Luxardo (2009) stated that more than one half of the population is likely to act as caregivers at least once in their lifetime. This statement is true for economically developed countries in which life expectancy is rapidly increasing as well as for developing Latin American countries, such as Mexico, in which the age revolution has resulted in a large group of individuals with fragile health (Gutiérrez-Robledo & Lezama-Fernández, 2013) who will require daily support and assistance from their family members. In fact, for Mexican individuals, taking care of relatives who are 60 or older ranked fifth in their domestic task list (Instituto Nacional de Estadística y Geografía, 2009).
The negative repercussions to caregivers’ health and well-being have been exposed (Brinda, Rajkumar, Enemark, Attermann, & Jacob, 2014), but the topic of older adult care has not yet been included in Mexico’s political agenda or Mexican society. Furthermore, Mexican academic research about caregivers is just commencing, and information on the subject continues to be scarce; many researchers do not divulge their results in scientific journals. Consequently, it is necessary to increase researchers’ contributions in Mexico about this significant topic in social gerontology and to divulge the results to encourage the interlocution that will generate interpretative frames not only to describe and explain the caregiver issue, but also to provide a foundation for taking action.
The Stress Process Model forms the basis of most international literature about caregivers. Haley, Levine, Brown, and Bartolucci (1987) applied the Stress and Coping Paradigm (Lazarus & Folkman, 1984) to the problem of individual differences in response to caregiving, indicating that caregivers’ well-being is negatively associated to caregivers’ perception of stress; furthermore, stress coping resources and social support serve as mediators between caregivers’ well-being and stress perception. Approximately three decades after its original approach, several pertinent contributions to the model have been made regarding detailing its components (Pearlin, Mullan, Semple, & Skaff, 1990), including new variables and relation routes between components (Reid, Stajduhar, & Chappell, 2010; Savundranayagam & Montgomery, 2010), diversifying methodological samples and strategies (Braun, Mura, Peter-Wight, Hornung, & Scholz, 2010), and creating intervention proposals (Gräßel, Luttenberger, Trilling, &, Donath, 2010). Nevertheless, a critical review of the available literature demonstrates important aspects relevant to the experience of caregiving that have not yet been studied at length within the Stress Process Model.
The mechanisms through which family affects the stress process have not yet been clarified, although for the most part caregiving takes place within the family context (Mitrani et al., 2006). The Stress Process Model as specified by Pearlin et al. (1990) includes family variables in the form of context characteristics; however, this model falls short given that the multiple influences that family variables can exert have not been explored (Mitrani et al., 2006). It is important to include the family’s perspective when studying the issues pertaining to Mexican caregivers of older adults given the transformation in structure, composition, size, and function of Latin American families that result from the ever-changing social and economic conditions in the region (Huenchuan, 2013).
Furthermore, assessing the caregiver phenomenon within a non-Anglo-Saxon environment demands a cultural relativity approach, as this cultural aspect has not been duly considered in research within the Stress Process Model. In this regard, Díaz-Loving (2011) stated that psychological researchers must consider every particular ecosystem and its specific participants to correct the possible universal bias that generalizes unproven assumptions in different idiosyncratic populations. Hilgeman et al. (2009) highlighted the importance of considering the cultural background of family caregivers by taking into account their cultural differences while applying the Stress Process Model because research has proven that Hispanic caregivers cope differently with this role than Caucasian and African American caregivers. In addition, Chakrabarti (2013) affirms that cultural factors have traditionally received the least research attention within the stress framework model for caregivers; this constitutes an important limitation to the model because the cultural context influences the whole of the caretaking experience by defining responsibilities and ways of coping with different care demands.
Within Mexican ethnic psychology, abnegation is considered to be a trait strongly influenced by sociocultural and historic premises, in which self-modification is preferred over self-assertion (i.e., denying one’s own needs and desires while favoring those of others) (Díaz-Guerrero, 2007). Abnegation is defined as the “behavioral disposition for other’s needs to be more important than our own, or the act of sacrificing oneself for the benefit of others” (Díaz-Guerrero, 1993, p. 4). Abnegation has been documented in studies concerning caregivers (Luengo, Araneda, & López, 2010) and has been identified as one reason why individuals care for their sick older adult family members. Caregivers thus become burdened with work and demands, which should ideally be distributed among family members and/or social or community institutions. This burden is detrimental to caregivers’ own well-being. In the current study, abnegation was incorporated in sociocultural and family variables, with the aim of better understanding the well-being of Mexican caregivers.
The purpose of the current study was to generate exploratory evidence regarding sociocultural and family influences within the Stress Process Model and to address the following question: Can sociocultural and family resources mediate the relation between burden and subjective well-being of Mexican caregivers of older adults? The authors hypothesized a statistically significant result for this mediation. Therefore, the objective of the current study was to analyze the influence of caregiver burden on caregiver well-being by exploring the mediating role of sociocultural and family resources.
By means of a nonprobabilistic sampling by convenience, data were obtained from 386 caregivers in the city of Hermosillo, Mexico. Inclusion criteria were (a) to be a relative of the older adult, (b) to live with the older adult or visit him/her at least once per week, and (c) to assist the older adult in at least two activities indicated in the functional dependency checklist (refer to Instruments section below). This checklist shows older adults’ needs to perform basic and/or instrumental activities of daily living.
Caregivers were between ages 19 and 87 (mean age = 49.05; SD =12.41 years), and most were women (88.1%). Of caregivers, 66.8% had spouses. Most caregivers had attended middle school (38.3%), and 29.5% possessed a Bachelor’s degree. Approximately one half had a paying job, with 62.4% reporting a monthly income <9,000 Mexican pesos (MXN) and 37.4% reporting a monthly income >9,000 MXN. Most caregivers were the older adult’s child (76.2%). The amount of care time for older adults ranged from 1 month to 60 years (average = 7.7 years). Older adults receiving care ranged in age from 60 to 102 (mean age = 78.29; SD = 8.5 years) (Table 1).
Sociodemographic Data of the Study Participants (N = 386) and Older Adult Care Recipients
As per the caregiving activities reported by caregivers, a classification scale to record caregiver type was created, demonstrating that 26.7% of caregivers were sole caregivers, 36.5% were main caregivers (i.e., individuals who had family support to perform caregiving tasks, yet invested the most time and effort in comparison to other family members), 29.5% served as co-caregivers (i.e., equal distribution of labor among all family members), and 7.3% were secondary caregivers (i.e., a different family member invested more time and held more responsibilities regarding caregiving).
To identify the caregivers’ activities that older adults depended on most, a checklist was applied that incorporates two geriatric evaluation indices whose original versions were modified by Domínguez-Guedea (2005) based on the proposal of Shah, Vanclay, and Cooper (1989). The indices used were the (a) Barthel Index (Mahoney & Barthel, 1965) and (b) Instrumental Activities of Daily Living Scale (Lawton & Brody, 1969). The current authors added items regarding the older adults’ capacity to communicate and maintain social relations. The checklist contains 18 items that indicate the level of aid that older adults require to perform basic and instrumental activities of daily living. Checklists were completed by the caregivers using the following response options: (1) does not need help to perform the activity; (2) performs the activity using the caregiver’s help; and (3) is totally dependent on the caregiver to perform the activity. A questionnaire concerning the sociodemographic data of the caregiver and older adult was also completed. Instruments to measure psychological variables were also applied.
Well-Being. The 20-item Subjective Well-Being Scale for Family Caregivers of Elder Persons (EBEMS/CFAM; Domínguez-Guedea et al., 2011) measures the frequency of the caregiver’s positive and negative affects during the past month and grades personal satisfaction and material possession satisfaction throughout their entire life. Cronbach’s alpha of the EBEMS/CFAM was 0.74 for the positive affect factor (4 items), 0.82 for the negative affect factor (4 items), 0.84 for the personal satisfaction factor (6 items), 0.91 for the material satisfaction factor (6 items), and 0.92 for overall internal consistency (Domínguez-Guedea et al., 2011). The EBEMS/CFAM uses a 4-point Likert-type scale, ranging from 1 (always) to 4 (never) for positive affects and inversely from 1 (never) to 4 (always) for negative affects, whereas personal satisfaction and material satisfaction range from 1 (not at all satisfied) to 4 (highly satisfied). In the current study, the EBEMS/CFAM item scores were averaged for an overall score that ranged from 1 to 4, with 4 indicating the highest level of well-being.
Abnegation. The 8-item Abnegation Scale for Family Caregivers of Elder Persons (EAb/CFAM; Domínguez-Guedea & Díaz-Loving, in press) measures the frequency in which the caregiver believes others to be more important than him- or herself or are willing to make sacrifices for the benefit of others. The EAb/CFAM uses a 4-point Likert-type scale, ranging from 1 (never) to 4 (always). The EAb/CFAM contains two factors: (a) self-modification to avoid possible family tension factor (Cronbach’s alpha = 0.90) and (b) self-sacrifice to satisfy family needs (Cronbach’s alpha = 0.83); the overall internal consistency of the entire scale is 0.90 (Domínguez-Guedea & Díaz-Lvoing, in press). The EAb/CFAM item scores were averaged to obtain an overall score. Scores ranged from 1 to 4, with 4 indicating the highest level of abnegation.
Burden. The 6-item Burden Scale for Family Caregivers of Elder Persons (ES/CFAM; Domínguez-Guedea, 2008) was used to measure the frequency of caregiver burden resulting from ongoing daily life. The ES/CFAM uses a 4-point Likert-type scale, ranging from 1 (never) to 4 (always). The overall internal consistency of the entire scale is 0.86 (Domínguez-Guedea, 2008). Item scores were averaged to obtain an overall score. Scores ranged from 1 to 4, with 4 indicating the highest level of burden.
Social Support. The 27-item Social Support Scale for Family Caregivers of Elder Persons (EAP/CFAM; Domínguez-Guedea et al., 2013) measures how frequently caregivers receive support when they need it and how satisfied they are with this support. The EAP/CFAM has four factors: (a) practical (Cronbach’s alpha = 0.93), (b) economical (Cronbach’s alpha = 0.95), (c) emotional (Cronbach’s alpha = 0.91), and (d) guidance (Cronbach’s alpha = 0.89). The scale was used to measure social support satisfaction with a 5-point Likert-type scale, ranging from 1 (never) to 5 (always), and satisfaction with a 5-point Likert-type scale, ranging from 1 (not at all satisfied) to 5 (highly satisfied). For the analysis of the current study, item scores regarding satisfaction were averaged for an overall score ranging from 1 to 5, with 5 indicating the highest level of social support satisfaction.
Family Environment. The Family Environment Scale for Family Caregivers of Elder Persons (ESAF/CFAM; Domínguez-Guedea, 2014) was used to measure how frequently caregivers perceived a positive family environment. This instrument has three subscales and contains five items that measure family organization and cohesion (Cronbach’s alpha = 0.82), five items that measure family conflicts (Cronbach’s alpha = 0.82), and four items that measure family recreational activities (Cronbach’s alpha = 0.80) (Domínguez-Guedea, 2014). The ESAF/CFAM uses a 4-point Likert-type scale ranging from 1 (never) to 4 (always). For the purpose of the current study, family conflict items were reverse-coded to measure positive family environment. Item scores were averaged for an overall score ranging from 1 to 4, with 4 indicating the highest level of positive family environment.
The current study as part of a larger ongoing project was approved by the Commission of Bioethics and Research of the Medicine and Health Sciences Department of the University of Sonora. This commission is registered with the Office for Human Research Protections and has complied with the terms of the Federalwide Assurance, thus institutional review board approval was received.
This study has a nonexperimental, cross-sectional design. Participants for the sample were selected from several institutions and organizations that provide services and activities for older adults, such as community clinics, general hospitals, mental health centers, older adult caregiving support groups, and religious groups in the community. To obtain access to participants, the research team provided pertinent information and support for those who participated. This was done to comply with the request made by the institutions and organizations where participants were contacted. This support came in the form of an information packet, which summarized the project’s objectives, procedures, and ethical implications and was given to every potential participant. Research team members were available to answer questions, and those candidates who accepted participation in the project read and signed a letter of informed consent.
Study interviewers agreed to apply some instruments in the same sequence. Thus, the survey for sociodemographic data and the index of functional dependency were based on a structured interview. Additionally, the scales in the instrument section were answered in an independent manner by caregivers or with the help of the interviewer, if requested. At the end of the data collection sessions, a support group and institution directory listing of personal and family services was given to each participant. The estimated time frame for data collection and instrument application was five sessions, which took place at caregivers’ homes or another place indicated by study participants.
The descriptive statistics and bivariate correlations for continuous variables used in the model to analyze and achieve the objective of the current study are shown in Table 2. On average, caregivers obtained high scores for social support satisfaction, abnegation, and positive family environment and intermediate scores in burden items and subjective well-being. In addition, the correlation between variables was significant, showing the need for subsequent analysis within the context of structural relationships. The magnitude of the correlations did not have multicollinearity problems because all variables had variance inflation factors <5.
Descriptive Statistics and Bivariate Correlations for Continuous Variables in a Model of Well-Being (N = 386)
Prior to analyzing the influence of burden and sociocultural and family resources on caregiver well-being, a confirmatory factor analysis (CFA) of the measurements was conducted (Table 3). The CFA of the burden scale indicated a good fit with five items, including emotional weariness, having less leisure time, worries, financial difficulties, and health problems. The individual model explained 99% of variance in burden with a moderate fit.
Structural Equation Model for Latent Variables in the Final Model of Well-Being (N = 386)
On the other hand, the sociocultural and family resources were integrated by relevant factors to this study: social support satisfaction, abnegation, being a sole/main caregiver, and positive family environment. It is important to note that the caregiver type was dichotomized, with 1 designated as sole/main caregiver and 0 designated as secondary or co-caregiver. The CFA found a good model fit, meaning that more social support satisfaction and positive family environment, less abnegation, and being a sole/main caregiver explained 99% of variance in sociocultural and family resources.
Well-being was not considered a latent variable (i.e., it was not necessary to use CFA to assess its own single model) because in this case, it was integrated in the structural equation model (SEM) as an observed variable conformed by the mean of scores from the four factors in the EBEMS/CFAM.
After its specification, the model was identified and estimated. An SEM was conducted, organizing the input of the variables according to the conceptual components previewed in the Stress Process Model but taking into account family and sociocultural variables. The SEM analysis consisted of the input of variables of the sociocultural and family resources as a mediator for perception of burden to explain caregivers’ subjective well-being. The results of the SEM analysis are shown in the Figure.
Structural equation model of subjective well-being in caregivers (N = 386).
Note. SRMR = standardized root-mean-square residual; RMSEA = root-mean-square error of approximation; df = degrees of freedom; CFI = comparative fit index.
The results showed that perception of burden had a negative direct affect on subjective well-being as well as on family environment, whereas sociocultural and family resources had a direct positive affect on subjective well-being and at the same time mediated the effect of burden over subjective well-being. To evaluate indirect effect, the Sobel test was used, resulting in a value significantly different from zero (Sobel test = 4.47, indirect effect = −0.27).
The method proposed by MacCallum, Browne, and Sugawara (1996) was used to calculate the power results produced by the study. A root-mean-square error of approximation (RMSEA) H0 = 0.08 was considered. The value of RMSEA obtained in this study was H1 = 0.04, df = 32, and α = 0.05 for a sample size of 386, which resulted in a statistical power analysis of 0.98 (i.e., the study has a 2% chance of stating a null hypothesis as true when it should be refused [error type II or b)].
No human characteristic exists or is exempt from influence because every characteristic finds its own meaning and greater expression in certain environments, including family and cultural systems, which have a great impact on individual growth (Bronfenbrenner, 1992). Thus, the complexity of culture and family influences should be studied in greater depth to overcome the individualist approach that prevails in the current family caregiver stress and well-being paradigm (Hsiao & Van Riper, 2010).
The results of the current study show that burden decreased well-being; however, the effect of burden on subjective well-being was diminished by the mediation effect of sociocultural and family resources between burden and well-being. Thus, the investigation question that was initially put forth was answered, confirming the hypothesis that mediation of sociocultural and family resources is statistically significant and may reduce burden and increase well-being. The current results support some of the tendencies indicated in the research about family and caregiving.
Ray and Street (2011) explained that the relationship diversity within the family context tends to be of help for caregivers, in such a way that family acts as one of the main support sources for the caregiver; in addition, Ray and Street (2011) emphasized that aspects of the family dynamics, such as the lack of support and decreasing frequency of contact with family members, are related to the decrease in the caregiver’s well-being over time.
The results obtained from the current study support the notions and ideas proposed by other researchers that underline the significance of considering family context as an important part of the caregiver stress and well-being paradigm. A good example of this proposal is embodied in the work of Mitrani et al. (2006), which identified family functioning as a mediator for the impact of burden on caregiver distress levels and, consequently, proposed family interventions aimed to increase cohesion and communication among family members, including the care recipient. Zehner and Walker (2014) also included family aspects in their research of the stress-process framework and found that perceived family demands were associated with caregiver health problems. Stansfeld et al. (2014) found that caregivers are exposed to family stressors other than those directly related to the caregiving task, thus support should be aimed not only at their caregiving needs, but also at other crucial aspects of their lives.
According to Gupta (2009), a family is defined by its members and the sociocultural environment in which it develops; therefore, culture is an important factor to consider when discussing caregiver well-being, as it influences family members’ behavior and the caregiver’s own behavior. Such behavior is ruled by norms imposed by the group to which the caregiver belongs, thus the culture establishes these parameters that will determine the group’s behavior (family) and the value conferred to them (Díaz-Loving, 2011). This being the case, the family is the social group within which the caregivers develop and regulate their behavior and at the same time within which the family passes on socioculturally defined values and norms that shape the caretaking experience as a whole (Chakrabarti, 2013).
Many sociocultural factors define the family dynamics of caregiving; the current study addresses abnegation as a characteristic of a strong cultural influence, a characteristic not found in the original Stress Process Model. The results of the current study suggest that a greater disposition toward abnegation implied lower resources for the protection of caregiver well-being. This finding is in agreement with the findings of Knight and Sayegh (2010) who proposed the Sociocultural Stress and Coping Model for caregivers; the authors identify the indirect relationship between adhesion to cultural values, such as fulfillment of family obligations, and the cultural tradition of caring for older family members, with the presence of psychological symptoms, depression, and poor health of the caregiver.
The current study has limitations that are inherent to a cross-sectional investigation in terms of the causality of its results. In this sense, the structural model that was analyzed and the mediation relations that were identified should be interpreted as exploratory and not as confirmatory causal relationship findings between variables. Furthermore, the use of a nonprobabilistic sampling hinders the ability to generalize these results to other caregiver samples.
The results of the current study suggest that to improve and strengthen caregivers’ resources, cultural and family aspects must be taken into account. Therefore, it is important to promote the involvement of other family members in the caregiving process, a positive family environment, and social support, as well as decreased abnegation of the caregiver. This improved family atmosphere will allow for the development of interventions that will help better satisfy caregivers’ needs. Professionals who integrate their interdisciplinary teams, such as nurses and other health care providers, should take into account cultural and family dynamics to offer better guidance and a more comprehensive care service.
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Sociodemographic Data of the Study Participants (N = 386) and Older Adult Care Recipients
| Female||340 (88.1)|
| Male||46 (11.9)|
| 19 to 41||122 (31.6)|
| 42 to 64||230 (59.6)|
| 65 to 87||34 (8.8)|
| Middle school||148 (38.3)|
| High school||119 (30.8)|
| Bachelor’s/postgraduate degree||114 (29.5)|
|Relationship with older adult|
| Child||294 (76.2)|
| Spouse||28 (7.3)|
| Grandchild||21 (5.4)|
| Sibling||16 (4.1)|
| Otherb||27 (7)|
| Female||273 (70.7)|
| Male||113 (29.3)|
| 60 to 74||122 (31.6)|
| 75 to 89||230 (59.6)|
| 90 to 102||34 (8.8)|
Descriptive Statistics and Bivariate Correlations for Continuous Variables in a Model of Well-Being (N = 386)
|Continuous Variable||Mean (SD)||VIF||Abnegation||Positive Family Environment||Emotional Weariness||Have Less Leisure Time||Worries||Financial Difficulties||Health Problems||Subjective Well-Being|
|Social support satisfactiona||3.96 (0.88)||1.42||−0.16**||0.46**||−0.28**||−0.28**||−0.27**||−0.39**||−0.21**||0.483**|
|Positive family environmentb||2.92 (0.64)||1.30||—||—||−0.18**||−0.18**||−0.23**||−0.17**||−0.08||0.35**|
|Emotional wearinessc||2.41 (0.68)||1.65||—||—||—||0.47**||0.519**||0.37**||0.44**||−0.39**|
|Have less leisure timec||2.53 (0.95)||1.56||—||—||—||—||0.45**||0.46**||0.41**||−0.39**|
|Financial difficultiesc||2.84 (0.87)||1.5||—||—||—||—||—||—||0.37**||−0.48**|
|Health problemsc||1.90 (0.89)||1.40||—||—||—||—||—||—||—||−0.31**|
|Subjective well-beingd||2.65 (0.60)||NA||—||—||—||—||—||—||—||—|
Structural Equation Model for Latent Variables in the Final Model of Well-Being (N = 386)
|Latent Variable and Indicator||β||CFI||RMSEA (CI = 90%)||SRMR||Chi-Square (df)||p Value|
|Sociocultural and family resources||0.99||0.045 [0.000, 0.120]||0.029||3.57 (2)||0.167|
| Social support satisfaction||0.94|
| Sole/main caregiver||−0.18|
| Positive family environment||0.49|
|Burden||0.99||0.060 [0.015, 0.0105]||0.026||11.96 (5)||0.035|
| Emotional weariness||0.71|
| Have less leisure time||0.69|
| Financial difficulties||0.60|
| Health problems||0.59|