CARING for a disabled older adult can be a highly

Casado, B., & Sacco, P. (2012). Correlates of caregiver burden among family caregivers of older Korean Americans. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 67(3), 331 336, doi:10.1093/geronb/gbr115. Advance Access published on October 31, 2011 Correlates of Caregiver Burden Among Family Caregivers of Older Korean Americans Banghwa Casado and Paul Sacco University of Maryland, School of Social Work, Baltimore. Objectives. Despite the rapid growth of older ethnic minority populations, knowledge is limited about informal caregiving among these groups. Our aim was to identify correlates of caregiver burden among family caregivers of older Korean Americans (KAs). Method. A cross-sectional survey collected data from 146 KA caregivers. Using a modified stress-appraisal model, we examined background and context characteristics (caregiver sex, relationship to care recipient, college education, English proficiency, time in caregiving role, family support network, friend support network), a primary stressor (care recipient functional dependency), a primary appraisal (caregiving hours), and resources (family agreement, care management selfefficacy, service use self-efficacy) as potential correlates of caregiver burden. Interactions between the primary stressor, primary appraisal, and resources were also tested. Results. Being female and the care recipient s spouse were associated with higher burden. Conversely, a larger family support network, greater family agreement, and greater care management self-efficacy were associated with lower burden. A significant interaction was detected between functional dependency and family agreement; higher levels of family agreement moderated the association between care recipient functional dependency and caregiver burden. Discussion. Interventions to reduce caregiver burden in KA caregivers may be more effective if they include approaches specifically designed to build family support, improve family agreement, and increase caregivers self-efficacy. Key Words: Caregiving Minority and diverse populations Stress. CARING for a disabled older adult can be a highly stressful experience (Pinquart & Sörensen, 2003). Caregivers sense of burden may lead to emotional distress (Clyburn, Stones, Hadjistavropoulos, & Tuokko, 2000), poor health, and decreased quality of life (Iecovich, 2008) and may also influence decisions to institutionalize care recipients (Gilley, McCann, Bienias, & Evans, 2005). Although caregiver burden in the general popula tion is well studied, research on the burden experienced by members of ethnic minority groups is limited and provides inconclusive evidence regarding differential effects of factors associated with caregiver burden in this population (Pinquart & Sörensen, 2005). Older Asian Americans and their caregivers are one of the least studied groups. Because this population is projected to grow from about 1 million in 2008 to almost 7.5 million by 2050 (Federal Interagency Forum on Aging-Related Statistics, 2010), research is needed to better understand caregiving in this group. This study focused on Korean Americans (KAs), one of the fastest growing subgroups within the heterogeneous Asian American population. Albeit limited in the current literature, studies have identified adverse effects of caregiving among KA caregivers, including poor physical health (Kim & Knight, 2008), depression, and anxiety (Chun, Knight, & Youn, 2007). Adverse effects of caregiving may be greater among Korean caregivers than American caregivers (Kim & Lee, 2003) because of lack of formal services designed for KAs and cultural or language barriers in accessing existing services (Han, Choi, Kim, Lee, & Kim, 2008). Studies conducted in Korea suggest that female sex, less education (Kim et al., 2009), spousal relationship (Hong & Kim, 2008), little social support, longer caregiving hours (M. Lee, Yoon, & Kropf, 2007), and greater functional dependency of care recipients (J. Lee, Friedmann, Picot, Thomas, & Kim, 2007) may be associated with increased burden among Korean caregivers. Although ethnic heritage explains some similarities between Koreans and KAs, the socioenvironmental context of KA caregivers is unique. Thus, we aimed to identify factors affecting the burden experienced by KA caregivers residing in the United States. Guided by a stress-appraisal model (Yates, Tennstedt, & Chang, 1999), we used a framework that incorporated the caregiving appraisal model (Lawton, Kleban, Moss, & Rovine, 1989) and the stress process model (Pearlin, Mullan, Semple, & Skaff, 1990). The model of Yates and colleagues (1999) emphasizes caregivers appraisal of stressful situations and examines how their reactions to the stressful situation and coping resources available to them may affect caregiving outcomes. It consists of five components: primary stressors (need for care, such as cognitive impairment, functional disability, and problem behaviors), primary appraisal (caregiver s immediate judgment of care needs manifested The Author 2011. Published by Oxford University Press on behalf of The Gerontological Society of America. 331 All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. Received September 16, 2010; Accepted September 8, 2011 Decision Editor: Rosemary Blieszner, PhD

332 CASADO AND SACCO Figure 1. Conceptual framework and study variables. in the care provided, such as caregiving hours), resources (personal and social resources that alter the effect of stressors, such as formal help, relationship quality, emotional support, and mastery), secondary appraisal (caregiver appraisal of the caregiving situation manifested as overload or burden), and outcome (psychological well-being). We made two modifications to the model of Yates and colleagues (1999): (a) inclusion of background and context variables (sociodemographics, caregiving history, family and social network) proposed by Pearlin s stress process model and (b) conceptualization of caregiver burden (secondary appraisal in Yates et al., 1999) as a caregivingspecific distress outcome. We hypothesized that background and context characteristics, a primary stressor, a primary appraisal, and resources would affect caregiver burden and that resources would moderate the impact of the primary stressor and primary appraisal on caregiver burden among KA caregivers (Figure 1). Method Sample and Recruitment Data were drawn from a cross-sectional survey of family caregivers of older KAs in the mid-atlantic region of the United States. Individuals were eligible if they were 18 years or older and cared for an elderly Korean relative (aged 60 or older) with a health, physical, or cognitive condition requiring care (we relied on potential participants self-report on these criteria). Participants were recruited with support from a variety of sources (e.g., county agencies for aging persons, community organizations, churches, senior centers, community events) that served KAs in the area. Potential participants were referred by these sources or called us directly for screening and successive telephone survey interviews. We screened 161 caregivers, and 146 completed the survey. All surveys were conducted by trained bilingual interviewers in Korean (n = 139) or English (n = 7), depending on participant preference. Measures Dependent variable. Caregiver burden was measured with a Korean version of the Revised Caregiving Appraisal Scale (J. Lee et al., 2007) developed by Lawton and associates (1989). It asks the extent of agreement (1 = disagree a lot to 5 = agree a lot) with a statement or the frequency (1 = never to 5 = nearly always) of having certain feelings as the result of caregiving and uses summed scores to measure caregivers appraisal of burden. We used eight burden factor items suggested by J. Lee and colleagues (gives trapped feeling, health has suffered, don t have time for self, social life has suffered, very tired, does not allow as much privacy, isolated and alone, lost control of own life). Background and context. Background variables included caregiver sex (0 = male, 1 = female), relation to the care recipient (adult child, spouse, and other relative, which are dummy coded using adult child as the reference group), college education (1 = college education, 0 = no college education), English proficiency (1 = not well at all, 2 = not well, 3 = relatively well, 4 = well, 5 = very well), and time in the caregiving role (years). Family and friend social networks were examined as contextual factors because social networks influence social support and access to resources (Berkman, Glass, Brissette, & Seeman, 2000) and are influenced by culture and ethnicity (Zhou & Kim, 2006). Support networks were measured by a Korean version (Hong, Casado, & Harrington, 2011) of the Abbreviated Lubben Social

CAREGIVER BURDEN AMONG KOREAN AMERICANS 333 Network Scale (A-LSNS) (Lubben et al., 2006). The A-LSNS asks the numbers of family or friends (0 = none, 1 = one, 2 = two, 3 = three/four, 4 = five to eight, 5 = nine or more) whom the respondent saw or heard from at least once a month, felt at ease with, and felt close to and measures the size of family (3-item scale) and friend (3-item scale) support networks using a summed score for each type of network. Primary stressor. We examined functional dependency as a primary stressor of caregivers and measured it with a Korean version (Kim & Lee, 2003) of the Activities of Daily Living section of the Older Americans Resources and Services Multidimensional Function Assessment Questionnaire (Fillenbaum & Smyer, 1981). It consists of 14 items: seven items each for activities of daily living and instrumental activities of daily living. We reverse coded the scale items so that a higher score measured greater functional dependency (0 = without help, 1 = with some help, 2 = completely unable) and used summed scores. Primary appraisal. Assistance provided was the manifestation of caregivers primary appraisal of caregiving need. It was assessed by the average number of caregiving hours provided in a typical week. Resources. Because traditional Asian culture views elder caregiving as a family responsibility (Yamashiro & Matsuoka, 1997), we conceptualized family agreement in caregiving as an external resource and assessed the extent of family agreement using the 8-item Family Conflict Scale (FCS) (Gaugler, Zarit, & Pearlin, 1999), which measures a caregiver s perceived disagreement with family members over caregiving-related situations (giving help, doing a share, spending enough time, showing appreciation, showing respect, visiting or telephoning, having patience, and giving unwanted advice). We reverse coded the items, so a higher score indicated greater family agreement (1 = quite a bit of disagreement, 2 = some disagreement, 3 = little disagreement, and 4 = no disagreement). Caregiver self-efficacy was conceptualized as an internal resource because certainty about performing caregivingrelated tasks would raise confidence in the caregiving role, and individuals who are confident in their capabilities are likely to view difficult tasks not as threats but as challenges they can master (Bandura, 1994). Compatible with the notion that the effects of caregiver self-efficacy are domain specific (Fortinsky, Kercher, & Burant, 2002), we examined caregiver self-efficacy in care management and service use. We used the two subscales of the Caregiver Self-efficacy Scale (CSES) (Fortinsky et al., 2002), which included five items for care management self-efficacy and four items for service use self-efficacy. A 10-point scale measured the certainty caregivers felt (self-efficacy) in performing the role described in each item (1 = not at all certain to 10 = very certain), and subscale scores measured domain-specific self-efficacy. Because no Korean versions were available for the FCS and CSES, we translated them for the study using a committee approach (Van de Vijver & Leung, 1997). Instruments were forward translated by two bilingual individuals separately, reviewed in a series of consensus meetings by a bilingual team, and pilot tested. Data Analysis Linear regression analyses of variables associated with caregiver burden were conducted using PASW Statistics (version 18.0). Interaction terms were tested in a second model and plotted using a SAS macro created by Hayes and Matthes (2009). To account for missing values (ranging from 0.7% to 15.5%), we used multiple imputation (Schafer, 1999) for the analysis. Results Characteristics of Sample and Study Variables Descriptive characteristics of the study sample and variables are summarized in Table 1. The majority of the caregivers were middle-aged females; about half of them were adult children and one third were spouses. The majority of those receiving care were female with an average age of 79 years. Correlates of Caregiver Burden In Model 1 (see Table 2), being female and the spouse of the care recipient were associated with higher burden; conversely, larger family network size, greater family agreement, and greater care management self-efficacy were associated with lower burden. In Model 2, we tested interactions of the primary appraisal and primary stressor with two personal resources (family agreement and care management self-efficacy) that exhibited a significant direct effect on caregiver burden. The results showed a significant interaction between functional dependency and family agreement, suggesting a moderating effect: among families with lower levels of agreement, higher levels of dependency were associated with greater burden, but among families with higher agreement, this relationship was attenuated (Figure 2). Discussion Using a modified stress-appraisal model, we examined correlates of caregiver burden among KA caregivers. Consistent with previous studies on caregiver burden and gender (Pinquart & Sörensen, 2006) and spousal relation (Pinquart & Sörensen, 2003), our findings indicated that female and spousal caregivers perceived greater burden in their caregiving role. Higher burden found in these two groups paralleled that found in Korean caregivers (Kim et al., 2009), suggesting similar vulnerability to burden among KA caregivers. Higher burden in KA spousal caregivers highlights the need for special attention to this group, as

334 CASADO AND SACCO Table 1. Descriptive Characteristics of Study Sample and Variables (N = 146) Variable % Mean SD Actual range Possible range Scoring α CR age a 78.6 9.2 60.0 99.0 CR female a 60.3 CG age a 58.0 12.7 27.0 84.0 CG female 79.8 CG relationship Adult child 62.4 Spouse 32.2 Other relative 5.5 CG college education 56.2 CG English proficiency 2.7 1.2 1.0 5.0 1.0 5.0 Higher = more proficient CG time in caregiving role (years) 6.0 5.9 0.8 30.0 Higher = longer years in role CG family support network (A-LSNS) 7.9 3.2 0 15.0 0 15.0 Higher = larger network 0.76 CG friend support network (A-LSNS) 7.0 3.6 1.0 15.0 0 15.0 Higher = larger network 0.86 CR functional dependency (ADL-OARS) 8.9 7.2 0 28.0 0 28.0 Higher = greater dependency 0.93 Caregiving hours 26.6 25.5 0 140.0 Higher = more care provided Family agreement (FCS) 22.2 5.6 10.0 32.0 8.0 32.0 Higher = greater agreement 0.83 Care management efficacy (CSES) 27.8 10.2 5.0 50.0 5.0 50.0 Higher = greater efficacy 0.84 Service use efficacy (CSES) 21.8 8.9 4.0 40.0 4.0 40.0 Higher = greater efficacy 0.86 Caregiver burden (K-RCAS) 20.3 7.0 8.0 40.0 8.0 40.0 Higher = greater burden 0.87 Notes. CG = caregiver; CR = care recipient; A-LSNS = Abbreviated version of the Lubben Social Network Scale; ADL-OARS = Activities of Daily Living section of the Older Americans Resources and Services Multidimensional Function Assessment Questionnaire (reverse coded); FCS = Family Conflict Scale (reverse coded); CSES = Caregiver Self-efficacy Scale; K-RCAS = Korean version of Revised Caregiving Appraisal Scale. a Not included in the regression model analysis. they may be more vulnerable than other caregivers. They had lower income (84.4% with annual household income less than $20,000 compared with 19.4% of nonspousal caregivers; χ 2 = 64.76, degrees of freedom [df] = 6, p <.001), indicated lower proficiency in English (t = 5.83, df = 143, p <.001, with mean of 1.91 for spouse and 3.04 for nonspousal caregivers), and reported poorer general health status (t = 4.84, df = 143, p <.001). Predictor (reference group) Table 2. Linear Regression Model for Predictors of Caregiver Burden (N = 146) Model 1 Model 2 B β B β Background and context CG female (male) 3.38.21** 3.10.18* Spouse (adult child) 4.99.33*** 4.99.33*** Relative (adult child) 0.52.02 0.52.02 CG college education 0.18.01 0.06.00 CG English proficiency 0.01.00 0.08.01 CG time in caregiving role 0.14.11 0.11.09 CG family support network 0.40.18* 0.43.19* CG friend support network 0.03.02 0.01.00 Primary stressor CR functional dependency 0.14.15 0.17.18* Primary appraisal Caregiving hours 0.02.08 0.02.08 Resources Family agreement 0.32.25*** 0.33.27*** Care management efficacy 0.16.23* 0.18.25** Service use efficacy 0.06.07 0.09.12 Interactions Functional dependency family agreement 0.04.25*** Functional dependency care management efficacy 0.00.02 Caregiving hours family agreement 0.01.14 Caregiving hours care management efficacy 0.00.02 Model statistics R 2 =.42 R 2 =.47 F(13,131) = 6.65*** F(17,127) = 7.39*** Change statistics R 2 Δ =.05 F Δ (4,127) = 2.89* Notes. CG = caregiver; CR = care recipient. * p <.05; **p <.01; ***p <.001.

CAREGIVER BURDEN AMONG KOREAN AMERICANS 335 Figure 2. Interaction of functional dependency and family agreement. According to the stress-appraisal theory (Yates et al., 1999), the caregiving experience is affected by the level of care need (primary stressor) as well as actual caregiving provided (primary appraisal). Research has supported this theory, finding a relationship between the care recipients functional dependency and burden of caregivers in the United States (Pinquart & Sörensen, 2003) and Korea (M. Lee et al., 2007). Our results showed no effect of actual caregiving hours on perceived burden, and the care recipient s functional dependency was significantly associated with burden only in the context of an interaction with family agreement. The amount of care provided may be more closely related to caregiver burden among dementia caregivers than among other types of caregivers (Pinquart & Sörensen, 2003). Thus, the lack of an effect of caregiving amount in this study may be due to our sample composition, which included caregivers for those with possible cognitive impairment as well as those with other needs. As the types and amount of care differ depending on the illness and condition of care recipients, future research with KA caregivers could focus on specific types of caregivers. One of the most notable findings of this study was the role of family in informal caregiving. Earlier research reported an ameliorative effect of social support for the psychological wellbeing of Korean caregivers (Chun et al., 2007). Our results indicate that having a large family support network rather than a support network composed of friends may alleviate burden among KA caregivers as well. As traditional Asian cultural values emphasize the role of family in elder caregiving (Yamashiro & Matsuoka, 1997), having a large family network may mean having greater availability of support. The vital role of family was also demonstrated by the effect of family agreement: caregivers with higher levels of family agreement perceived less burden in their caregiving role. This finding is consistent with research indicating that a low level of family agreement (or high incidence of family conflict) adversely affects the well-being of caregivers (Davis, 1997). As shown in the moderating effect of family agreement, it may also alleviate the sense of burden among KA caregivers. These findings point to the importance of attending to family dynamics in the caregiving situation among KAs. Research indicates that caregiver self-efficacy affects the emotional experiences of caregivers (Monin & Schulz, 2009) and has a direct effect on caregiver burden (Gonyea, O Connor, Carruth, & Boyle, 2005) as well as moderating effects on dementia caregiver intervention responses (Rabinowitz et al., 2006). Our results showed that only care management self-efficacy had a significant effect on caregiver burden among KA caregivers. Recent studies suggest that many KAs have limited health literacy and lack knowledge about treatments and services (Han, Kim, Kim, & Kim, 2011), providing some insight into additional challenges KA caregivers may face in care management. We hypothesized that caregiver self-efficacy would also buffer the impact of primary stressor and primary appraisal on caregiver burden but found no such moderating effect of either of the domain-specific caregiver efficacies. It may be that caregiver self-efficacy influences caregiver burden through other independent factors. Future research may include different stressor measures, such as upsetting thoughts and care recipients behavioral problems found in previous research (Romero-Moreno et al., 2011), to test the moderating effects of caregiver self-efficacy among KA caregivers. Several limitations of the current study should be noted. The cross-sectional survey design cannot establish causal relations. Purposive sampling from a geographically defined area limits the generalizability of our findings. Our reliance on caregivers subjective assessment may have introduced caregiver bias in the data. The magnitude of relationships between stressors and caregiver burden may vary between dementia and nondementia caregivers because the type of care recipient influences the scope of care needed (Pinquart & Sörensen, 2003). This study was limited in its measure of culture-specific caregiving experiences, so future research should assess the role of culture-specific constructs (e.g., familism) on perceived caregiver burden. In conclusion, our findings suggest that health care professionals designing interventions to reduce burden among KA caregivers should pay special attention to vulnerable spousal caregivers. Interventions may be more effective if they include approaches specifically designed to build family support, improve family agreement in caregiving, and increase caregivers self-efficacy in their caregiving role. Funding This study was supported by the John A. Hartford Faculty Scholars Program. Correspondence Correspondence should be addressed to Banghwa Casado, PhD, MSW, University of Maryland, School of Social Work, 525 West Redwood Street, Baltimore, MD 21201. E-mail: bcasado@ssw.umaryland.edu.

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