Dr. Lee is Associate Professor of Nursing, Harding University College of Nursing, Searcy, Arkansas.
This study was funded in part by the University of Arkansas for Medical Sciences Graduate Student Research Funds. The author expresses appreciation to Elaine Souder, PhD, RN, for her expert guidance and assistance with this research endeavor, as well as the participants and the many agencies that assisted with recruitment.
Address correspondence to Cheryl J. Lee, PhD, RN, CNE, CWOCN, Associate Professor of Nursing, Harding University College of Nursing, Box 12265, Searcy, AR 72149; e-mail: email@example.com.
© iStockphoto.com/rebecca Ellis
Currently, more than 33 million households across the United States provide care for older family members with chronic illnesses (National Alliance for Caregiving & AARP, 2004). Frequently, it is older women who are managing their own chronic health issues, taking on caregiving responsibilities, and sacrificing their health as they meet the needs of their spouse (Schulz & Beach, 1999). Society and health care professionals are duty-bound to prevent disability in this vulnerable population of older spousal caregivers and to help them sustain their health, well-being, and quality of life.
Early researchers (George & Gwyther, 1986) recognized the stress associated with caregiving, and later investigators studied the specific physical, emotional, and mental health effects of caregiving (Cannuscio et al., 2002; Schulz & Beach, 1999). While most caregivers experience problems with sleep, anxiety, and depressive symptoms, spousal caregivers also face chronic health problems, make fewer physician’s visits, and spend fewer days in bed when sick (Carter, 2002; Schulz et al., 1997). Spousal caregivers may ignore their own health needs, delay physician’s visits, and refuse hospitalization if no one can take over for them. Many caregivers are unable to take time to recover following an illness and resume their caregiving duties too soon. Spousal caregivers usually provide complex care for long durations, increasing their risk for decline in well-being.
This decline has serious potential health consequences. As female spousal caregivers age, their risk increases for developing chronic conditions such as heart disease (American Heart Association, 2002), diabetes (Centers for Disease Control and Prevention, n.d.), arthritis, and other physical and mental illnesses. Researchers report an increased risk for coronary heart disease in spousal caregivers who do not get enough sleep and physical activity (Lee, Colditz, Berkman, & Kawachi, 2003; Schulz et al., 1997). Stress management and other health promotion behaviors (HPBs) are important factors in managing chronic health conditions and preventing illness.
HPBs may be influenced by factors such as age, health, residential location, and other barriers. Although researchers have explored the impact of residential status on HPBs of adults in rural and urban areas (Scott & Jacks, 2000), few focus specifically on older adults and caregivers. Researchers report that rural women engage in fewer HPBs and report more barriers than urban women (Adams, Bowden, Humphrey, & McAdams, 2000; Scott & Jacks, 2000). In their study of rural women, Pullen, Walker, and Fiandt (2001) reported that 53% did not receive health promotion counseling from their health care providers in the previous year. The effect of residential status on HPBs of older women providing spousal care is unknown and warrants further study.
Few studies specifically focus on the HPBs of caregivers and those that have used heterogeneous groups of caregivers with wide variations in age (McDonald, Fink, & Wykle, 1999; Sisk, 2000). Therefore, the purpose of this study is to identify and compare the HPBs of older rural and urban community-dwelling female spousal caregivers. This study expands the science of caregiving by providing a clearer picture of the HPBs practiced by older women providing spousal care. The specific aims of this study were to identify the HPBs used by women age 60 and older providing spousal care and to determine whether differences in these HPBs exist.
An exploratory, descriptive survey design with a two-group approach permitted comparison of data from spousal caregivers in rural and urban areas. Participants completed surveys providing self-report data on health status, HPBs, and caregiving information.
This study used nonprobability, convenience sampling to recruit female participants. Inclusion criteria were:
- Age 60 or older.
- Being a care provider to a spouse living in the home dependent in one or more basic activities of daily living (ADLs) or not able to be alone for safety reasons (e.g., blindness, severe dementia).
- Being a care provider for at least 6 months.
- Ability to read and write English.
- Living at same residence for at least 2 years.
- Willingness to participate and give consent.
Women were excluded from the study if they were providing caregiving assistance with only instrumental ADLs (e.g., transportation, medications). A power analysis suggested a sample of 20 rural and 20 urban participants would be sufficient to answer the study’s specific aims yielding a power of 0.82 at an alpha level of 0.05.
The primary investigator (PI, C.J.L.) received permission to use the Health Promoting Lifestyle Profile (HPLP-II) and developed a demographic questionnaire for the study. The HPLP-II (Walker & Hill-Polerecky, 1996; Walker, Sechrist, & Pender, 1987) assesses the frequency of participation in 52 health-related behaviors and consists of six sub-scales: health responsibility, nutrition, physical activity, spiritual growth, interpersonal relations, and stress management. Women rated the frequency they engaged in each item using a 4-point Likert-type scale. The response choices and related scores were never (1), sometimes (2), often (3), and routinely (4). A mean score was obtained for each subscale and the total HPLP-II. The HPLP-II is a reliable and valid instrument with an overall Cronbach’s alpha coefficient of 0.95 in this study; coefficients for the subscales in this study were 0.80 (health responsibility), 0.85 (physical activity), 0.78 (nutrition), 0.86 (spiritual growth), 0.77 (interpersonal relations), and 0.80 (stress management).
A PI-developed questionnaire provided self-report data about the demographics, caregiving responsibilities, length of time in caregiving role, and amount of personal time. This information was useful in describing the sample. Three experienced geriatric researchers established content validity of the demographic survey, and adult caregivers confirmed face validity, adequacy of wording, and clarity. Specific demographic data such as income, education, race, length of time in care-giving, and amount of personal time had mutually exclusive categories. Information such as self-reported medical problems of caregivers and spouses included separate checklists with most common chronic health problems and space for additional information. Instructions were to include only those who had received a medical diagnosis from a health care provider.
After Institutional Review Board approval, the PI initiated recruitment of women age 60 and older through community-based resources including support groups, senior centers, caregiver educational programs, medical clinics, pharmacies, advertisements, and churches throughout rural and urban areas of a southern state. The PI distributed recruitment flyers, and caregivers responded to these flyers by contacting the investigator. Of the 115 women who self-referred, 84 met eligibility criteria, agreed to participate in the study, and gave initial verbal consent. The caregivers were categorized as rural or urban based on the designation provided by entering their home address into the U.S. Census Bureau’s (2000) fact finder map. Urban status was assigned to participants who lived in an urban cluster, a centralized area with a population density of 1,000 per square mile and at least 10,000 total, and to those living in an urbanized area with the same population density and at least 50,000 total. A participant not residing in an urbanized cluster or area received rural status designation.
The PI mailed eligible participants a packet containing an introductory letter, directions, consent forms, surveys, and a self-addressed, stamped return envelope. Surveys contained a number code to ensure anonymity. The PI telephoned participants 3 to 5 days after mailing the packet to address questions. A return rate of 85.7% was achieved for this study. Signed consent forms were returned to the PI with the completed surveys. The PI checked surveys for completeness and obtained missing data through follow-up telephone calls. The PI maintained a confidential database with participants’ contact information and identification code in a locked file. No one else had access to this database. This information was used by the PI to follow up after mailing the surveys to inquire about questions or concerns, to obtain missing data after receiving completed surveys, and to send participants a thank you letter for their time and participation.
The PI entered the raw data from the HPLP-II into SPSS, version 13.0, to calculate total and subscale scores. The PI and a research assistant checked for accuracy using standard processes. The PI reviewed and corrected discrepancies using the survey questionnaire data prior to calculating scores. Descriptive statistics were used to analyze the sample characteristics.
To address the first aim of the study, all items on the HPLP-II were reviewed, and items with >70% response rate of often or routinely for the total sample were determined to be the most commonly used behaviors by female spousal caregivers. Items with a <30% rate of often and routinely were determined to be the least used behaviors. Independent t-test analysis was used to compare the mean scores on the total and subscale scores between the rural and urban women to address the second aim of the study.
The total sample (N = 72) was primarily White American (93%), with 7% minority (4.2% Black American and 2.8% Native American). Every effort was made to recruit a diverse population for this study, and the researcher aimed for 15.7% of the sample to be Black American for consistency with state census data. Many Black women requested to participate in the study; however, most did not meet the inclusion criteria.
Most of the participants were retired (90.3%) with a mean age of 71.4 (SD = 7.4 years). The majority (52.8%) reported having 2 hours or less daily to devote to self-care. The length of time in the caregiving role varied, with 51.4% reporting fewer than 5 years. The amount of time spent in daily caregiving varied, with 3 to 6 hours daily being the most commonly reported (45.8%). Nine (12.5%) women reported being responsible for the care of another person in addition to their spouse. Educational level varied, with 11.1% having less than a 12th grade education or GED equivalent.
Urban participants represented 54.2% of the total sample. No significant differences existed between the rural (n = 33) and urban (n = 39) women regarding education, age, and income. Table 1 contains specific demographic data about the two groups. The rural and urban groups were similar in their demographic characteristics, length of time in caregiving, and amount of free time for self-care. There were no significant differences noted between the two groups on comparison of demographic variables.
Table 1: Demographic Characteristics of the Sample
Diabetes was significantly more prevalent among the rural caregivers than the urban caregivers (χ2  = 4.228, p = 0.04) with the Cohen’s measure of effect = 0.24. No significant differences were noted in the comparison of rural and urban caregivers regarding total number of self-reported medical conditions (mean = 1.9, SD = 1.4) or the total number of ADLs (mean = 5.7, SD = 3.6) performed by the caregivers. The care-givers reported a mean of 1.9 chronic illnesses (SD = 1.4) for themselves and a mean of 4.5 chronic illnesses (SD = 2.4) for their spouse. Less than half of the total sample (38.9%) reported that a health care provider discussed HPBs in the previous year. More specifically, 53.8% of the urban women and 69.7% of the rural women reported that a health care provider did not discuss HPBs with them in the year prior to the study.
The first study aim was to identify the HPBs of women age 60 and older who were providing spousal care. A frequency distribution count for each HPLP-II item was used to determine the most and least common HPBs practiced. The most common HPBs were associated with the interpersonal relations, spiritual growth, and stress management subscales. The least practiced HPBs related to exercise and nutrition. See Table 2 for behaviors and percentages.
Table 2: Health Promotion Behaviors of Rural and Urban Women Providing Spousal Care (N = 72)
The second study aim was to determine whether differences existed between the rural and urban women regarding HPBs. Total scores on the HPLP-II provided an overall indication of participation in HPBs, with higher scores indicating greater participation. Rural women scored a mean of 2.54 (SD = 0.50) and urban women scored a mean of 2.68 (SD = 0.46), indicating that overall, both groups practice HPBs somewhere between sometimes and often. Independent t-test analysis revealed no significant differences between the total HPLP-II scores comparing the rural and urban women (t = −1.230, p = 0.223). The women shared similar scores on the six subscales of the HPLP-II, and no significant differences were noted (Table 3).
Table 3: Independent t-Test Analysis of Hplp-II and Subscale Scores of Rural and Urban Women Caring for a Spouse at Home
There are limited health promotion studies comparing rural and urban older adults (Scott & Jacks, 2000). While more studies focus specifically on rural individuals (Adams et al., 2000; Pullen et al., 2001), none specifically focus on comparing older rural and urban caregivers; however, Easom and Quinn (2006) focused on rural elderly caregivers. Studies that focused on caregivers consisted of mixed groups of caregivers (spouse, parent, sibling, child, or friend), both men and women, and wide variations in participant age and definitions of caregiving (McDonald et al., 1999; Sisk, 2000). This study sought to expand the caregiving literature by providing a clearer picture of the HPBs of older rural and urban women who provide spousal care at home on a daily basis.
This sample consisted of primarily White American women, although much effort was devoted to recruiting Black Americans in both rural and urban areas of the southern study state. Black women who responded to flyers were very interested in participating in the study; however, they did not meet the criteria because they were not yet age 60 or their spouse was already deceased. Engaging in HPBs regularly has the potential to improve health and delay disease and disability. The 85.7% response rate to the study indicates that older female spousal caregivers are interested in HPBs.
The most commonly practiced HPBs were not physical in nature, but rather fit in the subscales of interpersonal relations, spiritual growth, and stress management. The most frequently reported behaviors (Table 2) do not require caregivers to leave their spouse and may involve the spouse. Additional research on HPBs reveals that older adults may be more willing to participate in HPBs that are likely to have a direct effect on health and well-being versus routine testing and screenings that do not directly affect daily life (Resnick, 2003). Although Resnick’s study did not focus on caregivers, it suggests that older women may be more willing to participate in HPBs that decrease stress and improve overall feelings of well-being. This may explain why the most commonly used HPBs in this sample were primarily from the interpersonal relations and spiritual growth subscales. Perhaps caregivers experience an improved sense of well-being when actively involved and feeling connected with others and a higher power.
The majority of the least practiced HPBs related to the physical activity subscale. Few women in this study took part in leisure activity (9.7%), stretching exercises (29.1%), or 20 minutes of exercise three times per week (29.1%), which is consistent with other reports (Adams et al., 2000; Easom & Quinn, 2006; Maiese, 2002). Older women may experience difficulty fitting exercise into their schedule due to time constraints imposed by the demands of daily caregiving or inability to leave their spouse alone or may not have the energy as a result of fatigue from responsibilities and lack of sleep.
In this study, only 27.8% of the women reported balancing time between work and play, which is understandable when 57.6% of rural and 48.7% of urban women reporting having 2 hours or less of free time on a daily basis. The women in this study may have benefited from having a home health aide or sitter to free up some time; only 23.6% reported having this resource. Although caregivers may not personally experience an immediate benefit from physical activity, there are long-term benefits in preventing disease and disability and managing stress. Further study to identify the barriers to caregivers’ participation in HPBs and more specifically to physical activity is needed.
In their comparison of rural and urban older adults, Scott and Jacks (2000) reported statistical significance in overall HPBs (r = −0.627, p < 0.05) and physical activity (r = 0.151, p < 0.05). However, results from the older rural and urban women in this caregiving sample indicate there is room for improvement in the practice of HPB. No significant differences existed between this population of rural and urban caregivers, as has been suggested in previous studies exploring HPBs (Adams et al., 2000; Scott & Jacks, 2000).
The findings from this study are based on a nonprobabability convenience sample of rural and urban women in one southern state and therefore cannot be generalizable, as sampling was not random. This study was limited by lack of ethnic diversity in the sample. Future replication studies using random sampling procedures, larger samples, and more ethnic diversity among participants is recommended. Future studies should focus on developing interventions to improve the HPBs of older female spousal caregivers in both rural and urban areas. Interventions designed to increase participation in physical activity are needed, along with further study exploring the barriers that hinder participation in health promotion activities. Longitudinal studies using consistent tools to measure health, HPBs, and barriers over time will help to understand the caregiving effects for older spousal caregivers.
Implications for Practice, Research, and Education
Findings from this study have implications for practice, research, and education. Nursing practice in all health care settings needs to include thorough holistic assessment of the health of older women who are providing spousal care and their participation in HPBs. A major gap exists in the discussion of HPBs by health care providers, and nurses must take time to discuss and teach HPBs, provide follow-up care, and assist older women in identifying activities they can do relative to their health and caregiving responsibilities. A collaborative approach with other disciplines that may be working with caregivers and recipients can help the caregiver maintain health and wellness. Because these spousal caregivers are less likely to attend educational programs, opportunities for teaching must take place within scheduled office visits for the caregiver or care recipient. One option may be to play videos in office waiting rooms that focus on HPBs and women. Short vignettes of older women who have mastered managing HPBs and physical activity within in their role of caregiver could share their experiences and positive outcomes. Educational packets could be provided to the women with detailed information regarding HPBs and physical activity and their importance in improving quality of life. This packet could also contain resources such as Internet support groups and telephone support.
Nurse researchers must continue expanding the health promotion research with caregivers of all ages, but specifically with those identified at greatest risk for illness and disability. Future studies need to include HPB interventions so evidence-based practice can grow in this area. Further research using multidisciplinary teams to individualize activity programs to improve the health of both the caregivers and their spouse is suggested.
Nurse educators must continue to prepare nurses to work with the aging population and to recognize those at high risk for the negative effects associated with caregiving. Nurse educators are in key positions to further the research on health promotion interventions with an aging caregiver population. Getting nursing students interested in such research may help expand the knowledge base of health promotion in caregivers. Nurse educators can create assignments that involve their students working with this vulnerable population and assist in developing a plan for activity, as well as identifying potential resources to support the caregiving dyad.
Capstone projects could include interviewing older women spousal caregivers who have successfully found ways to manage HPBs within their caregiving role and create video vignettes for use in local health care offices. Capstone projects involving a team of senior social work, nursing, nutrition, and physical therapy students could work with community caregiver dyads in becoming more active in HPBs. Such innovative capstone projects would be consistent with the Healthy People 2010 objectives (U.S. Department of Health and Human Services, 2000) to increase the number of people who participate in physical activity and improve nutrition to enhance quality of life. This very vulnerable aging population—if they are to continue meeting the needs of their loved ones—needs the help of health care professionals.
Education of spousal caregivers may best be offered during physician visits or at home. The high interest in HPB (85.7% response rate) deserves further exploration for teaching methods, learning content, and activities best suited for predominantly homebound caregivers. Nontraditional HPBs, such as interpersonal relationships, spiritual well-being, and stress management, suggest primary content areas to explore. Limited relief of caregiving burden needs to be addressed at points of interface with health care providers to discuss available options.
As the aging population continues to rise in number, more women will become spousal caregivers and seek balance between caring for their spouse and caring for themselves. Nurses will need to be vigilant in their efforts to discuss HPBs and help spousal caregivers identify activities that will sustain their physical, mental, emotional, and spiritual well-being. Nursing interventions aimed at managing stress and increasing physical activity will be necessary for both rural and urban older women providing spousal care at home.
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Demographic Characteristics of the Sample
|Characteristic||Rural (n= 33)||Urban (n= 39)|
|Mean age||70.4 (SD = 6.8 years)||72.3 (SD = 7.8 years)|
|Age range||60 to 85||60 to 90|
| 60 to 64||6 (18.2%)||8 (20.5%)|
| 65 to 74||19 (57.6%)||18 (46.2%)|
| 75 to 84||7 (21.2%)||10 (25.6%)|
| ≥85||1 (3%)||3 (7.7%)|
| White American||31 (93.9%)||36 (92.3%)|
| Black American||0||3 (7.7%)|
| Native American||2 (6.1%)||0|
| Less than high school||5 (15.2%)||3 (7.7%)|
| High school/some college||21 (63.6%)||25 (64.1%)|
| College graduate||7 (21.2%)||11 (28.2%)|
| Retired||30 (90.9%)||35 (89.7%)|
| Part time||3 (9.1%)||3 (7.7%)|
| Full time||0||1 (2.6%)|
| <$29,999||20 (60.6%)||17 (43.6%)|
| ≥$30,000||11 (33.3%)||16 (41%)|
| Unknown||2 (6.1%)||6 (15.4%)|
|Length of time caregiving|
| 6 months to 2 years||7 (21.2%)||10 (25.6%)|
| >2 years but <5 years||8 (24.2%)||12 (30.8%)|
| >5 years but <10 years||10 (30.3%)||13 (33.3%)|
| ≥10 years||8 (24.2%)||4 (10.3%)|
|Hours of daily free time for self|
| 60 minutes to 2 hours||19 (57.6%)||19 (48.7%)|
| 3 to 6 hours||14 (42.4%)||18 (46.2%)|
| ≥7 hours||0||2 (5.1%)|
Health Promotion Behaviors of Rural and Urban Women Providing Spousal Care (N = 72)
|Health Promotion Behavior||PracticeOftenandRoutinely|
|10 most common behaviors|
|Find it easy to show love, concern, and warmth to others||97.2%|
|Praise others for their achievements||94.4%|
|Connect with a higher power||94.4%|
|Aware of what is important||88.9%|
|Maintain meaningful and fulfilling relationships||87.5%|
|Accept things I cannot change||87.5%|
|Believe my life has purpose||86.1%|
|Touch and am touched by people I care about||86.1%|
|Question my health care provider to understand his or her instructions||79.1%|
|10 least common behaviors|
|Check pulse rate when exercising||8.4%|
|Take part in leisure time physical activity||9.7%|
|Reach target heart rate when exercising||9.7%|
|Eat 6 to 11 servings of bread, cereal, or pasta daily||9.8%|
|Attend educational programs about personal health care||11.1%|
|Find ways to meet my needs for intimacy||26.3%|
|Participate in light to moderate activity 30 to 45 minutes, five times per week||27.7%|
|Balance time between work and play||27.8%|
|Do stretching exercises at least three times per week||29.1%|
|Exercise 20 minutes or more at least three times per week||29.1%|
Independent t-Test Analysis of Hplp-II and Subscale Scores of Rural and Urban Women Caring for a Spouse at Home
|Rural (n= 33)||Urban (n= 39)|
|Variable||Mean (SD)||Mean (SD)||t–Test Score (df= 70)||pValue|
|Health responsibility||2.46 (0.64)||2.62 (0.59)||−1.141||0.258|
|Physical activity||1.83 (0.77)||1.87 (0.68)||−0.227||0.821|
|Nutrition||2.78 (0.59)||2.89 (0.56)||−0.769||0.444|
|Spiritual growth||2.84 (0.59)||3.00 (0.57)||−1.180||0.242|
|Interpersonal relations||2.87 (0.44)||3.08 (0.50)||−1.785||0.079|
|Stress management||2.49 (0.59)||2.66 (0.65)||−1.183||0.241|
|HPLP-II||2.55 (0.50)||2.69 (0.47)||−1.230||0.223|