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Abstract:
Introduction: The purpose of this study
was to examine the relationship between self-efficacy
and caregiver strain in family caregivers of
persons with Alzheimer's disease.
Methodology:
A descriptive, correlational research design
was used, and a convenience sample of 81 caregivers
was surveyed. Descriptive statistics were used
to examine selected caregiver demographics.
Statistical analysis included bivariate correlations
using the Pearson product-moment coefficient
correlation. The study's research question was
as follows: What is the relationship between
self-efficacy and caregiver strain? It was hypothesized
that there would be an inverse relationship
between the two variables
Results:
A statistically significance inverse relationship
(R = -0.539, P =0.01) was found to exist between
the variables, thereby supporting the study's
hypothesis.
Conclusion:
Findings implicate the need for further investigation
and development of supportive relevant caregiver
intervention strategies.
Key words: caregiver self efficacy,
caregiver strain, Alzheimer's
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Introduction
During the 20th century
the proportion of older persons continued to rise,
and this trend is expected to continue into the 21st
century. For example, the proportion of older persons
was 8% in 1950 and 10% in 2000, and is projected to
reach 21% in 2050[1].
60% of this number would
live in developing countries and unfortunately these
societies are not prepared to encounter the ageing
phenomenon and its social, economic and medical consequences.
Statistics show Iranian older persons numbered 6.6%
in 1996 and 7.8% in 2000 and is projected to reach
10% in 2020[2].
In recent decades there
has been increasing focus on the situation of family
members. It can be assumed that the responsibility
of family members to care for their sick relatives
will increase in the future[3].
In Iran, dutifulness
to parents and grand parents and extending kind and
respectful treatment to older people in general are
among the basic values. Because of this, most elderly
people continue to enjoy home care, within their family
homes[4]. Care giving research within the
context of Alzheimer's disease (AD) has emerged as
a major focus of empirical investigation. This focal
attention is explained by growth of the aged population,
the increasing incidence of dementia with age, and
the emphasis on community versus institutional care.
By the middle of this century, the number of persons
with AD could range from 11.3 million to 16 million[5].
In the early 1980s,
the term "family caregiver" began to be
used to describe family members who were caring for
an elderly person in their family home. Family care
giving has come to the forefront for two major reasons:
increasing number of persons who live longer and who
have chronic illness for a longer period of time;
and changes in the health care delivery systems[6].
Research findings have consistently confirmed that
caring for a family member with Alzheimer's dementia
(AD), is fraught with stress and often results in
tremendous strain among caregivers.
Caregiver strain, the
most widely studied caregiver outcome, is conceptualized
as the physical, emotional, social, and financial
hardships experienced by family members in providing
care to persons with AD. Although a plethora of care
giving research exists, empirical data related to
the spiritual dimension of AD care giving and care
giving outcomes, namely caregiver strain, are scant.
Family caregiver's burden can be classified as subjective
and objective. Objective burden relates to disruptions
in family life caused by the patient's illness, activity
restrictions, time spent on types of assistance and
tasks, and financial resources expended. Subjective
burden patients to the amount of felt strain experienced
by the family member in areas such as emotional status,
financial and work domains [7].
Self efficacy has been
conceptualized as a person's belief about her or his
ability to organize and execute courses of action
to manage given situations. Self efficacy beliefs
have diverse effects on physiologic functioning: they
(a) determine whether coping behaviors will be initiated,
how much effort will be expended and how long effort
will be sustained in the face of obstacles and adverse
experiences, and (b) affect vulnerability to emotional
distress and depression. The self efficacy model has
been widely used in research on chronic stress and
coping, this construct has recently been applied to
help explain the experiences of family caregivers
of persons with dementia [8-9].
The purpose of this
study was to examine the relationship between self-efficacy
and caregiver strain. The following research question
was addressed: What is the relationship between self-efficacy
and perceived caregiver strain? The study's hypothesis
was as follows: There will be an inverse relationship
between self-efficacy and caregiver strain.
Materials and methods
Using a cross-sectional correlational
research design, this study examined the relationship
between self-efficacy and caregiver strain in family
caregivers of persons with AD. Approval was obtained
from the University of Social Welfare and Rehabilitation
Sciences (USWR) and Iranian research center on aging
(IRCA). Permission to include participants was granted
by the Iranian Alzheimer's Association as an active
non-governmental organization.
The convenience sample consisted
of 81 participants meeting the following inclusion
criteria: 1) able to speak Persian; 2) had assumed
the caregiver role for at least 6 months; 3) at least
18 years of age; 4) being the primary person providing
care for a community-dwelling, non-institutionalized
relative diagnosed with AD or a related disorder;
and 5) family member of care recipients. Primary family
caregivers were identified as relatives (non-professional,
informal, unpaid) who were most responsible for the
day-to-day decision-making and care of the impaired
family member or care recipient.
Participants were included
from the Iranian Alzheimer's Association. A questionnaire
containing a consent form, and research instruments
was distributed directly to each person who consented
to participate in the study and who met sample criteria.
Participants were asked to read and sign the consent
form, complete the questionnaires, and return them
directly. Questionnaires were completed by the researcher
for illiterate persons, by structured interview based
on items from the questionnaire. To protect anonymity
of participants and for data analysis purposes, research
instruments were number coded.
Three instruments were used
to collect data: a demographic questionnaire, the
Self-efficacy Scale (SS), and the Strain index (SI)[10].
The demographic questionnaire, developed by the researcher,
provided information about the caregiver such as sex,
age, educational background, length of time in the
care giving role, marital status, employment status,
relationship to care recipient, and satisfaction from
care giving received family care giving education,
perceived about her/his own health.
In this study, the (SS) was
used to measure the caregiver's perception of self-efficacy.
SS was developed by a researcher based on Steffen
et. al. (2002), and modified by experts' ideas in
gerontology and geriatric areas, with cultural considerations.
This instrument measures self-efficacy as a complex,
multidimensional concept. The instrument comprises
21 Likert items, scored from 1 to 5 points. Responses
range from strongly agree to strongly disagree.
The scale consists of positively
and negatively worded items designed to minimize response
set biases. Total scores are obtained by summing across
all items on the scale. SS scores can range from 21
to 105. Another instrument was strain index (SI),
which had been developed by Robinson[11].
The instrument comprises 13 Likert items, scored from
1 to 5 points.
Responses range from strongly
agree to strongly disagree. SI scores can range from
13 to 65. Test-retest procedures have been performed
to determine reliability of instruments, resulting
in reliability coefficients for SS as 0.78 and SI
as 0.74. Content validity was assessed by experts'
ideas.
Results
Data analysis was conducted
using Statistical Package for the Social Science (SPSS)
for Windows version 10. Descriptive statistics were
used to examine specific caregiver demographics. Frequency,
percentage, mean, standard deviation, range, cross-tabulation,
were used to analyze descriptive statistics. Pearson
product-moment correlation was used to test for linear
bivariate relationships. The independent t test was
used to determine whether significant differences
existed between self-efficacy and caregiver strain
mean scores of different groups.
The sample was predominately
female (74.1%), married (79%), spouse of elder (69.1%),
under high school (48.1%), unemployed (67.9%), living
with elder patient at the same home (64.2%), without
education on home caring for patient (55.6%), satisfied
from care giving (65.4%), bad rating on self-perceived
global health (44.4%), perceived emotional distress
(43.2%), need for care-giving education at home (30.9%).
Mean and standard deviation
of caregiver's age (M= 53.41, SD=8.46) and duration
of care giving (year) (M=6.98 , SD=2.85), and average
time of caring per day (hour) (M = 6.9, SD = 5.49)
were computed to provide other descriptive information.
The profile of the caregiver's
characteristics by race is presented in Table 1.
Table 1: Demographic
Characteristics of caregivers (N = 81)
|
Variable |
N |
% |
Sex
Female
Male |
60
21 |
74.1
25.9 |
Marital
status
Married
Not married |
64
17 |
79.00
21.00 |
Education
<
High school
High
school
.>High
school |
49
25
7 |
60.5
30.9
8.6 |
Employment
Employed
Not
employed |
26
55 |
32.1
67.9 |
Relationship
to care recipient
Reside in same household
Reside in different household |
52
29 |
64.2
35.8 |
Satisfaction from care giving
Yes
No |
53
28 |
65.4
34.6 |
Received family care giving education
Yes
No |
36
45 |
44.4
55.6 |
Perceived about her/himself health
Good
Moderate
Bad
|
13
32
36 |
16.00
39.5
44.5 |
The independent t test
didn't determine significant differences between scores
of groups based on sex, employment, marriage, relationship
to care recipient, satisfaction from care giving,
and received family care giving education in self-efficacy
and caregiver strain. On the other hand, there were
significant negative relationships between SS and
CS with duration of care giving (month), and positive
relation with age of caregivers and average time of
caring per day.
The study sample revealed
a mild to moderate level of strain (M = 39.43, SD=13.97),
with scores ranging from 17 to 65, and almost high
level of self-efficacy (M = 66.96, SD = 27.02), with
scores ranging from29 to 106.
Pearson product-moment coefficient
of correlation (Pearson r) was used to examine the
relationship between self-efficacy and caregiver strain
and to test the hypothesis that suggested an inverse
relationship between the 2 concepts. Selection of
this measure was appropriate because it provided the
following information about the data: the nature of
the linear relationship (positive or negative) between
the 2 variables and information concerning the strength
or magnitude of the linear relationship. An alpha
level of .05 was selected as the level of significance.
A statistically significant negative or inverse relationship
(r = -0. 53, P = .01) was found to exist between the
self-efficacy and caregiver strain, thereby supporting
the study's hypothesis that self-efficacy reduced
caregiver strain (Table 2).
Table 2: Pearson
Product-Moment Correlation Coefficients for self efficacy
(SS) and Caregiver strain (CS) (N = 81)
|
Study variables |
ss |
cs |
|
SS |
1.00 |
-0.539 |
|
CS |
-0.539 |
1.00 |
P=0.01
Conclusion
The predominately female sample
in this study is consistent with trends in AD care
giving indicating that caregivers overwhelmingly tend
to be women. The longer average life span for women,
demographics of the aging population, and societal
role expectations of women all contribute to these
findings. Most of the caregivers were spouse of care
recipient, and it is predictable that these caregivers
are almost elders, and they are at risk of care giving
stress.
Most of them were educated,
but they didn't receive any education related to care
giving to their elder care recipients, and they reported
educational needs to asssist in taking care of their
relatives. Although most believed their health wasn't
at a good level, they were satisfied by caregiving.
These findings are corroborated by prior studies that
have examined differences in demographic characteristics
between dementia caregivers [12].
This study sought to address
a gap in the research literature on self-efficacy
and caregiver strain in family caregivers of persons
with AD. Caregivers reporting higher mean scores on
the SS scale reported lower mean scores on the strain
scale, reflective of their perception of the caregiver
experience as being less strain.
The high overall mean score
obtained on the SS may be reflective of the importance
of spirituality, cultural ideas and specialty Islamic
beliefs in the lives of caregivers participating in
this study. These ideas may offer them a coping strategy
for responding to stressful situations such as caring
for a family member with AD.
This finding is supported
by prior research done by such as Porter et al [13];
their findings revealed that there is not only a moderate
level of self efficacy and caregiver strain in cancer
patient caregivers, but also there was a negative
association between caregiver self efficacy and caregiver
strain for helping cancer patients manage pain. It
has also been reported that there were no significant
relationships between caregivers' characteristics
and self efficacy and strain.
The need to identify variables
that may lessen the degree of caregiver strain is
greatly needed. Findings from this investigation present
a preliminary understanding of the importance of an
holistic approach, especially spirituality in Moslem
Iranian caregivers in the care giving process and
its impact on care giving outcomes, and serves as
a precursor to the development of more specialized
holistic nursing assessments and culturally relevant
caregiver intervention strategies. Yet as a resource,
spirituality is often overlooked.
Limitations to this study
include use of a convenience sample. Therefore, generalizing
is limited pending further studies. Longitudinal studies
that examine spirituality and caregiver outcomes over
the trajectory of the care giving experience are further
indicated.
Taken as a whole, the ageing
of the population is a global phenomenon that demands
international, national, regional and local action.
Any plan of action on ageing and health care for older
persons should be built upon not only on the older
person, but also on family and community to provide
the basis for secure ageing.With increasing numbers
of elderly persons today, countries are recommended
to review current national policies and strategies
regarding the comprehensive care of older persons,
and support and education of family caregivers of
older people, and promote the retention of appropriate
traditional care, and positive social and cultural
values.
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