10* 0.15**
0.06 0.03 0.12**
0.02 0.01 0.11*
0.08 0.22***
0.09 0.20***
0.10 0.16***
0.14*
0.13*
0.01 0.23***
0.13 8.17*** 7,397
0.14 7.84*** 8,396 0.01*
0.11
0.40*** 0.05
0.34*** 0.02
0.29 16.07*** 10,394 0.15***
0.11* 0.14** 0.13** 0.34 15.78*** 13,391 0.05***
CR, Care recipient; aFor continuous variables: higher scores indicate a higher level of the measure; *p 0.05; **p 0.01; ***p 0.001.
The differences in psychological distress by group affiliation and by relationship type (as shown in the univariate analysis) disappeared once background variables and caregiving stressors were included in the first step. Of the caregiving stressors, only the existence of the care recipient’s problem behavior was significantly associated with psychological distress, suggesting that this, together with education, income and caregiver’s health explained much of the effect of immigration status or relationship type. In step two, caregiving primary appraisal (help provided for ADL) contributed only one percent but was significantly associated with distress. In step three, psychosocial resources had the largest contribution to the variance (15%), yet only mastery was significantly associated with distress. In step four, all three secondary appraisal factors were significantly associated with psychological distress, contributing additional 5% to the final 34% of explained variance The association of caregiving primary appraisal with psychological distress became non-significant (see Table III). In an additional step (data not shown), none of the interaction terms of group affiliation or relationship type with these variables was found to be significant. The interaction of group affiliation with social support was of borderline significance (beta ¼ 0.224, p ¼ 0.075), however, bivariate examination of the source of the interaction showed that social support was significantly and inversely associated with distress among the non-immigrants but the association was nonsignificant among the immigrants. The final model shows that, controlling for the significant effect of physical health status, psychological distress was
significantly higher in the presence of the care recipient’s problem behaviors, among those with lower mastery, and those who reported higher role overload, role captivity and economic problems due to caregiving.
Discussion The major findings of the current study show that: (a) immigrant and non-immigrant caregivers have different caregiving patterns, expressed in significant differences in caregiving primary and secondary appraisal variables and in resources; (b) there are differences by relationship type; (c) the differences between non-immigrant and immigrant caregivers in primary appraisal vary by relationship type; and (d) the differences in psychological distress by immigration status and by relationship type were fully explained by caregiving stressors, resources and caregiving appraisal. The associations of these variables with caregivers’ psychological distress are similar across immigration status and relationship type as suggested by the final finding, the nonsignificant interactions of group affiliation or relationship type with stressors, resources and appraisal. These findings support those who assert that socio-cultural background (Aranda & Knight, 1997) and role relationship (Montgomery & Williams, 2001) shape unique caregiving contexts that determine how care is provided and perceived (primary and secondary appraisal), and the available psychosocial resources.
Immigration, family caregiving, and psychological distress The bivariate analyses of the differences by immigration status and relationship type highlighted the context of caregiving in more detail. While there were hardly any differences in the care recipients’ status, immigrant caregivers provided significantly greater assistance (primary appraisal), reflecting their socioeconomic conditions, and, probably, a strong cultural norm that the family should carry out the bulk of eldercare noted in previous studies (Remennick, 2001; Slonim-Nevo, Cwikel, Lusky, Lankry, & Shraga, 1995). This caregiving context, together with the lower social support of the immigrants that might be due to restricted social networks (Litwin, 1995; Soskolne, 2001), was further expressed in secondary appraisal—higher role overload, role captivity and economic difficulties. Consistent with previous findings (Li et al., 1997; Yates et al., 1999), several caregiving appraisal variables and psychosocial resources differed significantly by relationship type. Although the generation gap may explain these findings (Montgomery & Williams, 2001), in the current study, the significant interaction effects of immigration group by relationship type in all the primary appraisal measures, suggest that relationship type accounts for caregiving variability within cultural populations (Aranda & Knight, 1997). The social conditions force greater provision of caregiving activities upon immigrant adult caregivers of their parents (Remennick, 2001) than upon immigrant spouses, while no such differences were observed among the non-immigrant caregivers, making them the group with the highest caregiving duties. Yet, this vulnerability was not expressed in a higher secondary appraisal; they were similarly different from non-immigrant caregivers as were the spouses. Although the higher level of psychological distress among the immigrant caregivers is consistent with previous studies of immigrants from the FSU (Ritsner & Ponizovsky, 1999; Zilber & Lerner, 1996), belonging to the immigration group had no independent significant contribution to psychological distress. While these findings are consistent with studies showing that caregiving stressors, cognitive appraisal and psychosocial resources mediate the cultural or ethnic differences in psychological health (e.g., Haley et al., 1996; Knight et al., 2000; Patterson et al., 1998; Young & Kahana, 1995), they contradict several others that found an independent association of ethnicity (race) with distress (Farran et al., 1997; Lawton et al., 1992; Miller et al., 1995). These variables also mediated the difference in psychological distress by relationship type, similar to Yates et al. (1999) who found that relationship status was associated with primary appraisal (the intensity of care), but not directly with depression. Care recipient’s behavioral problems, being the only caregiving stressor related to distress, is congruent with previous cross-cultural caregiving research, not only in those of Alzheimer caregivers
11
(Haley et al., 1996; Knight et al., 2000), but also in those that were not restricted to caregivers to elderly with dementia (Bookwala & Schulz, 1998). Because the presence of behavioral problems is a common phenomenon among care recipients suffering from dementia, this finding may indicate that the impact is due, at least in part, to caregiving to people with dementia, rather than to disabled care recipients. These behaviors make caregivers feel helpless, and upset them more than physical and cognitive impairment of the care recipient (Pinquart & So¨rensen, 2003). Their effect on psychological distress was not attenuated even when mastery, the only, but highly significant resource related to distress, was included, suggesting that even though greater mastery is the most important factor in reducing distress, as in prior studies (e.g., Yates et al., 1999), it is not sufficient to offset the impact of the care recipient’s behavioral problems on psychological health. The finding that social support was not associated with distress, contradicting prior evidence of its role on caregiver’s health outcomes in the model by Yates et al. (1999) and in cultural comparisons (e.g., Haley et al., 1996; Patterson et al., 1998), is perplexing. Possibly, the significant bivariate differences in social support between the two cultural groups were less important than the effects of the other determinants of distress. Our finding, indicating that the association of social support with distress was non-significant among the immigrants, while it was significant among the non-immigrants may have another explanation. Findings from a prior study also showed that supportive relations were not associated with self-rated health among elderly immigrants from the FSU (Carmel, 2001). In light of their restricted social networks (Litwin, 1995) the role of social support may be different in this unique group of immigrants. Caregiving secondary appraisal measures mediated the association of caregiving primary appraisal (amount of assistance with ADL), with distress suggesting, as elsewhere (Lawton et al., 1992; Yates et al., 1999), that the amount of caregiving tasks is less important to psychological health outcomes than the secondary, negative appraisal of the caregiving role. The additional secondary appraisal measure—economic difficulties resulting from caregiving—implies that the spillover of caregiving to other life-domains contributes to higher distress (Stephens, Townsend, Martire, & Druley, 2001). Together with the association of the mastery resource, these associations support the model by Yates et al., (1999) that served as the conceptual framework for the current study, and provide further evidence for the conclusion that cultural context determines caregiving outcome via its effect on the other variables in the model (Young & Kahana, 1995). When these are considered, group affiliation is no longer significant. Finally, it is
12
V. Soskolne et al.
important to note that the current findings are consistent with those reported recently in a study that included only Alzheimer’s caregivers; despite significant differences in resources and stressors, the predictors of depression were relatively uniform across ethnic groups (So¨rensen & Pinquart, 2005). The methodology of the current study poses several limitations. The selection of participants from one metropolitan area in Israel and only through formal services limits representativeness. The current analysis did not allow for additional exploration of within-group differences, such as by region of origin in the FSU among the immigrant caregivers or by religiosity among the nonimmigrants. Since non-caregivers are not included in the current study, the differences between the groups may reflect general differences between the immigrant and the non-immigrant populations or immigration stress. However, we believe that the differences represent different socio-cultural context of caregiving rather than immigration stress; since the majority of the immigrant caregivers had already been living in Israel for eight to ten years they were probably more acculturated, and their mean psychological distress level was lower than that reported for more recent (55 years) immigrants (Ritsner & Ponizovsky, 1999). Finally, the crosssectional design of the study limits conclusions about causality. Despite these limitations, this study adds important new information on the caregiving stress process in these two distinct populations in Israel and contributes to the literature on socio-cultural differences in caregiving. The study population was not limited to dementia caregivers, thus allowing for greater generalization to all caregivers, and the samples of the two groups were larger than in many of the previous studies. The study presents a comparison in a multi-cultural, multi-ethnic society but is not based on racial differences, responding to the need for cultural comparisons within less heterogeneous populations (Dilworth-Anderson et al., 2002) or other rarely studied populations. Several important implications may arise from these findings. Although the structure and values of Jewish families in Israel remain relatively traditional and the majority of families still prefer to care for the disabled or ill elderly at home (Brodsky, 1998), further refined understanding of the sociocultural context in which family caregiving is provided and the impact on mental health of the caregivers is needed. The heavier caregiving burden and more limited resources of the immigrant caregivers might effect their functioning as caregivers for an extended period of time. The current findings imply that interventions should primarily target the caregivers of care recipients with problem behaviors, and find ways to assist the immigrant caregivers, particularly adult children, in reducing their
caregiving burden and feeling of role captivity, in order to alleviate psychological distress.
Acknowledgements The study was funded by the Chief Scientist Office, Israel Ministry of Health (# 4745). We thank the staff of the home-care units of Maccabi, Meuhedet, Leumit and Clalit Health Services, and of the Geriatric Unit, Hospice Home Care Unit and the Retired Personnel Services of Hadassah University Hospitals for their assistance.
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