Male caregivers are an important source of informal care for functionally impaired older adults in the community. In fact, it is reported that 28% of caregivers are men, which has increased from 25% in 1987 (Wagner, 1997). There have been numerous studies and reports published related to the female caregiver with far fewer studies related to the male caregiver. Some of the literature that does exist indicates that men provide different types of care with different responses to caregiving than women. This article provides an overview of what is currently known about male caregivers, as well as implications for interventions to support male caregivers.
The role of the male caregiver is an important one, and the need for more men to become involved in caregiving in the future is anticipated. Demographic predictions suggest an increase in the number of older adults who are functionally impaired and changes in the pool of informal caregivers. These changes include decreases in family size, increases in social mobility, delayed parenthood, and increases in divorce rates.
There are also competing employment and caregiving responsibilities for women, as more women join the work force (Gould, Haslanger, & Viadeck, 1992; Hibbard, Neufeld, & Harrison, 1996). The reason women have dominated as primary caregivers in the past was thought to be related to greater flexibility associated with the homemaker role and the cultural definition of a woman's role as being caring and nurturing (Archer & MacLean, 1993). The stereotypical perception of the woman's role in caregiving is no longer accurate, as the role of men and women in society continues to evolve.
Past studies, however, have shown gender differences related to the type of care men and women provide to family members in the home (Chang & White-Means, 1991; Kramer & Kipnis, 1995; Stoller, 1990). In a sample of 243 caregivers, 41% of whom were men (Stoller, 1990), researchers found that cooking, laundry, and routine household chores were more likely to be performed by women and that women assisted with a broad range of tasks. Men were found more likely to assist those older adults who were independent in activities of daily living (ADLs) and to be as likely as women to assist with financial management, heavy chores, and shopping.
In this sample, men undertook routine household chores less frequently than they did nonroutine tasks. The researchers concluded that the patterns of care provided were consistent with "a gender-based division of labor" (Stoller, 1990, p. 234). They suggested there was a need for further research to assess whether men were providing care as a result of deliberate choice and willingness or because of other reasons.
Data on 516 male caregivers who participated in the 1982 to 1984 Channeling Study also suggested that men provided less direct care related to ADLs than women (Chang & White-Means, 1991). Women were found to be more likely to prepare meals, while men were more likely to help with household chores and arranging for social services, benefits, and transportation. The researchers agreed that patterns of care are related to traditional family gender roles and suggested that in the future, gender roles may be less clearly defined because of increased employment of women.
More recent research supported the premise that employment of women affects gender roles in caregiving. In a study of 262 spousal and filial caregivers, Barber and Pasley (1995) found there were no significant differences between gender in relation to the performance of specific caregiver tasks, including assistance with personal care. In their sample, more female caregivers were employed (42%) compared to male caregivers (36%).
Studies also support that when the characteristics of care provided by male caregivers are analyzed separately related to sons and husbands, the gender differences are not as pronounced. Chang and White-Means (1991) found that even though female caregivers provided more hands-on care, husbands and wives provided similar assistance with toileting and getting out of the bed and chairs. They also found that husbands provided more hours of care per week than wives, while sons and brothers provided less care per week than daughters and sisters.
Merrill (1997) found in interviewing 50 working and middle class caregivers, that many sons provided extensive amounts of care up to the time of interference with employment. This is in contrast to earlier studies that found sons were more likely to provide intermittent assistance with tasks and less routine household aid (Dwyer & Coward, 1991; Stoller, 1990).
There has been scant research conducted on male caregivers of Latino, African American, or Asian descent. Most samples of male caregivers tend to be small, selfselected studies of fairly well educated, middle class, White men (Kaye, 1997). A study by Delgado and Tennstedt (1997) examined the role of Puerto Rican sons as caregivers. It was found that sons provided more help with transportation and financial management than daughters, as well as more help with shopping and housekeeping, which have traditionally been considered women's functions. The sons provided similar amounts of care and used fewer services than daughters. This study is an important study in examining the differences in male caregiving role among cultures.
Kaye and Applegate (1994) found that despite the traditional portrayal of men focusing on instrumental tasks and providing care from the periphery, men are now being granted societal permission to be nurturing and caring. Research conducted on 178 male caregivers revealed that older men had an androgynous perception of themselves. The caregiver's approach to care was found to be task-oriented, while at the same time very intimate. Older men were found to commit to a long-term caregiver arrangement more often than young men.
The men in this sample had minimal assistance from family members and this assistance declined over time. Additionally, few community services were used. Kaye (1997) proposed that the low usage of services by men may be because of resistance to seek or ask for help, lack of availability of services, or lack of knowledge.
One study found that older adults cared for by a caregiver who used few formal services had an increased possibility for nursing home placement (Jette, Tennstedt, & Crawford, 1995). The researchers also found that elderly individuals being cared for by male caregivers had more than twice the risk of being admitted to a nursing home compared to elderly individuals being cared for by women. The researchers proposed the reason for increased nursing home use by male caregivers may be related to gender differences in the type of care being provided by family caregivers.
The female caregivers were found to be more likely to assist with meals, housekeeping, and personal care, which are important functions to help maintain older adults in the community. Male caregivers were more likely to assist with shopping and finances, which are considered less important for preventing nursing home placement. However, the reasons for the association between having a male caregiver and the increased risk of nursing home placement were not explored adequately in this study. Further research exploring the reasons for this finding may assist gerontologicai nurses in developing programs to address these issues.
Many studies have addressed social support and the family caregiver, but few have examined gender differences in social support and implications for nursing interventions. The underrepresentation of men in samples has been an issue in interpreting results. A study of 159 spousal caregivers, 25% of whom were men, found that lack of affective support and assistance contributed to a sense of abandonment by the caregiver (Given, Stommel, Collins, King, & Given, 1990). This is an example of a study that does not analyze the data by gender, so one cannot determine if the findings would have differed if the subgroup of men was analyzed separately. Small sample size prohibited gender analysis.
In another study related to social support, Lyles et al. (1990) found that perceptions of social support were influenced most by telephone contact from family and friends, and contact usually occurred several times per week. However, in this sample of 203 caregivers, only 15% were men. Little difference was found in the sources of caregiver support between men and women, with friends being identified as the most common source of support (Hibbard, Neufeld, & Harrison, 1996). Despite men and women having a high level of satisfaction with support, the researchers found that men of lower socioeconomic status and older men reported fewer sources of support. They advocate careful assessment of support networks and identify men as being at risk because of low levels of social support.
The themes of social isolation and loss of companionship have been identified as being important to husband caregivers in research studies (Harris, 1993; Harris Sc Bichler, 1997). Kramer (1997) found in a study of 74 husbands caring for their wives that many of the men reported that their friends no longer called and that their social lives changed because they were unable to find time to participate in social activities in which they were previously involved. They also reported that those husbands who indicated satisfaction in social relationships expressed less strain or burden related to caregiving.
In a qualitative study using a grounded theory approach, Carmack (1997) interviewed 14 well functioning male and female caregivers. The theme of balancing engagement with detachment was important for all participants and a continually changing process learned over time. Balancing had several influences, including setting limits and boundaries, monitoring self, maintaining consciousness and pragmatism, and practicing self-care. Self-care activities included spirituality, sense of humor, time away, outside interests, solitary activities, and caring for one's body.
This study was not focused specifically on men, the sample size was small, and it included both formal and informal caregivers. However, the study did raise questions about its relevance to male caregivers, including:
* Is there a relationship between a man's ability to balance engagement and detachment and their level of emotional and physical health?
* What is the relationship between social relationships and the balancing of engagement with detachment?
Barker et al. (1998) found differences in the social support networks between men and women in a sample of urban African American caregivers age 65 and older. Women were found to have larger, more extended social support networks than men, and men's networks were found to be more vulnerable than women's. Even though the study did not focus specifically on caregivers, this rinding may have implications related to the responses and needs of elderly family caregivers.
Allen-Kelsey (1998) studied burden in African American and Anglo American caregivers. Results from the study indicated that caregiver burden was less among male African American and Anglo American caregivers compared to female, and that less burden was perceived by African Americans than Anglo Americans. The effect of social support was not a significant predictor of burden.
RESPONSES TO CAREGIVING
Research has suggested that men generally have different responses to caregiving than women. In a study of 20 male and 20 female caregivers, Hibbard et al. (1996) found that women experience more conflict than men. Other researchers have found that women experience more stress (Ingersoll-Dayton, Starrels, & Dowler, 1996) and higher levels of burden (Kramer & Kipnis, 1995).
In a study involving 148 male caregivers who were support group participants, Kaye and Applegate (1990) concluded that those men who were employed and provided care reported the greatest burden. They also found that those who reported excellent health reported lower levels of burden. Barber and Pasley (1995) found that male caregivers experienced less strain in family relationships than women, with daughters reporting the greatest relationship strain.
Many studies related to burden do not analyze gender differences. Browning and Schwirian (1994) studied 102 elderly male (38%) and female caregivers, and found the presence of mental impairment in the care recipient had a negative impact on caregiver burden. The relationship the male caregiver has with his family and the care recipient has been found to have a strong impact on reported burden (Kaye & Applegate, 1990). In a sample that was 79% female, Chappell and Penning (1996) found that greater depressive symptoms were reported by those caregivers who reported greatest burden and by those caregivers who reported greater behavior problems by care recipients.
Daughters indicated the greatest distress, while burden and depression were more pronounced in spousal and child caregivers than in other caregivers. Depression has been found to predict a decline in physical health, as well as burden in spousal caregivers (Pruchno, Kleb an, Michaels, & Dempsey, 1990). Researchers propose that depression may affect health in caregivers because of failure of caregivers to care for themselves properly. When husbands were analyzed alone, the relationship between depression and health did not emerge, but the sample was limited because only 32% of the sample were men.
Several studies have examined the impact of caregíving on the physical health of the male caregiver. Kaye (1997) concluded that lower levels of overall health, mental health, and financial well-being in the male caregiver were associated with increases in the quantity of care provided. In another study comparing male caregivers to men who were not caregivers, researchers found that caregiving men showed higher levels of depression, increased respiratory symptoms, and poorer health habits when compared to men who were not caregivers (Fuller-Jonap & Haley, 1995). Women have been found to report greater declines in health than men as a result of caregiving (Barber & Pasley, 1995). Wives reported the highest declines in health, followed by daughters.
Health status of men was found to affect the ability to provide care. Kaye and Applegate (1990) reported that despite men's perceptions that they are in good health, more than 40% reported their health limited the amount of care they provided. Better health was strongly associated with positive mental health and a lower sense of burden.
Researchers have examined possible explanations for the differences in response to caregiving between men and women. In a sample of 74 men caring for their wives with dementia, Kramer (1997) found the strongest predictor of strain in the caregiver was related to certain strategies used to regulate emotional responses to stress. These strategies included s elf -blame, avoidance, denial, wishful thinking, and suppressing feelings and contributed little to a sense of relief or control. Men were more likely to suppress feelings than women (Adams, 1994).
Other researchers reponed results that differ and conclude that men experience great physical and emotional caregiving demands (Kaye & Applegate, 1994). They found that caregiving could be extremely "isolating and insular" and that older men experience role strain because of demands on their physical and financial resources.
Kaye and Applegate (1994) reported that men often used their workplace skills and resisted offers of help and resources. They adopt a "tough it out" attitude and the business place "workaholic" becomes a "domestic workaholic." Their findings suggested that men admit to only moderate levels of strain and burden. Men also are thought to underreport depression (Horowitz, 1 992) and self reports of feelings and differences in coping styles may explain some of the gender differences found related to burden and depression (Lutzky & Knight, 1994).
INTERVENTIONS TO SUPPORT MALE CAREGIVERS
To develop programs supporting male caregivers, more research is needed to define the impact of caregiving on the male caregiver. Information about the health status and health care needs of the caregiver needs to be identified so interventions can be developed that are appropriately targeted to the male caregiving population. It is important to establish whether the responses of husbands and sons to caregiving are similar, so interventions can be designed to address such differences.
Despite diverse findings related to male caregivers to date, there are data that can guide the gerontologicai nurse in developing interventions for male caregivers. Research has shown that men do experience a feeling of social isolation (Harris, 1995), and it has been suggested that respite care may be an important service for male caregivers (Harris, 1995; Kaye, 1997; Kramer, 1997). Because men were found to be low users of formal services, the need to educate men about the availability and benefits of supportive services might be useful in terms of their willingness to avail themselves of respite services.
In a study of 690 caregivers (34% men), 80% identified the need for more information about community services with 79% reporting a need for education about stress management (Krach & Brooks, 1995). Men are socialized to be self-reliant, and this may inhibit their ability to deal with social service agencies (Kramer, 1997). Education related to a caregiver's role as a coordinator of services may be helpful.
The use of respite services, including adult day care by male caregivers, has not been widely studied. In a study that included 80.6% female caregivers, it was found that caregivers of family members with dementia reported better psychological well-being and lower levels of stress related to caregiving if they used a day care program for 3 months or longer (Zarit, Stephens, Townsend, & Greene, 1998). The data, however, were not analyzed for gender differences.
Adult day care may be a helpful service for male caregivers to assist them in addressing the issue of social isolation identified by some researchers. Research related to day care use by male caregivers to determine its acceptability and effectiveness is an important area for gerontological nurse involvement.
A challenge for the gerontological nurse is to develop programs that help sustain men in the role of caregiving by providing support and education. Decreasing social isolation is another important objective of intervention programs. Men have been found to appreciate advice and information related to caregiving (Kaye, 1997). Skills related to network building (Hibbard, Neufeld, & Harrison, 19%) may also be helpful to men who are feeling a sense of social isolation or abandonment (Given, et al., 1990).
Support groups have been considered advantageous for family caregivers of functionally impaired older adults (Bergman-Evans, 1994; Kaye & Applegate, 1990; 1993). However, little research Has been done to evaluate whether this means of support is helpful for male caregivers and whether it improves outcomes of caregiving. It has been suggested that marketing support groups to male caregivers should be strategic and focus on the educational component, rather than support (Kaye & Applegate, 1993; 1997). The accessibility of the support group to the male caregiver, as well as the necessity to tailor the content and approach to the needs of the group members also are important considerations for nurses developing a support group program.
The use of technology also should be explored in terms of its availability, acceptance, and effect with male caregivers. Perhaps computer-based support programs would be an accepted means of support and education for male caregivers who consider it important to maintain their own independence. Nurses educated in computer technology could have direct access to caregivers in their own homes, and caregivers could likewise communicate with each other, building a network that would be available on a daily basis.
Computer technology integrated with direct personal contact may provide a more comprehensive system of caregiver support and education than is currently available to most caregivers. Limited information is available addressing the availability and effect of computer-based programs for caregivers (Smyth & Harris, 1993). Further research in this area would help nurses design programs to best meet the needs of men providing care.
The importance of multidimensional nursing assessments of patient attributes, the caregiving environment, and caregiver characteristics to understand caregiver reactions and to develop effective interventions for caregivers has been recognized (Given, Stommel, Collins, King, & Given, 1990). The tool developed by MeIiUo and Futrell (1995) is a helpful guide for collecting data related to the characteristics of the caregiver, the functional ability of the care recipient, the resources available to the caregiver, and the educational needs of the caregiver. By performing a comprehensive assessment of the male caregiver's health and functional status (Bergman-Evans, 1994) and the self-care activities and the needs of the caregiver, gerontological nurses can assist in the development of programs to facilitate men in the caregiving role and promote caregiver health and well-being.
Despite the large amount of literature on caregiving, there is little information available related to the needs of the male caregiver, and whether traditional interventions for caregivers as a group are of any value to men. Gerontological nurses can play a key role in the development of interventions for male caregivers, including educational support groups, respite programs, and computer-based support programs. The evaluation of the effectiveness of these interventions and exploration of the expanded role of technology, support, and respite care for male caregivers is important.
The question of whether different interventions are appropriate for husbands and sons because of differing needs also deserves exploration. Comprehensive assessments of caregivers and care recipients, and the identification of perceived needs will provide important information to gerontological nurses that can be used to target appropriate interventions for male caregivers in the home.
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