Religiosity and the expansion of caregiver stress.

We present a stress process framework as a model for understanding how religiosity may influence the expansion of stress. Survey data from informal caregivers to a spouse with Alzheimer's disease or a related dementia (n = 200) were analyzed to observe the relationships among three variables: (1) care-related stress, (2) religiosity, and (3) depression. This sample, which has a mean age of 73 years, demonstrates high rates of self-described religiosity, church attendance and frequency of prayer. Using these criteria, women and racial/ethnic minority caregivers are the most religious. In a series of multivariate analyses, we found strong evidence to suggest that there is an expansion of care-related stressors leading to depression in this sample. Religiosity, as measured here, appears to be largely unrelated to stress and stress expansion. We found no evidence to suggest that it moderates stress expansion. However, these data do suggest that one stressor--feelings of role overload--is correlated with greater levels of self-perceived religiosity, which among caregivers who have health problems of their own is associated with greater depressive symptomatology. Thus, for a sub-sample of these caregivers, we find weak evidence of a mediation effect wherein one subjective, non-organizational dimension of religiosity is a conduit of the harmful effects of stress (rather than a suppressor). Results and data limitations are discussed in relation to better assessing the role of religiosity and spirituality in the experience of the stress process.

Family involvement in nursing homes: effects on stress and well-being.

While it is clear that families remain involved in the lives of loved ones following placement in a nursing home, little research has examined whether visiting and the provision of care has effects on the emotional stress and psychological well-being of family members. Utilizing pre-placement and post-placement data from the Caregiver Stress and Coping Study (n = 185) as well as a theoretical framework to delineate the manifestation of caregiver stress (i.e., the stress process model), the goal of this analysis was to determine whether frequency of visits and provision of personal and instrumental activities of daily living assistance following institutionalization were related to post-placement emotional distress, family conflict, and psychological well-being among family members. Following control of a wide array of pre-placement and post-placement covariates, multiple regression models found that visiting was negatively associated with post-placement role overload; moreover, the provision of instrumental activities of daily living help was negatively related to loss of intimate exchange at post-placement. The results suggest that family involvement following institutionalization may operate differently than when in the community, and add to the literature emphasizing the positive implications of family involvement in residential long-term care.

Relinquishing in-home dementia care: difficulties and perceived helpfulness during the nursing home transition.

Institutionalization of an elderly relative suffering from dementia is a key transition in the caregiving career. This study determines factors that predict the problems and help dementia caregivers perceive while institutionalizing an elderly relative. By using a sample of 185 dementia caregivers interviewed before and after institutionalization, the authors conducted a multivariate regression to identify relevant predictors of search difficulties, professional help, and family help during the nursing home transition. The personal and social resources of caregivers prior to placement (e.g., mastery, family conflict, socioemotional support, duration of care, education, and physical health) were reliable predictors of search difficulties and perceived helpfulness. Such findings will prove useful to long-term care practitioners who wish to facilitate the institutionalization process for caregiving families.

Modeling caregiver adaptation over time: the longitudinal impact of behavior problems.

Although cross-sectional research has established the link between care demands and various indicators of caregiver adaptation, few studies have examined the impact of care recipients' problematic behavior over time. The present analysis determines the importance of behavior problems when predicting rates of change in subjective stressors (role overload and role captivity) and depression. Using 4-wave longitudinal data (N = 137) on dementia caregivers, the authors fit individual growth curve models for care demands (i.e., behavior problems, activities of daily living dependencies, and cognitive impairment), subjective stressors, and depression. Subsequent structural equation models found that increases in behavior problems were most likely to predict increases in role overload. The findings emphasize the deleterious long-term impact of behavior problems on individuals' emotional adaptation to caregiving.

The transition from home to nursing home mortality among people with dementia.

OBJECTIVES: This article examines the impact of nursing home admission on mortality among persons with dementia, comparing social selection and social causation explanations of excess deaths occurring immediately after relocation. METHODS: Data from a multiwave panel survey of caregivers to persons with Alzheimer's Disease (N = 555) are analyzed with proportional hazard models of time from illness onset to death of the care recipient and, for those admitted to a nursing home (N = 272), time from admission until death (N = 272). RESULTS: Relocation is associated with a two-fold increase in mortality risk net of health status. Social selection effects were found for poor health, advanced age, being male, and being White. Patients admitted for reasons other than poor health also experienced elevated mortality immediately following admission, which is inconsistent with a social selection interpretation. However, none of the specific indicators of stressful admission or unsatisfactory nursing home conditions are significantly related to mortality. DISCUSSION: These data demonstrate selection processes for postadmission mortality, but indicate that the admission of patients in poor health may not fully account for the elevation in mortality that occurs immediately following admission.

Caregiving and institutionalization: perceptions of family conflict and socioemotional support.

This study examines the impact of family conflict and socioemotional support among caregivers who institutionize their relatives. Fifty-two wives, forty-three husbands, and sixty-seven daughters were interviewed before and after the placement of a cognitively impaired relative. A repeated measures ANOVA was performed to examine differences in reports of family conflict and socioemotional support among caregivers. Husbands reported greater increases in family conflict than wives or daughters during the institutionization process. Conversely, wives and daughters indicated higher levels of socioemotional support than husbands. Hierarchical regression equations were then calculated to assess the independent contributions of family conflict and socioemotional support to postplacement adaptation. Decreases in socioemotional support during institutionalization significantly predicted postplacement anger among husbands and increases in family conflict significantly predicted postplacement depression among wives. Overall, family conflict and socioemotional support have important implications among caregivers who institutionalize their relatives.

Sources and determinants of social support for caregivers of persons with AIDS.

This study examines the determinants of social support among a sample of 642 caregivers of persons with AIDS living in San Francisco and Los Angeles. Respondents include both traditional family caregivers (mothers, spouses, other relatives) and non-traditional caregivers (friends, homosexual partners). Multiple regression analyses are conducted to assess the independent effects of six sets of variables on emotional and instrumental support: social-structural factors (age, education, employment status), caregiver's relationship to the person with AIDS, situational variables (caregiver's HIV status, patient's functional disability, interpersonal conflict), social network factors (contact with family, contact with friends, community integration), personal resources (mastery, caregiving competence), and use of formal community services (patient-directed services, caregiver-directed services). A number of factors and conditions appear to be relevant for caregiver support. For example, results indicate that network factors, including frequency of contact, conflict, and community integration, are importantly related to caregivers' perceptions of emotional support. There is also a trend suggesting lower emotional support among traditional family caregivers, relative to nonfamily caregivers, within gender categories. With respect to instrumental assistance with caregiving, factors that place greater demands and time constraints on caregivers, such as being employed and caring for an AIDS patient with greater functional limitations, appear to increase the level of informal instrumental support the caregiver receives. Partners and spouses, however, receive significantly lower instrumental assistance, independent of other factors. Implications of the findings are discussed.

The forms and mechanisms of stress proliferation: the case of AIDS caregivers.

Processes of stress proliferation are explored in a sample of informal caregivers to people with AIDS. Proliferation refers to the tendency for stressors to beget stressors. Two forms of proliferation are explored, each based on the distinction between primary and secondary stressors. Among AIDS caregivers, primary stressors are the hardships rooted in the caregiving role. Secondary stressors result from primary stressors, but arise in roles and activities outside of caregiving. One form of proliferation is the expansion of primary stressors, reflected in an increase in role overload and a growing sense of being a captive of the caregiver role. Expansion is largely driven by the course of AIDS and the elevation of demands it places on the caregiver. The second form of proliferation is the surfacing of secondary stressors in social and leisure life and in the occupational realm. This form arises from the strains imposed by the emerging caregiver role on the other roles and activities of the caregiver. It is proposed that the systematic assessment of proliferated stressors can help illuminate the dynamic connections between stress and health.

Transitions in the caregiving career: effects on sense of mastery.

Although a sense of mastery is usually treated as a stable personal resource that can moderate the effects of stress on well-being, in this article we are interested in mastery as an outcome, examining the impact of transitions in the careers of Alzheimer's caregivers on their sense of mastery. Using longitudinal data collected from 456 spouses and adult children caring for a family member with Alzheimer's disease, we found that for those who continue to care for their relative, mastery declines; for those who place their relative in a care facility, mastery remains unchanged; and for those who experience the death of their relative, mastery increases. A series of regression analyses revealed different patterns of predictors of change in mastery over time and across transitions.

Stress and the life course: a paradigmatic alliance.

Research both into the stress process and into the life course is concerned with changing lives. Yet, the conceptual paradigms that guide the work of these two fields are largely segregated, borrowing little from each other. This article explores some of the junctures at which the study of social stress might benefit from life-course perspectives and, conversely, those at which life-course research might profitably employ the vantage points of stress research. In the first case, an awareness of life-course trajectories can sensitize stress researchers to the restructuring of lives across time, particularly to the shifting landscape of stressors to which people are exposed and changes in their access to resources in dealing with the stressors. For its part, stress research may be useful in clarifying some basic life-course constructs. Thus, it can direct attention to conditions that help to define the experiential distinctiveness of historical cohorts and to conditions that produce intracohort variations. It is also useful in providing an interpretive framework for understanding how the timing and sequencing of transitional events impact people's lives. The perspectives of the stress process, finally, are also relevant to the critical appraisal of the constructs of life satisfaction and successful aging.

Stress, role captivity, and the cessation of caregiving.

Difficulties experienced when caring for an impaired elderly relative, including decisions to place this person in institutional care, are examined as a function of caregiver stress. Three annual interviews were conducted with 555 caregivers to parents or spouses with Alzheimer's Disease. All patients were initially cared for at home, but 192 were subsequently placed in institutional care and 146 died. Background-contextual factors and disease characteristics have only limited associations with institutionalization. Two secondary stressors--consequences of caregiving that do not directly involve care-related tasks--exert the most proximal impact upon placement: role captivity and economic strain. Role captivity is stable over time when in-home care continues, but institutionalization alleviates this sentiment. The odds of patient death increase substantially following institutionalization, even when health status is controlled. These results illustrate that in-home care may be beneficial for care-recipients, but increase role-related stress for the care provider.

Caregiving: role engulfment and the loss of self.

"Loss of self" was examined in a sample of spouses and adult children caring for a relative with Alzheimer's disease. Defined as a loss of identity that comes about as a result of engulfment in the caregiver role, it was found to be more common among spouses, females, and younger caregivers. Limited social contact and lack of social roles outside that of caregiver were found to be related to greater loss of self. It is associated with lower self-esteem and mastery and with greater depressive symptomatology.

Structure and meaning in medical sociology.

The point of all this, one made by others as well (e.g., Cook and Reichhardt 1979), is to emphasize the potential for a synergistic exchange between structuralists who do surveys and meaning-oriented workers who do qualitative work. The ways in which survey researchers come to understand the social worlds of people can and should be influenced by the ways in which people understand and interpret their own worlds. Correspondingly, our efforts to capture the social life of people through their eyes can be advanced by an understanding of the structures in which their lives are embedded and the effects of these structures. Each orientation benefits from drawing on the other. In this way, sociology is the ultimate beneficiary. I see nothing to be gained from intellectual antagonism and the distancing of one side from the other. I do not claim that there is more similarity and less difference between the two than meets the eye. The substance of interests and the styles of inquiry are really quite different. That's as it should be. Indeed, their differences permit each to give something to the other. Both should be nurtured and developed. However, in the training of new medical sociologists and in the research of old ones, we should have enough appreciation and knowledge of both orientations so that even if we are planted firmly in one, we are at least prepared to dip into the other. Those searching for structural effects and those searching for meaning are potentially natural partners, a relationship much superior to being unnatural antagonists.

Caregiving and the stress process: an overview of concepts and their measures.

This paper views caregiver stress as a consequence of a process comprising a number of interrelated conditions, including the socioeconomic characteristics and resources of caregivers and the primary and secondary stressors to which they are exposed. Primary stressors are hardships and problems anchored directly in caregiving. Secondary stressors fall into two categories: the strains experienced in roles and activities outside of caregiving, and intrapsychic strains, involving the diminishment of self-concepts. Coping and social support can potentially intervene at multiple points along the stress process.

The sociological study of stress.

This paper presents a critical overview of current concepts and analytic practices in stress research and considers how they can be changed to make the research more consistent with core sociological interests. An overarching concern of the paper is the analytic use of basic information about people's social and institutional affiliations and statuses. It is important that such information be treated not simply as data that need to be controlled statistically; we must examine the bearing of these data on each domain of the stress process: the exposure to and meaning of stressors, access to stress mediators, and the psychological, physical, and behavioral manifestations of stress. The conceptualization and measurement of stressors should move away from their focus on particular events or chronic strains and should seek instead to observe and assess over time constellations of stressors made up of both events and strains. Moreover, the effects of the mediators--coping and social support--are evaluated most fruitfully in terms of their effects in limiting the number, severity, and diffusion of stressors in these constellations. Finally, sociological stress researchers should not be bound to outcomes that better serve the intellectual interests of those who work with biomedical and epidemiological models of stress, nor should the research be committed exclusively to a single outcome.

Stress of AIDS caregiving: a preliminary overview of the issues.

This paper describes the stressors experienced by lovers and friends who were caregivers to AIDS patients and the social supports and coping strategies they drew on in efforts to mediate stress. From exploratory, intensive interviews with San Francisco men who provided care in their homes or those of the patients, three types of stressor were identified. One involves exigencies within the caregiver role itself, such as the demands and burdens encountered in housekeeping and nursing activities and in the management of financial and legal affairs. A second type of stressor involves the uncertainties caregivers experience concerning their own future, uncertainties that arise from the fact that homosexual caregivers are often exposed to the same set of health risk factors as the patients. Third, being a caregiver can create stressful problems in other roles. Thus, the demands of caregiving can disrupt multiple areas of life--occupational, economic, and social. Once disrupted, these become independent sources of stress. Formal and informal support systems appear to be important resources in sustaining caregivers and allowing them to continue in this role. In addition to support systems, a variety of coping strategies that may also help caregivers to sustain themselves have been identified. These strategies fall into three classes: those that function to minimize the physical and management demands of caregiving; cognitive and perceptual devices that reduce the level of threat the situation holds for the caregiver; and behaviors and practices that keep tensions and anxieties within manageable bounds.