HEALTH-RELATED QUALITY OF LIFE OF
RURAL THAI FAMILY CAREGIVERS
By
Saowaluk Netchang

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILSOPHY
Nursing
2012

ABSTRACT
HEALTH-RELATED QUALITY OF LIFE OF
RURAL THAI FAMILY CAREGIVERS
By
Saowaluk Netchang
Background/Purpose: The number of older Thai people is projected to increase every year, and
most of them experience problems, such as changes in mental and physical status. They also
need help with activities of daily living. Increasing dependence of chronically ill elders results in
a need for more family members to care for them. Studies have shown that family caregivers
experience physical difficulties as a result of assisting with elders’ increasing impairments and
behavioral problems. Caregivers’ functional status as an ability to perform their own daily life
tasks was considered to be one of the important variables in the caregiving role that may
influence caregiver health-related quality of life (HRQOL). The primary purpose of the study
was to examine a model in which selected family caregiver and elderly care recipient (ECR)
characteristics were hypothesized to predict HRQOL among rural Buddhist Thai family
caregivers. Framework: The study was guided by the revised Wilson and Cleary model for
HROQL, a conceptual model of client outcome assessing caregiver HRQOL. Specific Aims: To
examine (1) the relationships among the following variables: family caregiver characteristics
(age, sex, relationship to ECR, religious activities, chronic health conditions, household income,
and social support), ECR characteristics (age, sex, levels of physical disability, and ECRs’
symptoms), length of caregiving, caregiver tasks of care, rewards of caregiving, and caregiver
functional status; (2) the relationships among family caregiver characteristics, ECR
characteristics, selected variables from Specific Aim 1, and overall HRQOL of rural Buddhist
Thai family caregivers; and (3) whether the relationship between family caregiver functional

status and overall HRQOL of family caregivers is mediated by the rewards of caregiving,
controlling for all other variables. Methods: This study was a cross-sectional, descriptive study
conducted from October 2011 to January 2012 at two primary care units in two rural districts in
the Uttaradit province of northern Thailand. The study sample included rural primary family
caregivers of ECRs who had one or more chronic conditions and needed assistance for two or
more ADLs at home for at least three months. A total of 201 family caregivers were included.
Results: (1) Younger male caregivers with few chronic health conditions and caring for ECRs
with fewer symptoms were more likely to have better functional status than were older female
caregivers with more chronic health conditions and caring for ECRs more symptoms. (2). Older
and spousal caregivers participating in more religious activities, who had few chronic health
conditions, better functional status, higher perceived social support, and higher perceived
rewards of caregiving were most likely to have a greater overall HRQOL. (3) Rewards of
caregiving appear to significantly, partially mediate the relationship between caregiver functional
status and overall HRQOL. Implications: Positive aspects of caregiving include religious
activities, social support and rewards of caregiving, and are to be of concern for health care
teams. Hospital and/or community health care providers are able to improve caregivers’ overall
HRQOL by offering training programs or discharge plans that include knowledge and skills
suited to their elders’ conditions. In addition, in wards or primary care units, private rooms with
the Buddha image for praying or chanting and meditating would allow caregivers to participate
in religious activities when their elders are admitted. Also, the Ministry of Public Health should
request an annual budget to fund educational institutes of nursing for research and nursing
education not only on elders, but also on family caregivers.

This dissertation is dedicated to my family:
To my beloved mother, Somsri Netchang, and father, Boonklue Netchang, for their inspiration,
patience, and hard work, and to my sister, Taweevan, and brother, Komgrich, who have been
taking good care of our mom and dad while I have been away; I could not have completed this
dissertation or any of the doctoral program without their constant love, encouragement and
support.
A special dedication in memory of my grandmother. Her pride in my accomplishments meant the
world to me. She was so proud of all my successes and been with me at every one of my
previous graduations.
I wish she was still here to see me complete this dissertation and graduate. Please be in peace.

iv

ACKNOWLEDGEMENTS

Since the beginning of the program, I have experienced lots of challenging situations. It
has felt as though sometimes I am climbing up and going down hills, or into chasms of various
levels of height and depth. Along the way, I have met many brilliant people who I would like to
thank, even though my appreciation in words might not be enough.
I would like to acknowledge Dr. Barbara Given for her guidance and support throughout
the process of dissertation completion. The expertise and knowledge she has shared and the time
she has given me, as well as unending patience with my writing, have allowed me to accomplish
my degree. She is a good model of the researcher; I wish I could do just half of what she has
done.
I would also like to acknowledge all of the other members of my dissertation and
guidance committees: Dr. William Corser, previous major professor, for his initial guidance,
encouragement, and support at the beginning of proposal development; Dr. Louise Selanders and
Dr. Zhenmei Zhang for their shared knowledge, expertise and support; and Dr. Amita Chudgar
for her statistical expertise, guidance and support. I would like to thank the first advisor, Dr.
Linda Spence for her warmth and kind support since I first entered the PhD program.
I would like to acknowledge the various sources of funding I received, which supported
my doctoral education as well as my dissertation. Specifically, I would like to acknowledge the
funding I received from: the Thai government through Boromarajonani College of Nursing,
Uttaradit, Praboromarajchanok Institute for Health Workforce Development, the Ministry of
Public Health; funding from the Graduate School at Michigan State University–which included a

v

Summer Support Fellowship and a Dissertation Completion Fellowship–and funding from the
Michigan State University College of Nursing, which included the Dean’s Fellowship.
In addition, I need to acknowledge the sites, Pasao and Bantha Primary Care Units, which
allowed me to recruit family caregivers, and the nurses and health care providers at these sites
who identified individuals for my study. I would also like to thank my colleagues at
Boromarajonani College of Nursing Uttaradit for their coordination in data collection, especially
Seubtrakul Tantalanukul for his immense help. Special thanks go to the elders and their family
caregivers who participated in the study. Without their help, I would not be able to achieve my
goal.
I give special thanks to the faculty and staff of the Michigan State College of Nursing for
providing me with various fields of knowledge and experiences both in nursing and research
practice. My gratitude also goes to my cohorts, Phanarat Chenchop, Arunee Chaiyarit, Chia Tai
Hung, Lisa Singleterry and all the other classmates and students in the program. Each and every
one of them has given me friendship, support, feedback, and encouragement when needed. I
would also like to thank all my friends in Thailand and in other universities in the United States
and United Kingdom, who always mentally support me via social networks.
Lastly, I would like to acknowledge again my family who has provide me support and
encouragement during this process. Also, I would like to thank my love, my personal English
instructor, John Gamble, who for the last five years has been at my side helping me when things
became difficult and made me laugh when I was feeling down. He has helped me so much when
things got hard, and he always kept me going with words of encouragement.

vi

TABLE OF CONTENTS

LIST OF TABLES

ix

LIST OF FIGURES

xi

CHAPTER 1
INTRODUCTION
HRQOL among Family Caregivers
Caregiving of Chronically Ill Elders in Rural Thailand
Significance of Study
Specific Aims
Purpose of Study

1
3
8
20
23
24

CHAPTER 2
CONCEPTUAL FRAMEWORK
Characteristics of the Individual Caregiver
Characteristics of Rural Thai Family Caregivers
Characteristics of ECR
Characteristic of Environments
Caregiver Functional Status
Overall HRQOL of Family Caregivers
Summary

25
31
31
34
35
37
37
38

CHAPTER 3
LITERATURE REVIEW
HRQOL of Caregiver
Functional Status of Caregiver
Relationships between Caregivers’ HRQOL and Functional Status
Influences on Family Caregiver HRQOL
Summary

41
41
46
48
51
59

CHAPTER 4
METHODS
Research Design
Subjects
Settings
Sample Size
Instruments
Procedure for Data Collection
Plan for Data Management
Plan for Data Analysis
Human Subjects Protection

62
62
63
64
65
65
72
74
76
77
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Women and Minority Inclusion in Clinical research
CHAPTER 5
RESULTS
Study Measures
Predictors/Covariates
Dependent Variable
Sample
Results and Analysis
Specific Aim 1
Specific Aim 2
Specific Aim 3
Additional Analysis
Power
Summary

79

82
83
83
89
90
97
97
100
103
107
110
110

CHAPTER 6
DISCUSSION & IMPLICATIONS
Discussion of Sample
Discussion Results for Specific Aim 1
Discussion Results for Specific Aim 2
Discussion Results for Specific Aim 3
Discussion of Additional Analysis
StudyLimitations
Implication for Nursing Practice
Implication for Research
Implication for Policy
Conclusion/Summary

112
112
113
116
122
126
131
133
134
136
138

APPENDICES
APPENDIX A - Study Instrument (Thai-Translated Version)
APPENDIX B - Study Instrument (English Version)
APPENDIX C - Study Consent Form (Thai-Translated and English Versions)
APPENDIX D - IRB Approval Letter
APPENDIX E – Permission for Models

140
161
177
186
189

REFERENCES

193

viii

LIST OF TABLES

Table 1: Summary of Study Measures

80

Table 2: Reliability Coefficients for Study Instruments

90

Table 3: Sample Characteristics of Caregivers and Elderly Care Recipients, N and %
for Categorical Variables

93

Table 4: Caregiver Religion and Religious Activities

93

Table 5: Clinical Characteristics of Caregivers and Elderly Care Recipients, N and %
for Categorical Variables

94

Table 6: Sample Characteristics of Caregivers and Elderly Care Recipients, μ and SD
for Continuous Variables (N = 201)

95

Table 7: Categorical Sociodemographic Characteristics of Caregivers, Caregiver
Functional Status and Overall HRQOL

97

Table 8: Correlation Estimates of Caregivers’ and Elderly Care Recipients’ Characteristics
and Caregiver Functional Status (N = 201)

99

Table 9: Coefficients for Final Linear Regression Model Indicating Significant Predictors
of Caregiver Functional Status

100

Table 10: Correlation Estimate of Caregiver’s and Elderly Care Recipients’ Characteristic,
Other Selected Caregiving Factors and Overall HRQOL (N = 201)

102

Table 11: Coefficients for Final Linear Regression Model Indicating Significant Predictors
of Caregiver Overall HRQOL

103

Table 12: Coefficients for Linear Regression Model Indicating Caregiver Functional Status
as a Significant Predictor of Rewards of Caregiving

104

Table 13: Coefficients for Linear Regression Model Indicating Caregiver Functional Status
as a Significant Predictor of Overall HRQOL

105

Table 14: Model Summary for Multiple Regression Indicating the Variance of Caregiver
Functional Status and Rewards of Caregiving in Predicting Caregiver Overall
HRQOL

106

Table 15: Coefficients for Multiple Regression Model Indicating Caregiver Functional
Status and Rewards of Caregiving as Significant Predictors of Overall HRQOL

106

ix

Table 16: Correlation Estimate of Significant Caregiver’s Characteristic, Other Selected
Caregiving Factors and Rewards of Caregiving (N = 201)

108

Table 17: Categorical Sociodemographic Characteristics of Caregivers and Rewards of
Caregiving

109

Table 18: Coefficients for Final Linear Regression Model Indicating Significant Predictors
of Rewards of Caregiving

110

Table A1: Caregiver Religious Activities Questions (Thai)

141

Table A2: Personal Resource Questionnaire Part II (PRQ85-II; Thai)

145

Table A3: Rewards of Caregiving (Thai)

147

Table A4: Memorial Symptoms Assessment Scale – Section 1 (Thai)

152

Table A5: Memorial Symptoms Assessment Scale – Section 2 (Thai)

154

Table A6: Oberst Caregiving Burden Scale (Thai)

155

Table A7: Ferrans and Powers Quality of Life Index, Part 1 (Thai)

157

Table A8: Ferrans and Powers Quality of Life Index, Part 2 (Thai)

159

Table B1: Caregiver Religious Activities Questions

162

Table B2: Personal Resource Questionnaire Part II (PRQ85-II)

166

Table B3: Rewards of Caregiving

168

Table B4: Memorial Symptoms Assessment Scale – Section 1

170

Table B5: Memorial Symptoms Assessment Scale – Section 2

172

Table B6: Oberst Caregiving Burden Scale

173

Table B7: Ferrans and Powers Quality of Life Index, Part 1

175

Table B8: Ferrans and Powers Quality of Life Index, Part 2

177

x

LIST OF FIGURES

Figure 1: Revised Wilson and Cleary model for health-related quality of life

28

Figure 2: A modified model of the study: Caregiver health-related quality of life

30

Figure 3: Data vollection flowchart

74

Figure 4: Summary model of the partial mediation of rewards of caregiving in
the relationship between caregiver functional status and their overall healthrelated quality of life (HRQOL)

107

xi

Chapter 1
Introduction
The ability of family members to continue to provide care for their elderly relatives in the
context of the demographic and social changes of Thailand has been a critical concern for many
researchers (Caffrey, 1992; Chan, 2005; Subgranon, 1999; Subgranon & Lund, 2000). While the
number of elderly continues to rise, the increasing dependence of chronically ill elders results in
a need for more family members to care for them. The more dependent the elderly are, the more
difficulties family caregivers experience and the more help they need to provide proper care.
The purpose of this study was to examine a relationship in which selected family
caregivers’ and elderly care recipients’ (ECR) characteristics, including the caregivers’ task of
care, are hypothesized to influence or be related to Heath-Related Quality of Life (HRQOL)
among rural Buddhist Thai family caregivers of ECRs with one or more chronic conditions and
who possessed at least two activity-of-daily living deficits. In chapter 1, the problem statement,
significance, purposes, specific aims, and an overview of the study are discussed.
The number of older Thai people is projected to increase every year, and most of these
people experience problems such as changes in mental status, immobility, sensory deficit, and
sleep disorders; they also need help with personal activities of daily living (Chan, 2005; Sasat,
2006). Additionally, more elderly individuals in Thailand have been diagnosed with chronic, but
manageable conditions such as stroke, cancer, dementia, congestive heart failure, and
Alzheimer’s disease due to improved medical therapies and technologies (Chan; Jordhoy et al.,
2007; Moons, 2004; Plasqui, 2008). The majority of Thai elders live with family in rural areas
where there is limited access to formal health care services (Ministry of Social Development and
Human Security [MSDHS], 2007).

1

The dramatic increase in the chronically ill, elderly population in Thailand has a
significant impact on families with ECRs and has resulted in the worsening physical and mental
health of many family caregivers (Chatcheydang, 2005; Chung, Nsu, Wang, Lai, & Kao, 2007).
The impact of caregiving on caregivers’ HRQOL may be due to (a) the effect of physical
exertion that produces muscle strain or pain; (b) negative changes on personal health-related
activities, such as diet and exercise; or (c) physiological effects of psychological distress on their
own chronic conditions, such as depression (Chatcheydang; Morimoto, Schreiner & Asano,
2003; Pinquart & Sorensen, 2007). Studies in Thailand have shown that family caregivers
frequently experience physical difficulties from direct care, such as muscle strain, low back pain,
and weakness of arms and legs as a result of assisting with ECRs’ increasing impairments and
behavioral problems (Chatcheydang). For this study, caregivers’ functional status as an ability to
perform their own daily self-care and household activities was considered an important variable
in the caregiving role that may influence their HRQOL.
In this study, it was hypothesized that family caregivers who care for ECRs with physical
disability tend to experience problems of caregiver functional status because of the degrees of
ECR disability, age- and disease-related symptoms, and increased caregiver tasks of care.
Moreover, this study also investigated whether or not caregiver functional status was influenced
by various characteristics of caregivers and ECRs, including environmental characteristics such
as social support, length of care, and the rewards of caregiving perceived by the caregivers.
Similarly, in the United States and Thailand, more care recipients are elders with an average age
of more than 60 years and are more often now diagnosed with one of these chronic illnesses:
cancer, stroke, dementia, or heart disease (Foundation of Thai Gerontology Research and
Development, FTGRD, 2009; National Alliance for Caregiving, NAC, 2004; 2009). Assistance

2

provided to elders with chronic diseases includes managing instrumental activities of daily living
(IADLs), along with everyday living and activities of daily living (ADLs) personal care activities
that may have an effect on caregivers’ ability to care.
Moreover, age- and disease-related symptoms, such as weakness, pain, fatigue, insomnia,
poor appetite, cognitive impairment, emotional and psychological behaviors, and so forth, are
other factors predicting care demands of the elderly (Chan, 2005; Chatcheydang, 2005; Given,
1995; NAC, 2009; Pinquart & Sorensen, 2007). However, family involvement in tasks of care
depends on elders’ physical disability in daily self-care activities; each form of involvement
demanding different skills and capacity, as well as psychological strengths, from family
members (Given; Given & Sherwood, 2006). Although there have been some U.S. studies that
have examined caregiver functional status and its relations in terms of physical function
(Fredman, et al., 2009; Tong et al., 2002), there are few published studies that have specifically
focused on caregivers’ functional status, influenced factors, and the consequences of providing
care for elders in Thailand.
The findings of this study will increase understanding about the relationship between
caregivers, ECRs’ characteristics, and caregivers’ functional status, particularly in rural Thai
family populations with few health care facilities. Moreover, the findings from this study should
provide essential knowledge concerning specific characteristics of caregivers and ECRs—
positive caregiving aspects in rural Buddhist Thai context—that can predict optimal caregivers’
health outcome, HRQOL.
HRQOL Among Family Caregivers
In Thailand, most family members providing care scarcely know how to care for an
elderly patient, regardless of the hospital or the institution in which care was given

3

(Chatcheydang, 2005; Jones & Peters, 1992; Subgranon, 1999). In some health care facilities in
rural areas, family caregivers may not receive adequate information about caregiving at home
because of insufficient time and a lack of knowledgeable health care professionals
(Chatcheydang). Under such circumstances, Thai family caregivers of chronically ill elders have
to find their own way to manage problems regarding the care they provide to their loved ones.
Caregiving tasks include managing ADLs, administering medication, and providing for other
needs, such as arranging everyday living -- housework, meal preperation, transportation, grocery
shopping and financial tasks, for instance (Subgranon & Lund, 2000). In the United States, 1,480
caregivers reported that 72% of care recipients they cared for are older persons with conditions
such as Alzheimer’s disease or confusion, cancer, mental or emotional illness, heart disease, and
stroke; long-term physical conditions are present in 69% of caregiving situations (NAC, 2009).
On average, caregivers spend 18 to 20 hours per week providing care, which includes
helping the care recipient get into and out of bed and chairs, assisting with housework, preparing
meals, administering medications, arranging transportation, shopping for groceries, arranging
outside services, managing finances, and assisting with personal care tasks such as getting
dressed, bathing or showering, toileting, dealing with incontinence, and feeding (FTGRD, 2009;
NAC, 2004).
Caring for an older individual with chronic conditions such as stroke, cancer, diabetes
mellitus, arthritis, or mental illness at home can place demands on a caregiver’s physical and
mental health (Caffrey, 1992; Chaoum, Intarasombat, & Putwatana, 1996; Frias, Tuokko, &
Rosenberg, 2005) and result in negative consequences to his or her emotional and physical health
(Barnes et al., 2006; Chatcheydang, 2005; Chung et al, 2007, Given & Sherwood, 2006). In
2005, Chatcheydang examined a model of relationships between caregivers’ characteristics and

4

HRQOL of Thai female family caregivers of elder stroke survivors. The study found some
negative health outcomes, such as anxiety, stress, depression, and fatigue, from providing longterm care at home. Kurtz, Kurtz, Given, and Given (2004) investigated the impact of cancer
caregiving at home on caregivers’ mental and physical health over a one-year period with a
sample of 491 caregiver/ patient dyads. Results showed that caregivers’ personal perceptions of
three dimensions of their caregiving experience (impact on schedule, lack of family support, and
social functioning) played a central role as determinants of caregivers’ both mental and physical
health (Kurtz et al.).
Consistently, Morimoto et al. (2003) examined the relationship between a caregiver’s
burden and HRQOL in family caregivers of older stroke patients in Japan. The study found that
an increased burden from multiple caregiver tasks of care was significantly related to worsening
HRQOL, particularly worsening mental health. Their results were consistent after controlling for
caregiver age, sex, chronic illness, average caregiving hours per day, and functional dependence
of the care‐recipient.
Similarly, in relation to the overall HRQOL of caregivers, Kim and Given (2008)
reviewed literature on the quality of life of cancer survivors’ family caregivers during the acute
phase (the period of diagnosis and treatment up to two years postdiagnosis), middle or long-term
survivorship phases, and the bereavement phase (one year posttreatment). Their findings
suggested that the quality of life of family cancer caregivers frequently varied along the illness
trajectory, just as the various types and amounts of assistance provided by caregivers varied,
indicating that further testing of family-based interventions across the trajectory of the illness
was needed (Kim & Given). Authors have concluded that family caregivers frequently
experience various problems from their caregiving experiences, including conflict within their

5

social roles, restrictions of activities, strain in marital and family relationships, psychological
distress, and diminished physical health (Kim & Given; Haley, LaMonde, Han, Burton, &
Schonwetter, 2003). Caring for the ECR with a positive attitude creates an overall sense of
satisfaction toward the experience and may help family caregivers to recognize the rewards of
caregiving. Rewards of caregiving may associate with the caregiver’s ability to perform their
daily life tasks and to care for the ECR. In addition, the caregivers’ ability to provide care may
also relate to their own quality of life, which is multidimensional and includes psychological,
mental, social, physical, spiritual, and behavioral components, not only during the time that they
are providing care but also throughout the trajectory of the illness.
Additional factors that may serve as either direct or indirect determinants of caregiver
HRQOL can include ECR characteristics—such as the extent of their symptoms, their disability
in personal care and everyday living, the severity of their health conditions, the types of
treatments and comorbidity—and caregiver characteristics—such as relationship to the ECR,
education, the length of care, and a positive aspect, the rewards of caregiving (Barnes et al.,
2006; Blanes, Carmagnani, & Ferreira, 2007; Chatcheydang, 2005; Chung et al. 2007; Kurtz et
al., 2004; Northhouse, Kershaw, Mood, & Schafenacker, , 2005; Rees, O’Boyle, & MacDonagh,
2001; Riedijket al., 2006). As shown in Chung et al.’s (2007) study, authors found elderly ADLs
deficits, sex, marital status of caregivers, and the presence of a primary caregiver to be
significant predictors of HRQOL of caregivers of chronically-ill elders. In the study of Chung et
al., most Taiwanese caregivers were female spouses who professed having religion, shared good
relationship with elders, had high functional status, and reported moderate HRQOL.
In Thailand and many other countries, caring for elderly persons with chronic illness has
become increasingly complex because of the increased number of age-related, preexisting

6

comorbid conditions many elders possess, which require more aggressive treatment protocols
and prolonged survival periods after diagnosis (Chatcheydang, 2005; Chung et al, 2007; Given &
Sherwood, 2006). Because more caregiving for chronic disease is now provided in home
settings, increased involvement in managing medication and finances and in arranging outside
services is frequently needed from family members. It is important for family members to
coordinate and actively participate in providing assistance with everyday living and personal care
for loved ones with chronic conditions (Chung et al.; Subgranon & Lund, 2000).
It has been demonstrated that a chronic illness experience can affect not only the
individual but also his or her family and friends (Given & Sherwood; Markowitz, Gutterman,
Sadik, & Papadopoulos, 2003; Morimoto et al., 2003; Pinquart & Sorensen, 2007). However, it
remains largely unknown what most significantly influences HRQOL levels for Thai elderly
caregivers (Chatcheydang; Sasat, 2006). Little is known about how ECRs’ and caregivers’
characteristics and other caregiving aspects subsequently influence caregivers’ functional status
and their HRQOL, particularly in rural Thailand settings where there are fewer health care
facilities (Barnes et al., 2006; Blanes et al., 2007; Chatcheydang; Sasat).
In Thailand, there are few research and supportive services focused on family caregivers
of chronically ill elders. Most prior studies have focused on caring for these elderly patients in
hospital settings (Sasat, 2006; Subgranon, 1999). The family caregivers of chronically ill elders
are briefly instructed on how to care of their relatives at home before hospital discharge
(Subgranon). Since 1993, some stroke survivors have been visited by home health-care teams,
including physicians, nurses, nutritionists, and social workers, every three months. However,
these home health-care programs are mainly focused on the patients’ needs and not those of the
caregivers, with most programs in Bangkok and several big cities. No current, established

7

special-supportive programs are known that directly aim to reduce psychological and physical
effects on rural family caregivers and/or enhance caregivers’ functional status and HRQOL
(Chatcheydang, 2005; Subgranon; Subgranon & Lund, 2000).
Regardless of whether or not family caregivers experience a positive or negative health
outcome, caregiving influences the caregivers’ overall life experiences. Because caregiving for
chronically ill persons, particularly elders, is a long-term commitment for family caregivers and
their loved ones, such commitment will likely influence the HRQOL of caregivers themselves.
Caregiving of Chronically Ill Elders in Rural Thailand
In Thailand, the prevalence of chronic diseases in elders—including stroke, cancer,
dementia, diabetes mellitus, heart failure, hypertension, and arthritis—is relatively high (Ministry
of Social Development and Human Security [MSDHS], 2007; Puangwarin, 2001). In 2005, the
Ministry of Information and Communication Technologies found that the group of individuals
who are aged 60 and older has the largest proportion of those who suffer from chronic diseases
or have personal unhealthiness (50% of all older persons). The northern part of Thailand,
including Uttaradit province, the purposed setting of the study, has the largest proportion of
chronically ill older persons at 59.2%. The statistical report of Uttaradit Hospital, a medical
center of Uttaradit Province in northern Thailand, revealed that the number of the patients
increased from 5,013 in 2009 to 7,085 in 2010 (Information Department of Uttaradit Hospital,
2010). It is therefore expected that the number of patients will continue to increase because of
the growing elderly population, the group most affected by those chronic diseases.
ECRs symptoms and disabilities that affect caregiver tasks of care. At present, most
Thai patients tend to be hospitalized for shorter lengths of stay than in the past because of the
high cost of care, as well as limitations in budget, nurses, and hospital beds (MSDHS, 2007;

8

Puangwarin, 2001). Therefore, patients with stable and noncrisis conditions are discharged
earlier from the hospital. However, the patients still need to have continuing care at home, so
family members must take on the caregiving role for their relatives. Ninety percent of the Thai
chronically ill elders who have been discharged from the hospital still have some disabilities
requiring care at home (Lausawatchaikul, 2001; Lawang, Sunsern, & Rodjarkpai, 2005; Periard
&Ames, 1993; Sasat, 2006), such as partial weaknesses, communication problems, cognitive
impairment, memory loss, and swallowing problems. Because of their disabilities, many elders
require help with IADL tasks, including housework, meal preparation, transportation, or grocery
shopping, and ADLs, including providing help getting in and out of bed and chairs, bathing, or
toileting. Moreover, ECRs’ care demands are caused by age- and disease-related symptoms such
as vision impairment, weakness, pain, fatigue, nausea, vomiting, insomnia, coordination
problems, poor appetite, constipation, bed sores, inability to concentrate, and so forth. (NAC,
2004; FTGRD, 2009).
Christ & Diwan (2010) reported the bio-psychosocial health needs of chronically ill
elders, who need information and education about illness, treatments, costs, health maintenance,
and services available to them. Also, ECRs need help in managing illness throughout the
different phases of the diseases—for example, prevention, diagnosis, treatment, remission and
exacerbation—and advanced illness, as well as material and logistical resources, such as
transportation and home care. Some elders need help in coping with the emotions that
accompany illness and treatment. The majority of elders with chronic illness need assistance in
changing their behaviors to minimize the impact of disease and increase the impact of treatment.
They also need assistance with managing their medication side effects and administration, as
well as coping with disruptions in their work, activities, family life, and social network. Finally,

9

financial assistance, including daily life expenses and managing and maintaining extra copay
health insurance, is frequently another need. Family caregivers are frequently the most important
people to help elders meet those needs.
Caregiver tasks of care from giving care for elders. ECRs’ disabilities and symptoms
increase their long-term dependency and needs, which demand some permanent care from other
professional care providers or caregivers when the elderly patients are discharged to their home.
ECRs’ conditions can worsen when coupled with the ECRs’ symptoms caused by the diseases,
including (a) the patients’ disabilities, as they are unable to help themselves because of weakness
or pain, and so forth, and the caregivers have to make every decision on the patients’ behalves;
and (b) the patients’ symptoms, such as frustration, irrationality, impatience, and bad temper or
mood.
The person who assumes the caregiver’s role will take more responsibility, which
includes (a) managing everyday living, such as providing transportation, shopping for groceries,
assisting with housework, managing finances, preparing meals, giving medication, and arranging
outside services; (b) helping with personal care, such as getting in and out of beds and chairs,
dressing, bathing, toileting, feeding, and dealing with incontinence; and (c) monitoring and
assisting with symptoms management, such as weakness, pain, fatigue, insomnia, constipation,
nausea, and vomiting, which may cause physical and psychological problems. Moreover,
monitoring and assisting with age- and disease-related symptoms in elders is challenging in
home care situations for family caregivers (Given & Sherwood, 2006), which may increase
caregiving demands and tasks of care that could result in a decrease in a family caregiver’s care
ability.

10

Caregiver functional status.
Physical function. The change in the caregiver’s lifestyle results in a change in physical
activities and behaviors. In other words, the caregiver’s daily routine has to be adapted because
of this new responsibility, including assisting the ECR with eating, exercising, and participating
in recreational activities (Chung et al., 2007; Fredman et al. 2009). At the same time, caregivers
must take time to maintain their own daily living activities. Family caregivers may be frustrated
when they are forced to change their daily life activities. Their caregiving also might lead to
feelings that they are not as strong as they used to be, and they could experience fatigue,
insomnia, and fear that they may not be able to provide good enough care. Some caregivers may
be afraid to be left alone with the ECRs (Caffrey, 1992; Chatcheydang, 2005; William, 1994). In
addition, long-term care requiring a large commitment of energy, resources, and time may lead
to changes in physical health. Caregivers may need to make decisions and carry out many
activities on behalf of the ECRs, which can lead to stress. This can be observed in different
physical symptoms, such as weight loss, headache, back pain, exhaustion, and lack of energy,
which will impact a caregiver’s ability to care for elders (Belasco et al., 2006; Blanes et al.,
2007; Bull, 1990; Krach & Brooks, 1995; Teel, Duncan, & Lai, 2001).
Psychological function. Caregivers may suffer from stress, anxiety, or strain, which is
caused by expanded and unprepared caregiving roles—including tasks of personal care and
everyday living management for ECRs— which is a result of the ECRs’ worsened conditions
and behavioral problems. Furthermore, caregivers’ psychological problems may result from the
environment and family surroundings. For instance, caregivers have to do household work
without the usual assistance, or financial problems could arise. Most importantly, psychological
problems may be a result of the caregivers’ own emotions, as they may feel that they cannot

11

provide appropriate care to the patients. They could not act to meet their own expectations and
therefore put blame on themselves, because of an imbalance between care demands and the
availability of resources to meet those demands (Belasco et al., 2006; Blanes et al., 2007; Given
& Sherwood, 2006; Teel, et al., 2001).
Interestingly, Shaw et al. (1997), Patterson and Grant (2003), and Vitaliano et al. (2003)
reported that psychological problems, such as burden and depression, may cause negative
hormonal changes, increase susceptibility to infectious agents, and disrupt health habits, such as
getting enough sleep and engaging in healthy eating patterns. In addition, depressed caregivers
may over report physical problems (Frias et al., 2005), which could associate with caregivers’
physical health and impact their ability to care for their elderly relatives.
Social function. When taking care of an elder at home, many caregivers may miss some
other social activities they’d usually participate in. Social function is one domain of the ability to
perform caregiving tasks (Wilson & Cleary, 1995; Ferrans, Serwic, Wilbur, & Larson, 2005) and
is indicated as the ability of the individual to interact in society in a normal or usual way, which
can be viewed from various perspectives (Ferrans et al.). As mentioned in physical and
psychological function, caregivers spend most of their time caring for an elder with a chronic
illness, resulting in a lack of time for their own social activities, such as maintaining
relationships with other family members and friends or participating in rest and recreation
(Caffrey, 1992; Northouse et al., 2002; Tang & Chen, 2002; William, 1994; Chatcheydang,
2005). Moreover, caregiving for chronically ill elders frequently has a strong influence on
normal social activities, which is due to physical and psychological problems; therefore,
caregivers cannot complete their social function needs. Similarly, for instance, Ebrahim and
Nouri (1987), Caffrey (1992), William, Northouse et al., (2002), Tang and Chen (2002) and

12

Chatcheydang (2005) pointed out that two thirds of the families of elderly stroke survivors spent
more time caring for the patients, and the provision of care affected their daily life activities.
Caregivers had to spend less time on their social activities and were unable to cope with
emotional problems, which created strain. Taking on the role of caring for elders with chronic
illness may impact the ability of caregivers to interact in society in the normal or usual way
(Belasco et al., 2006; Blanes et al., 2007).
Role function. By taking care of elders with chronic diseases, caregivers encounter
problems that are results of the diseases’ physical and mental effects on the elders. Caregivers
must respond to the patients’ constant needs, which require both time and effort and create
different perceptions in caregivers (Bakas, Lewis, & Parsons, 2001; Fredman et al., 2009; Tong
et al., 2002; Wilkins, Bruce, & Sirey, 2009). Hoyert and Seltzer (1992) studied underlying
factors in happiness and family activities and found that there were differences between
caregivers with responsibilities and caregivers without. In two studies, caregivers who had to
take care of chronic patients had poorer health statuses, less self-satisfaction, and more
depression (Nelson et al., 2008; Lu & Austrom, 2005). Additionally, when assessing the effects
of caring, the researchers found that being a caregiver led to other negative aspects, including
problems in household management, occupation, social activities, marital satisfaction, and health.
Caregivers have many roles to play in daily life, not only in caregiving. Caregivers may
suffer from attempting to fulfill all their roles, including caregiver, wife or husband, and
employee, as well as from attempting to perform those roles in line with expectations held by
themselves or by others (Knodel & Chayavan, 2011; Wright, 2000). Thus, some problems with
work or other daily activities can occur in family caregivers as a result of physical health or
emotional problems that might result from taking on multiple roles.

13

Environmental characteristic: social support. Family caregivers may experience
difficulties dealing with physical and emotional problems of chronically ill elders and strained
relationships with potential support providers, and thus, may feel overwhelmed, isolated, or
alone. They may experience difficulty communicating their needs to other family members and
health professionals because of a perceived lack of support (Sammarco, 2001).
Social support is indicated as an environmental characteristic of caregiving because of its
reported association with HRQOL in elderly caregiving (Northouse et al., 2002). Social support
is the perception that leads individual caregivers to believe they are cared for, loved, esteemed,
and valued, and that they belong to a network of communication and mutual obligation (Brandt
& Weinert, 1981; Sammarco, 2001). Social support may positively affect caregivers’ functional
status by reducing their stressors, including assisting with care tasks (Chappell & Reid, 2002),
helping to develop effective coping strategies (Losada, Montorio, Marquez, & Izal, 2005), and
promoting positive health behaviors (Tang & Chen, 2002). Also, Uchino, Kiecolt-Glaser, and
Cacioppo (1992) and Tong et al. (2002) reported that lower levels of social support were
associated with worse physical function in caregivers, while caregivers reported better
psychological well-being if they were highly satisfied with their social support in Ownsworth,
Henderson, and Chambers’s study (2010).
Buddhist beliefs. Buddhist beliefs that have been reported by rural Thai family
caregivers have involved karma, the concepts of boon (merit or good deed) and babb (demerit or
bad acts), which can be measured by the participation in religious activities (Sethabouppha &
Kane, 2005; Subgranon & Lund, 2000). The majority (94.5%) of Thais is Buddhist
(Wibulpolprasert, 2007), so, for this study, most caregivers were assumed to be Buddhist.
According to Buddhist beliefs, karma means action performed with intention. The law of karma

14

means that good acts will lead to good consequences and bad acts will lead to bad results
(Payomyong, 2000; Payutto, 1995, 1998). Thai Buddhist caregivers often strongly believed that
the reason they had to take care of their ill family members was the result of the law of karma in
their current and past lives. Accordingly, most of the caregivers performed boon, or good deeds
for their ill elderly family members, to achieve a better life in their next rebirth. Caregivers
followed Buddhism in caring for their chronically ill elders (Sethabouppha & Kane; Subgranon
& Lund).
In summary, in the traditional Thai culture, children have to take care of their parents,
and wives and husbands have to look after their spouses to show their love and feelings, as well
as the prime responsibilities for the children. A qualitative study of caregiving at home in
Thailand has confirmed that some caregivers believe caregiving of parents is a moral obligation
for sons and daughters, and also believe caregiving of spouses shows love and attachment
(Subgranon & Lund, 2000). Buddhist belief expressed as participation in religious activities has
been shown to be a resource that people use when facing a problem or dealing with a difficult
situation. Family caregivers of chronically ill elders may positively perceive their caregiving
role, which is hypothesized to enhance their HRQOL in long-term care at home.
Positive impact: rewards of caregiving. A growing number of previous caregiver
studies have reported that many caregivers could identify positive aspects of caregiving, such as
personal uplifts, becoming closer to family spiritually (Kinney & Stephens, 1989), rewards
(Picot, 1995; Picot, Debanne, Namazi, Wykle, 1997), gratifications (Motenko, 1989), or gains
(Kramer, 1997). In nursing research, positive aspects of caregiving have been discussed using
term such as rewards, uplifts of caregiving, caregiving esteem, caregiving satisfaction, gain in
the caregiving experience, and caregiver appraisal (Hunt, 2003). Numerous terms used to

15

represent rewards of caregiving included an improved relationship with the care receiver or other
family members (Kramer, 1993; Lawton et al., 1991; Picot), an increase in self-esteem (Karmer,
1993; Picot), a feeling of appreciation (Braithwaite, 1996; Picot; Stephens, Franks, Townsend,
1994), an enhanced sense of meaning or purpose (Karmer), and a feeling of pleasure (Picot).
Previously, it had been reported by Farran et al. (1991) that 90% of caregivers perceived
rewards of caregiving in various areas, such as the positive growth in family and social
relationships, the positive relationship they shared with the care recipient, the memories of an
accomplishment with others, the feeling of appreciation from the care recipient, and the feeling
of pride about the quality of care they provided. Also, rewards of caregiving have been reported
in terms of self-satisfaction, increased interactions between the caregiver and the care receiver
(Picot et al., 1997), and reduced feelings of difficulties for the caregiver (Riedel, Fredman, &
Langenberg, 1998).
More recently, Cohen, Colantonio, and Vernich (2002) examined the positive aspect in
caregiving and reported that 73% of the caregivers of seniors in rural communities could identify
at least one specific positive aspect of caregiving, and 69% could identify more than one. In fact,
some caregivers even reported significant gratification—such as satisfaction in life from caring
for their loved ones—or positive gains from caregiving, such as a positive self-view and spiritual
growth (Bacon, Milne, Sheikh, & Freeston, 2009; Cohen, Gold, Shulman, & Zucchero, 1994;
Folkman, 1997; Lawton et al., 1991; Motenko, 1988; Picot, 1995; Pinquart & Sorensen, 2003).
Kim, Schulz, and Carver (2007) and Helgeson, Reynolds, and Tomich (2006) reported
that positive effects result from traumatic events, including caregiving for chronically ill patients.
Similarly, researchers identified that domains of benefit finding included an accepting attitude
toward life, positive changes in self-view, a change in interpersonal relationships, and a deeper

16

sense of purpose in life with greater focus on important goals and priorities (Bower &
Segerstrom, 2004; Kim et al., Helgesons et al.). A meta-analytic review of benefit finding and
growth (Helgeson et al.) and other related studies (Kim et al.; Mock & Boerner, 2010) revealed
that benefit findings including rewards of caregiving were associated with life satisfaction,
depression, and positive well-being.
According to the positive experience of caregivers, the rewards of caregiving are one
aspect that needs to be assessed and understood. In the United States, Rachick and IngersollDayton (2004) reported that a few studies have pointed to the positive experiences of caregiving,
especially for men (e.g., Kramer, 1997), and husbands and wives (Fitting, Rabins, Lucas, &
Eastham, 1986). The results showed a greater proportion of husbands reported their relationships
with their spouses who had dementia had improved since they began providing care.
There is no unified or commonly accepted definition for those who mentioned positive
caregiving experiences, but most definitions include feelings of satisfaction in the ability to meet
challenges; an improved sense of self-worth; a sense of growing closer to the care recipient; and
the experience of warmth, comfort, and pleasure in caregiving (Motenko, 1989).
Providing continuous long-term care, including helping with IADLs and ADLs for ECRs
leads to some other benefit finding in elder caregiving experiences even in the midst of multiple
caregiver tasks of care.
Other caregiver factors related to rewards of caregiving. Previous research studies
both in Thailand and other countries have revealed that most of the caregivers of chronically ill
elders were spouses, children, and kinship of the patients (Chatcheydang, 2005; Joolamate, 1997;
Kasemkitwattana, 2006; Sasat, 2006; Pinquart & Sorensen, 2007). In Thailand, an estimated
90% of elders live with their children or relatives at home in rural areas, including most disabled

17

ECRs with chronic diseases (MSDHS, 2007; Subgranon & Lund, 2000). The major reasons for
family members to take care of elders in rural Thailand include Buddhist beliefs that (a) older
Thais should be offered a high status that demands care, respect, and obedience from their
younger children or relatives; (b) one has an obligation to care for one’s parents at home, causing
most Thais to refuse to let their parents move into an institution; and (c) every act, word, or
thought affects their later lives as they hope to receive good future care as a reward, according to
the law of karma (Sethabouppha, & Kane, 2005).
Motenko (1988) found that husband caregivers experienced a sense of competence and
pride from caring for their wives. Although few studies have explicitly examined relationship
differences in caregiver benefits, some evidence suggests that adult children experience more
rewards than spousal caregivers. For example, when comparing caregiving daughters and
caregiving sons with caregiving wives, adult children caregivers were more likely to report an
improvement in their relationship with the care recipient (Hinrichsen, Hernandez, & Pollack,
1992).
Similarly, in a study of husband and son caregivers, Harris (2002) concluded that sons
were more likely than husbands to experience gratification from caregiving. That is, caregiving
sons were particularly appreciative of the opportunity to pay back their parents for the nurturance
they had received. It may be that adult children experience more rewards because of qualitative
differences in caregiving responsibilities, with spousal caregivers having more intensive
responsibilities than adult children.
In the context of parents caring at home for an adult child with mental illness, Schwartz
and Gidron (2002) explored the positive aspects and rewards of caregiving. Specifically, the
authors measured the extent to which parents perceived their ill child as providing assistance and

18

support—practical and emotional—and perceived their own caregiving as emotionally and
mentally rewarding. In 2004, using a social exchange perspective and data from a national
sample of 978 spouse and child caregivers of older family members, Raschick and IngersollDayton assessed the association between caregiver relationship and gender and the costs and
rewards of caregiving. The authors also evaluated whether relationship and gender moderate the
effects of helpfulness on caregiver costs and rewards. Results supported the hypotheses that
women, whether wives or daughters, experience more caregiving costs than men, and that adult
children experience more rewards than spousal caregivers. In addition, care recipient helpfulness
was associated with a greater increase in rewards for spousal caregivers than for adult children
caregivers.
In Thailand, there are few published studies focused on the positive experience of family
caregiving, especially the rewards of caregiving. Researchers have seldom reported the factors in
caregiving that influence rewards of caregiving in the context of rural Thai family caregivers of
elders. However, some researchers found that caregiving for an older family member can also be
a satisfying and rewarding experience despite the possible stress imposed from managing one’s
life (Kopachon, 2002; Playpetch, 2002; Sethabouppha, & Kane, 2005). Kopachon examined
influences on preparedness, rewards of caregiving and factors in caregiver-role strain for those
providing care to patients with strokes and found that almost all caregivers are Buddhists (99%).
Caregivers had high scores in preparedness and rewards of caregiving, but had low scores in
caregiver-role strain.
Similarly, the study of Playpetch (2002) aimed at investigating how self-transcendence
and help from others influenced the rewards of caregiving among family caring for head-injured
patients in the recovery stage. The results showed that 99% of caregivers were Buddhists, and

19

the scores of the rewards of caregiving were relatively high. Age and the duration of time spent
being a caregiver were not related to the rewards of caregiving, but being a child of the patient,
self-transcendence, and help from others had a positive relationship to the rewards of caregiving.
As specifically mentioned above, Buddhist beliefs toward elders may impart a sense of
obligation on Thai caregivers to care for parents, and karma-based thought may create positive
feelings from assuming the role of family caregiver, such as the rewards of caregiving
(Sethabouppha, & Kane, 2005). In addition, Donprapeng (2006) and Kasemkitwattana, (2006)
proposed that a caregiver’s warm and supportive attitude toward the care recipient can
sometimes help the individual cope with the caregiver role. However, the influences of religious
activities resulting from Buddhist belief and karma-based thought on rewards of caregiving are
not known. Perceived the role as a positive experience of caregiving, rewards of caregiving may
positively influence caregivers’ functioning that ultimately affect improved HRQOL.
Significance of Study
As a result of the increase in the number of elderly Thais with chronic manageable
illnesses, more elderly Thais require assistance at home that is due to age-related physical and
mental deterioration (Sasat, 2006). More family members are now frequently required to assume
daily caregiver roles for their elderly relatives.
In rural areas, most Thai elders live with their children or relatives at home because
family members in rural Thailand believe in Buddhism. Buddhist beliefs dictate that older Thais
should be offered a high status, respect, and obedience from younger Thais, and that children
have an obligation to provide good care for their elders at home, leading most Thais to refuse to
let their parents move into a day-care institution. Moreover, Thai people believe in karma,
meaning that good acts, words, or thoughts affect their future lives as they wish to receive good

20

care in return when they are older (Payomyong, 2000; Payutto, 1995, 1998; Sethabouppha, &
Kane, 2005). This Buddhist belief and karma thought may help caregivers to accept what
happens in caregiving situations and roles, such that the rewards of caregiving are perceived.
These domains of religious-related benefit finding in elder caregiving may be perceived by
caregivers, and they are expected to be associated with caregivers' overall HRQOL.
In recent years, however, there has been a growing trend of business and economic
changes, resulting in the migration of young people to urban areas for work (Choowattanapakorn, 1999; Pongpaichit & Baker, 1996; Warr, 1997). As a result, the economy has drawn
large numbers of young adult Thai men and women from rural villages to larger cities and other
countries. In 2005, the study of the MSDHS demonstrated that these dramatic economic and
social changes have caused many elders to now live alone with their aged spouses at home.
Those ECRs who do not have a family member or spouse living with them frequently live alone
near other family relatives (MSDHS, 2007).
Consequently, rural Thai elders are frequently living at home with an elderly spouse,
older daughter or son, or grandchildren, and have limited health care facilities or support
(MSDHS; Subgranon & Lund, 2000). Because of the disabilities and bio-psychological needs of
ECRs, the long-term dependency and need of care increases. ECRs require permanent caring
from their family caregivers when they are discharged from the hospital. And so, the person who
takes on the caregiver’s role will take more responsible in an expanded role by helping with
IADLs and ADLs, which may lead to physical and psychological problems. Buddhist beliefs
might help the caregiver positively perceive existing phenomena of care as rewards of
caregiving, which will help improve caregiver’s HRQOL in the dimension of psychological
adjustment for taking on the caregiver role.

21

The goal of caring for elders with chronic diseases is not only to maintain health and
delay death of ECRs, but also to maintain or improve HRQOL of their caregivers. The concept
of HRQOL has frequently been discussed as a key element of nursing practice and clinical
outcome criteria (Ferrans, Serwic, Wilbur, & Larson, 2005; Wilson & Cleary, 1995). Although
some studies have been conducted in Thailand focusing on caregivers, they have focused on
other aspects (e.g., perceived burden, depression) of family caregivers, rather than the positive
aspects of caregiving, caregivers’ functional status, or HRQOL (Knodel & Saengtienchai, 1999;
Namthamongkolchai, Makapat, Charupoonphol, & Munsawaengsub, 2007). Nursing researchers
have increasingly attempted to clarify and measure relevant caregiving factors in order to
examine influences affecting caregivers’ HRQOL (Chan, 2005; Chung et al., 2007).
This was one of the first studies to explore those relevant negative and positive
caregiving aspects for specifically understanding caregivers’ functional status and HRQOL, and
for further research to develop appropriate interventions to improve Thai family caregivers’
HRQOL. The results of the study examined the relationship among caregivers’ clinical
outcomes, functional status and HRQOL, which will further affect sustainability of caring for
elders in the community.
Although it is especially challenging to support ECRs and family caregivers in Thai rural
areas where there are fewer health care facilities, few researchers have previously studied the
aspects of functional status and HRQOL including caregiving in rural settings. Most of the prior
studies have focused on caring for chronically ill elders in hospital settings, and very few studies
have focused on family caregivers (Chatcheydang, 2005; Knodel & Saengtienchai, 1999). In
response, this study filled the ongoing knowledge gap by examining (a) the relationship among
ECR and caregiver characteristics, ECRs symptoms, length of caregiving, social support,

22

caregiver tasks of care, caregivers’ functional status, and rewards of caregiving and (b) whether
rewards of caregiving mediate the relationship between Thai family caregiver functional status
and family caregiver HRQOL. Such results will be particularly innovative, contributing to the
understanding of factors that influence caregivers’ HRQOL in a non-Western, rural context and
furthering the investigator’s research trajectory of caregiving for ECRs with Buddhist beliefs
measured by caregivers’ participation in religious activities. It will also be discussed whether or
not the participation in religious activities such as praying, meditating, going to the temple,
offering food and things for monks, or donation for others are shown to associate with family
caregivers’ perceived reward. Moreover, such results will lead to a new religion-related model of
assessing caregiving consequences and will provide guidelines for the development of culturally
appropriate intervention, including religious activities as resources of heightened caregiver
rewards to enhance caregivers’ functional status, further resulting in improved HRQOL.
Specific Aims
Specific aims of this study were to examine:
1. The relationships among family caregiver characteristics (age, sex, relationship to
ECR, religious activities, chronic health conditions, household income, social support), ECR
characteristics (age, sex, levels of physical disability, ECRs’ symptoms), length of caregiving,
rewards of caregiving, caregiver tasks of care, and rural Buddhist Thai family caregiver
functional status.
2. The relationships between family caregiver characteristics (age, sex, relationship to
ECR, religious activities, chronic health conditions, household income, social support), ECR
characteristics (age, sex, levels of physical disability, ECRs ‘symptoms), length of caregiving,
rewards of caregiving, caregiver tasks of care, family caregiver functional status, and overall

23

HRQOL of rural Buddhist Thai family caregivers.
3. Whether the relationship between family caregiver functional status and overall
HRQOL of family caregivers were mediated by the rewards of caregiving, controlling for all
other variables.
Purpose of Study
The purpose of this study was to examine the relationship in which selected family
caregiver characteristics (age, sex, relationship to ECR, religious activities, chronic health
conditions, household income, social support), ECR characteristics (age, sex, levels of physical
disability, ECRs’ symptoms), length of caregiving, rewards of caregiving, caregiver tasks of
care, and caregiver functional status are hypothesized to associate with HRQOL among rural
Buddhist Thai family caregivers of ECRs who have one or more chronic conditions and possess
at least two ADLs deficits. Furthermore, whether rewards of caregiving mediate the relationship
between Thai family caregiver functional status and family caregiver HRQOL was tested.
Although many researchers attempted to define HRQOL in their studies, the wide
variation in conceptual definitions still exists and challenges further research. This study was
based on the Wilson and Cleary (1995) HRQOL conceptual model; HRQOL will be the ultimate
outcome and will be discussed in chapter 2, along with conceptual definitions for each variable
provided. In chapter 3, a review of the literature describing caregiver HRQOL, functional status,
rewards of caregiving, and all caregivers’ and ECRs’ characteristics will be presented. Study
design and methods, and planned data management and analysis will be described in chapter 4.
Study findings and data interpretation will be presented in chapter 5. Nursing implication for
clinical practice, future research, and policy based on this study will be discussed in chapter 6.

24

Chapter 2
Conceptual Framework
Originally, the concept of quality of life had its roots in classical Greek thought—the
religious teaching that is concerned with an individual’s personal satisfaction with life—and its
academic roots in the discipline of psychology and sociology (Peterson& Bredow, 2009). Quality
of life has been known as an interesting concept in multidiscipline professions, but the variety of
perspectives from each discipline has caused little general agreement on defining the term.
Anderson and Burckhardt (1999) revealed the differences among philosophers concerned with
the nature of human existence and with the definiton of “the good life.” Ethicists debate the shift
in health care decision-making, while economists are concerned with the allocation of resources
to achieve alternative goals. Physicians focus on health- and illness-related variables, while
nurses have a holistic approach to the quality of life.
Quality of life measures are considered important in health care, and research implies that
quality of life is the major focus. Wilson and Cleary (1995) indicated that HRQOL could be
increasingly used as an outcome in clinical trials, effectiveness research, and research on quality
of care. Moreover, Ferrans et al. (2005) and Murdaugh (1997) found that although quality of life
research has increased in methodologic rigor and sophistication, progress has been hindered by
the fact that the term quality of life has been used to mean a variety of different things, such as
health status, physical functioning, symptoms, psychosocial adjustment, well-being, life
satisfaction, and happiness. Thus, the term health-related quality of life was presented to narrow
the focus of the broad quality of life to the effect of health, illness, and treatment on quality of
life. Increasingly, HRQOL is used in many research areas of nursing—patient and caregiver
(Blanes et al., 2007; Chatcheydang, 2005; Fang et al., 2004; Halvorsrud & Kalfoss, 2007;

25

Krethong, 2008; Markowitz et al., 2003; Morimoto et al., 2003; Richter, Schwarz, & Bauer,
2008; Osoba, 1994; Sandau, Lindquist, Treat-Jacobson, & Savik, 2008; Sousa, Holzemer, Henry,
& Slaughter, 1999; Sprangers & Schwartz, 1999; Wang, Beyer, Gensichen, & Gerlach, 2008). In
addition, the Food and Drug Administration addresses quality of life by imposing documentation
on not only the safety and efficacy of new products, but also their effects on a user’s quality of
life (Spilker, 1996).
Wilson and Cleary (1995, p. 60) defined HRQOL as the aspects of quality of life that
relate specifically to the person’s health and developed a causal model to assess HRQOL
consisting of five components: biological and physiological factors, symptom status, functional
status, general health perception, and overall quality of life.
First, biological and physiological factors are commonly conceptualized, measured, and
applied in routine clinical practice. The assessment of biological and physiological factors
focuses on the function of cells, organs, and their systems—including diagnoses laboratory
values, measures of physiological function, and physical examination findings. Second, symptom
status focuses on a shift from specific cells and organs to the organism as a whole. It is defined
as a patient’s perception of an abnormal physical, emotional, or cognitive state. Symptom reports
are described to be related to biological and physiological factors and as an important
determinant of functioning. Third, functional status, or functioning, measures and assesses the
ability of the individual to perform a particular defined task. Functioning is determined by
patient-specific factors: personal ability and motivation, and many aspects of an individual’s
social environment. Also, functional status is measured in four domains: physical function, social
function, role function, and psychological function.
Fourth, general health perceptions compose two outstanding characteristics: that they

26

represent an integration of all of the health concepts in earlier components, and they are, by
definition, subjective ratings. This is a synthesis of all the various aspects of health in overall
evaluation. Fifth, overall quality of life was characterized as subjective well-being relating to
how happy or satisfied someone is with life as a whole.
In 2005, Ferrans, Zerwic, Wilbur, and Larson revised the Wilson and Cleary model of
HRQOL to facilitate the use of HRQOL in nursing and health care. The revision of the model
(see Figure 1) clearly indicates the elements of HRQOL; their determinants have been described
explicitly, as have the theoretical grounding of characteristics of the individual and the
environment. Characteristics of the individual in the revised model are categorized as
demographic, developmental, psychological, and biological factors that influence health
outcomes. Thus, an arrow from characteristics of the individual to biological function has been
added. Biological factors include body mass index, skin color, and family history related to
genetically linked disease and disease risk. Demographic factors that commonly have been
linked to the incidence of illness are sex, age, marital status, and ethnicity.
Also, characteristics of the environment are categorized as either social or physical.
Social environmental characteristics are the interpersonal or social influences on health
outcomes, including the influence of family, friends, and health care providers. Ferrans et al.
attempted to revise and clarify the model to focus on the identification of each domain, including
characteristics of the individual and the environment, which was not clearly described in Wilson
and Cleary’s (1995) model. The revisions to the model have helped to define the scope of quality
of life by making clear that the term of HRQOL refers to all of life, not just physical health
status.

27

Characteristics of
the Individual

Biological
Function

Symptoms

Functional
Status

General
Health
Perception

Overall
Quality of
Life

Characteristics
of
Environment
Figure 1. Revised Wilson and Cleary model for health-related quality of life. From “Conceptual
Model of Health-Related Quality of Life,” by C.E. Ferrans, J.J. Zerwic, J.E. Wilbur, & J.L.
Larson, 2005, Journal of Nursing Scholarship, Volume 37(4), p. 338. Copyright by Sigma Theta
Tau International. Reprinted with permission. (see Appendix E)
However, according to the Wilson and Cleary (1995, p. 62) causal model and Ferrans et
al. (2005, p. 340), overall quality of life will be the ultimate outcome for this study, defined as "a
multidimensional evaluation of a person’s satisfaction with the areas of life that are important to
him/her influenced by diverse factors in life." Wilson and Cleary identified causal relationships
among the elements resulting in the overall quality of life. Similarly, Patrick and Chiang (2000)
proposed the quality of life model with various individuals of internal and external concepts, but
primarily used the same health elements as Wilson and Cleary’s. Overall quality of life is not
only affected by health-related factors but also influenced by other individual and environmental
factors, including socially environmental and physically environmental characteristics, and other
aspects in life. Thus, it is unavoidable for professionals to focus on overall quality of life in order
28

to maintain and improve patients’ outcomes in all life aspects.
This study was based on a modified form of Wilson and Cleary’s HRQOL theory (1995)
and Ferrans et al. (2005), a causal model depicting a direct linear relationship between each of
the following components: characteristics of the family caregiver (age, sex, religious,
relationship to ECR, household income, and number of chronic health conditions) and the ECR
(age, sex, physical disability, and symptoms related to age and diseases), which associate with
how the caregiver tasks of care affect caregiver’s functional status (Specific Aim 1).
Simultaneously, one of the characteristics of environment, social support, is perceived by the
family caregiver and directly influences the caregiver functional status. Then, family caregiver
functional status—as an ability to perform their own daily activities—will be affecting family
caregivers’ overall quality of life, or how happy or satisfied caregivers are with their lives as a
whole (Specific Aim 2). For rural Thai caregivers who believe in Buddhism, the relationship
between caregiving factors—family caregiver characteristics, ECR characteristics, functional
status, length of caregiving, and rewards of caregiving—and the levels of overall HRQOL of
elderly rural family caregivers (Specific Aim 3) was examined, as shown in Figure 2. Buddhist
beliefs and karma-based thoughts may create positive feelings from assuming the role of family
caregiver, such as the rewards of caregiving. Buddhists believe that, out of a sense of obligation,
children should provide good care at home for ill older Thais or parents and that karma— found
in good acts, words, or thoughts—affects future lives, as everyone wishes to receive good care in
return when they become older. These Buddhist beliefs can lead to a supportive attitude in Thai
caregivers and may help them positively perceive the rewards in their caregiver role, influencing
their performance and overall HRQOL. The following sections of this chapter will describe the
conceptual schematic of this study and define concepts of each variable in the model.

29

Figure 2. A modified model of the study: Caregiver health-related quality of life. From “Revised Wilson and Cleary Model for
Health-Related Quality of Life,” by Carol E. Ferrans, Julie J. Zerwic, Jo E. Wilbur, & Janet L. Larson, 2005, Journal of Nursing
Scholarship, Volume 37(4), p. 338. Copyright by Sigma Theta Tau International. Adapted with permission (see Appendix E).

30

Characteristics of the Individual Caregiver
In the modified model, characteristics of the individual were categorized as demographic,
developmental, psychological, and biological factors that influence health outcomes.
Epidemiological evidence indicates links between individual characteristics and biological
function by identifying attributes or behaviors that increase or decrease the likelihood of
developing a given health problem (Ferrans et al., 2005). Biological factors include body mass
index, skin color, and family history related to genetically linked disease and disease risk.
Demographic factors that commonly have been linked to the incidence of illness are sex, age,
marital status, and ethnicity. For this study, selected characteristics were included in the model as
caregivers’ characteristics: age, sex, relationship to ECR, household income, number of chronic
health conditions, and social support. Characteristics of the ECRs for whom those caregivers
provided care are also included: age, sex and physical disability. Also, ECRs’ symptoms, an
essential care recipient factor for understanding the context of ECR health behavior and care
needs, were included.
Characteristics of Rural Thai Family Caregivers
Age. Age was conceptualized as having an effect on caregiving experiences, functional
status, and HRQOL of family caregivers. The literature has been inconsistent with regard to the
influence of age on family caregiver functional status (Lawang, Sunsern, & Rodjarkpai, 2005;
Serrano-Aguilar, Lopez-Bastida, & Yanes-Lopez, 2006; Wongchantra, 1996). It is unclear
whether or not age affects caregivers’ performance during their provision of care, so age of
family caregivers has been included in this study design. For this study, age was conceptually
defined as the caregiver’s chronological age in complete years at the time the questionnaire was
administered.

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Sex. Sex was conceptually defined as the distinction between male and female and is
conceptualized as impacting caregiving experiences, functional status, and HRQOL. The sex of
family caregivers was also included in this design because women are often socialized to be
family caregivers and may be better prepared than men for the family caregiver role (Chaoum,
Intarasombat, & Putwatana, 1996; Cheewapoonphon, 1998; Stoller, 1994).
Religious Activities. A definition for religious activity was derived from the previously
used concept of religion which has been defined narrowly, focusing on personal feelings and
attitudes (Heisel & Faulkner, 1982). A religious activity in this study was conceptually defined
as the behaviors that reflect participation in religious activities, religious involvement, and the
subject’s reports of feelings of religiosity (Levin, Chatters, & Taylor, 1995; Picot et al., 1997). A
religious activity resulting from Buddhist belief and karma thought, one of a caregiver’s
resources, may impact positive caregiving experiences. Religious activities were added in this
design because it has been reported to lessen the effects of stress and heighten perceived
caregiver rewards (Picot et al., 1997; Subgranon & Lund, 2000).
Relationship to ECR. Relationship to ECR was conceptualized as having an effect on
caregiving experiences, functional status, and HRQOL of family caregivers and was
conceptually defined as the particular type of connection existing between caregiver and ECR.
Most previous research with Thai samples found that spouses are the primary family caregivers
for ECRs (Cheewapoonphon, 1998; Belasco et al., 2006; Heru & Ryan, 2004). Because of their
spousal role, the impact of caregiving tends to have ongoing negative effects on the health of
elderly family-caregiver spouses (Pinquart & Sorensen, 2007).
Household income. Household income was defined as the total income of family
caregivers and those living in the same place of residence and is conceptualized as having an

32

effect on caregiving experiences, functional status, and HRQOL of family caregivers. It has been
found that caregivers with a higher household income were less likely to be affected by patient
caregiving demands and more likely to have a better overall HRQOL (Ekwall, Sivberg, &
Hallberg, 2004; Lawang, Sunsern, & Rodjarkpai, 2005). Caregivers with lower income levels
frequently have to work harder to pay for living expenses, which may result in a decline in their
functional status and health (Sasat, 2006).
Chronic health conditions. A caregiver’s chronic health condition was conceptually
identified as the total number of chronic health conditions that a family caregiver possesses
(Chatcheydang, 2005; Pinquart & Sorensen, 2007) and is conceptualized as having an effect on
caregiving experiences, functional status, and HRQOL of family caregivers. Many family
caregivers experience one or more chronic illnesses, which have been shown to affect their
health status (Blanes et al., 2007; Frias, Tuokko, & Rosenberg, 2005).
Caregiver tasks of care. Caregiver tasks of care were conceptually identified as the
perception of time and difficulty of caregiving activities provided for the ECR during the day, at
night, and on weekends, as well as on demand (Carey, Oberst, McCubbin, & Hughes, 1991;
Oberst, 1990). Family involvement in care tasks depends on ECR physical disability and
symptoms. Tasks of care cover those related to ADL, IADL, financial management, emotional
support, and medication and symptom management (FTGRD, 2009; Girgis, Lambert, &
Lecathelinais, 2011; Given, 1995; NCA, 2004; Sasat, 2006). A caregiver task of care was
conceptualized as having an influence on caregiver functional status and HRQOL of family
caregivers. Eighty percent of caregivers are helping with three or more IADLs and are more
likely to be in fair or poor physical health (NCA, 2004; 2009; Sasat, 2006).

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Characteristics of ECR
Age. Age refers to the ECR’s age in complete years. For this study, age of all ECRs was
60 years and older. The age of 60 is generally used in older-adult related research to define
elderly samples, as the Thai government has previously used the age of 60 as a marker for
reporting statistics describing older adult populations (MSDHS, 2007). Age-associated changes
in physical and mental status and sensory deficits happen over time in elders (Jordhoy et al.,
2007; Sasat, 2006). Thai elderly patients with chronic conditions have an appreciable decline in
functioning and frequently need more help with personal ADLs (Sasat).
Sex. Sex was conceptually defined as the distinction between male and female. The sex
of the ECRs has also been included in this design because the differences of sexes may result in
differences in conditions, diseases, and overall well-being for ECRs (Sobieszczyk, Knodel, &
Chayovan, 2002). Also, among Thai elder populations, there is a higher proportion of women
than men with chronic disease (MSDHS, 2007).
Physical disability. Physical disability of ECR was defined as the limitation of
performing ADL and is an indicator of the dependence and need of ECRs (Chatcheydang, 2005;
Pinquart & Sorensen, 2007). Family caregivers must provide higher levels of care for more
dependent ECRs. Physical disability is conceptualized as having an effect on the caregiving
experiences, functional status, and HRQOL of family caregivers. Additional information
regarding the Bathel Index (BI; Mahoney, & Barthel, 1965) measuring ECRs’ physical disability
will be presented in chapter 4.
ECRs’ symptoms. Approximately 80% of older people live with chronic disease and
experience about 3.9 symptoms per day (Lorig, 1993; Manton, Corder, & Stallard, 1997; Ory,
Abeles, & Lipman, 1992). ECRs’ symptoms for this study were defined as ECRs’ present or

34

absent changes in physical, emotional, and psychological behaviors as perceived by family
caregivers, including delusions, hallucinations, dysphoria, anxiety, agitation or aggression,
euphoria, dis-inhibition, irritability orlability, apathy, aberrant motor activity, nighttime behavior
disturbances, appetite changes and eating behaviors (Cummings et al., 1994). The ECRs’
symptoms were also included in this design because the different number of symptoms may
result in differences in ECR care needs, caregiver tasks of care that would associate with
caregiver functional status, and HRQOL of family caregivers (Girgis et al., 2011; Osse,
Vernooij-Dassen, Schade, & Grol, 2006; Pinquart & Sorensen, 2007).
Characteristic of Environments
Social support. Social support was defined as the level of support currently available to
the caregiver. Social support originally included five relational dimensions: (a) provision for
attachment or intimacy; (b) social integration—being an integral part of a group; (c) opportunity
for nurturance behavior; (d) reassurance of worth as an individual and in role accomplishments;
and (e) the availability of informational, emotional, and material assistance (Brandt & Weinert,
1981; Weinert, 1987; Weinert & Brandt, 1987). Additional information regarding the perceived
social support measurement (Personal Resource Questionnaire; PRQ-85) will be presented in
chapter 4. Social support is conceptualized as the caregivers’ perception of supports and
resources from others that may positively affect family caregivers’ HRQOL by enhancing their
rewards of caregiving (Chappell & Reid, 2002).
Length of caregiving. Length of caregiving was conceptually defined as the period of
time in months or years that family caregivers have spent in the caregiver role for the current
ECR. A longer time spent in the caregiving role was reported to be associated with negative
health outcomes including physical health, burden, and depression (Pinquart & Sorensen, 2007).

35

Taking care of ECRs with chronic illness is a long-term care challenge for family caregivers,
requiring both physical and psychological effort. Moreover, time has been reported as a
significant predictor of positive well-being in instances when the time spent caregiving was more
than two years, but caregivers reported less anxiety when the time spent was two years or less
(Helgeson, Reynolds, & Tomich, 2006). Changes in functional status frequently occur over time
in family caregivers with a chronic physical illness (Liedy, 1994) and might be associated with
decreases in their overall HRQOL.
Rewards of caregiving. Rewards of caregiving were conceptually defined as levels of
family caregiver’s overall sense of satisfaction toward the experiences of caring for the ECR
with a positive attitude during the period in which he or she performs the caregiving role
(Raschick & Ingersoll-Dayton, 2004; Sasat, 2006; Stewart & Archbold, 1997), which can be
measured by the Reward of Caregiving Form (Archbold & Stewart, 1986; Stewart & Archbold,
1993). Additional information regarding the Reward of Caregiving Form will be presented in
chapter 4.
Caregiving for an older family member can also be a satisfying and rewarding
experience, despite the possible stress imposed from managing one’s life (Kramer, 1997; Davis,
2005). Buddhist beliefs toward elders of Thai caregivers may impart a sense of obligation to care
for parents, and karma-based thought may create positive feelings from assuming the role of
family caregiver, such as the rewards of caregiving (Sethabouppha, & Kane, 2005). The positive
experience of caregiving, rewards, and relations to Buddhist beliefs might help caregivers
understand and accept their roles, which may impact their ability to care for ECRs. Moreover,
rewards of caregiving can be explained as the positive perceptions of caregivers, as well as the
willingness to care for ECRs with chronic illness, which may impact the caregiver’s desire to

36

perform a caregiving role.
Caregiver Functional Status
The third element of the model, functional status or functioning, measures and assesses
the ability of the individual to perform a particular defined task. Caregiver functional status is
affected by previous elements of the caring situation for elders, including characteristics of the
family caregiver and ECR, as well as characteristics of environments. Caring for older people
living with chronic disease and experiencing various age- and disease-related symptoms has an
impact on the caregiving tasks that caregivers perform. Caregiver functional status as an ability
to perform daily activities is expected to affect caregivers’ overall quality of life, or how happy
or satisfied caregivers are with their lives as a whole. Functional status assessment originated in
clinical rehabilitation practices for the purpose of determining caregivers’ capacity to perform
daily tasks in relation to expected performance and has been used in studies with chronically ill
elder patient samples (Chung et al., 2010; Knight, 2000; Moons, 2004).
Functional status of family caregivers, for this study was conceptually defined as “the
caregiver’s ability to perform activities of daily living or the level of involvement in activities in
multiple domains of function—physical, psychological, social, and role” (Acton, 1994; Wilson &
Cleary, 1995, p. 61). A caregiver’s functional status is affected by previous elements of the
model, characteristics of the family caregiver and the ECR, and characteristics of the
environment, as well as the social support. It was measured by the 12-item Short Form Survey
(SF-12; Ware, Kosinski, & Keller, 1996), which will be discussed in detail more in chapter 4.
Overall HRQOL of Family Caregivers
An ultimate outcome of the model, overall HRQOL was conceptually defined as
subjective well-being related to how happy or satisfied someone is with life as a whole. It was an

37

integration of all of the concepts in earlier components of the model, and they are, by definition,
subjective ratings. This was a synthesis of all the various aspects of health in an overall
evaluation affected by previous components, including characteristics of family caregivers and
ECRs, characteristics of environments, and caregiver functional status.
Overall HRQOL was characterized by Wilson and Cleary (1995, p. 62) as a subjective
life quality related to “how happy or satisfied someone is with their life as a whole.” The life
domains selected by researchers have varied depending on the specific measures used in the
studies. However, for this study, using both the Wilson and Cleary and Ferrans (2005) models,
HRQOL dimensions were studied with Thai family caregivers and included four life domains:
health, psychological or spiritual, social and economic, and family. HRQOL levels might also be
influenced by various caregiving-related factors experienced in their current caring situations.
Additional information regarding the HRQOL measuring by Quality of Life Index (QLI; Ferrans
& Powers, 1985) will be discussed in chapter 4.
Summary
The conceptual model for this study depicts a direct linear relationship among the
following components: characteristics of the family caregiver (age, sex, relationship to ECR,
religious activities, household income, and chronic health conditions) and the ECR (age, sex, and
physical disability); characteristics of environments (social support); length of caregiving;
rewards of caregiving; caregivers’ functional status; and overall quality of life of caregivers. In
this study, relationships between variables in each component and overall HRQOL were
examined. Also, this study initially tested the mediating effect of a positive experience of care
and rewards of caregiving, in the relationship of functional status and overall HRQOL. The
findings showed the influence of Buddhist beliefs regarding elders in Thai family caregiver

38

populations.
Chapter 3 will provide a literature review as to what is known and what is unknown
regarding the caregivers’ HRQOL, functional status, rewards of caregiving, and other
characteristics, as well as the relationship among these variables. The significance of and the
need for research addressing caregivers’ HRQOL will also be presented.

39

Chapter 3
Literature Review
The purpose of chapter 3 is to provide an overview and synthesis of the literature
regarding the caregiver HRQOL, caregiver functional status, relationship between HRQOL and
caregiver functional status, and influences on HRQOL of rural Thai family caregivers who are
caring for elders with chronic illness. The developed conceptual schematic of the study (see
Figure 3) serves as a guide for the following literature review. The model components, including
characteristics of the family caregiver (age, sex, relationship to ECR, religious activities,
household income, chronic health conditions), characteristics of the ECR (age, sex, physical
disability, symptoms), and the characteristic of environments (social support), will be discussed
as section headings. Also, other main components of the model, including caregiver tasks of
care, length of caregiving, and the rewards of caregiving—which were expected to be supported
by religious activities resulting from Buddhist beliefs—served as section headings.
The literature review here will begin with the ultimate outcome of this study, the HRQOL
of the family caregiver, in order to specifically focus on a significant and critical caregiver health
outcome. Maintaining HRQOL in the process of care is an essential component of a caregiver’s
psychological well-being (Chung et al., 2007; Morimoto et al., 2003), which, in turn, may affect
the quality of the care provided (Riedijk et al., 2006).
Every year presents an increase in the number of elderly Thais. Most elders experience
physical and psychological health problems that lead to behavioral changes and the need for help
with ADLs and IADLs, as well as help managing symptoms (Chan, 2005; Sasat, 2006). Some
Thai elders have been diagnosed with more than one age-related chronic condition or disease
(Chan; Jordhoy et al., 2007; Moons, 2004; Plasqui, 2008). Additionally, they require a lot of

40

care, and because the majority of chronically ill Thai elders live with family in community
dwelling areas where there is limited access to health care facilities they receive this care from
family members.
HRQOL of Caregiver
The impressive growth of chronically-ill elders has had a significant impact on families
with ECRs and has demonstrated the negative outcomes for caregivers, including worsening
physical and mental health, and an increase in caregiver burden and distress, which also relates
to a decrease in mental and physical health, as well as lower HRQOL (Chatcheydang, 2005;
Chung et al., 2007; Frias et al., 2005; Given & Sherwood, 2006; Jones & Peters, 1992; Morimoto
et al., 2003; Northouse et al., 2002; Northouse et al., 2005; Osse et al., 2006; Pinquart &
Sorensen, 2007; Subgranon, 1999; Subgranon & Lund, 2000). The impact of caregiving
experiences on HRQOL may be due to factors from both sides: from the caregiver (the effect of
physical exertion from providing care, negative health-related behavioral changes, and
psychological distress on their own chronic conditions) and from the ECR’s disabilities,
symptoms, and needs (Chatcheydang; Chung et al.; Frias et al.; Morimoto et al.; Pinquart &
Sorensen; Riedijk et al., 2006).
Studies in Thailand have shown that family caregivers frequently have physical
difficulties from direct care dealing with ECRs’ increasing impairments and behavioral
problems, which impact caregivers’ HRQOL (Chatcheydang, 2005; Subgranon & Lund, 2000).
This chapter will also review and discuss caregiver functional status as another health outcome
for caregivers during the process of care and its influence their HRQOL. Also, caregivers’
functional status—as an ability to perform their own daily self-care and household activities,
along with other relevant variables in relation to functional status—will be discussed to reveal

41

the relationship between them.
In this study, overall HRQOL was characterized by Wilson and Cleary (1995) as a
subjective life-quality related to “how happy or satisfied someone is with his/her life as a whole”
(p.62). The life domains selected by researchers have varied depending on the specific measures
used in the studies. The domains have been characterized by Ferrans (1990) as health,
psychological or spiritual, social and economic, and family. Smith, Avis, and Assmann (1999)
posited that HRQOL is the subjective appraisal of one’s current life based primarily on one’s
psychological functioning and, to a lesser degree, physical functioning. However, using both the
Wilson and Cleary (1995) and Ferrans (2005) frameworks, HRQOL dimensions can be studied
with Thai family caregivers by including four life domains: health, psychological or spiritual,
social and economic, and family. HRQOL levels might also be influenced by various caregivingrelated factors experienced in their current caring situations.
As previously mentioned, a number of elders in Thailand have been diagnosed with
chronic, manageable diseases such as stroke, dementia, cancer, arthritis, congestive heart failure,
diabetes mellitus, and Alzheimer’s disease, because of an advance in medical therapies and
technologies (Chan, 2005; Moons, 2004; MSDHS, 2007; Sasat, 2006). From such diseases,
elders experience physical limitations, behavioral changes, and diseases-related symptoms and
have an increased demand for long-term care from family members. Their disabilities and the
severity of their symptoms could lead to an increase in the demands on their family caregivers.
Responsibilities for decision-making or managing care situations, with regard to arrangements
for long-term care, are often shared between the elderly and their family caregivers (McCullough
et al., 1993; Chung et al., 2007; Wang, Chung, Lai, Chou, & Kao, 2004).
Taking the role of caregiver at home for chronically ill elders suffering from stroke,

42

cancer, diabetes mellitus, arthritis, or mental illness can place demands on one’s physical and
mental health (Caffrey, 1992; Chaoum et al., 1996; Frias et al, 2005; Jones & Peters, 1992;
Wang et al., 2008) and result in negative consequences to the caregiver’s emotional and physical
health, as well as HRQOL (Barnes et al., 2006; Chatcheydang, 2005; Chung et al.; Frias et al.;
Given & Sherwood, 2006; Jones & Peters; Moritomo et al., 2003; Northouse et al., 2002;
Northouse et al., 2005; Osse et al., 2006; Pinquart & Sorensen, 2007; Subgranon & Lund, 2000).
HRQOL of family caregivers of ECRs with chronic illness is influenced by various factors and
can be impacted in different ways.
Some researchers have examined HRQOL and its influences on caregivers of elders with
chronic illnesses. Chatcheydang (2005) examined a model of relationships between caregivers’
characteristics and HRQOL of Thai female family caregivers of elder stroke survivors and found
some negative health outcomes from providing long-term care at home, such as anxiety, stress,
depression, and fatigue. Chung et al. (2007) and Wang et al. (2004) found elderly ADLs deficits,
sex, marital status of caregivers, and family caregiver age to be significant predictors of HRQOL
of caregivers of chronically ill elders. Moreover, there are numerous factors that can serve as
either direct or indirect determinants of caregiver HRQOL, including ECR characteristics—such
as number of symptoms, disability in personal care and everyday living, and severity of health
conditions—types of treatments, and comorbidity. Caregiver characteristics are also factors and
include relationship to ECR, education, and length of care, as well as a positive aspect: rewards
of caregiving (Barnes et al., 2006; Blanes, Carmagnani, & Ferreira, 2007; Chatcheydang; Chung
et al.; Kurtz et al.; Northhouse, et al., 2005; Rees, O’Boyle, & MacDonagh, 2001; Riedijk et al.,
2006).
In addition, some researchers have examined caregiver-related experiences varying along

43

the illness trajectory and associated with caregiver HRQOL, such as the burden from tasks of
care in caregivers of stroke patients, (Hughes et al., 1999; Morimoto et al., 2003), Alzheimer’s
disease patients (Markowitz et al., 2003; Riedijk et al., 2006; Watanabe, Araki, & Kurihara,
2003) and multiple sclerosis patients (Buchanan & Huang, 2010; Rivera-Navarro et al., 2009).
These experiences require various types and amounts of assistance in caregivers (Bakas, Lewis,
& Parsons, 2001; Kim & Given, 2008; Northouse et al., 2002; Northouse et al., 2005; Sammarco,
2001) and create conflict among their social roles, restrictions on activities, strain in marital and
family relationships, psychological distress, and diminished physical health (Haley et al., 2003).
As shown in previous studies, caregiver HRQOL has been examined with some chronic
diseases but not specifically in elders, particularly in Thai elderly populations. However, for this
study, the recruited caregivers were not specifically caring for elders with only one particular
chronic disease because the sample size would have been limited. The study instead focused on
caregivers who were caring for elders with one or more chronic conditions and who possessed at
least two ADL deficits.
In this study, HRQOL, as a subjective life-quality related to “how happy or satisfied
someone is with his/her life as a whole,” (p.62)—was examined using both the Wilson and
Cleary (1995) and Ferrans (2005) frameworks—has dimensions including four life domains:
health, psychological or spiritual, social and economic, and family. The degree to which family
caregivers have an overall sense of satisfaction toward the experiences of caring for ECRs can
result from various caregiving factors. One of the caregiving factors that is very important in
providing care for the ECR is the caregiver’s ability to perform his/her owns life tasks, or the
level of involvement in the caregiver’s activities, known as functional status. Taking caregiving
roles may affect family caregivers’ ability to perform their daily life tasks and to care for their

44

beloved ECRs. Caregivers’ ability to perform life tasks is also expected to relate to their own
HRQOL.
It has been shown that experiencing a chronic illness can affect not only the individual,
but also family and friends, as above mentioned studies have shown (i.e., Chatcheydang, 2005;
Chung et al, 2007; Given & Sherwood, 2006; Markowitz et al., 2003; Morimoto et al., 2003;
Pinquart & Sorensen, 2007; Wang et al., 2004). An increase in chronically ill elders has
increased the demand for long-term care; caregivers experience extra and unpredictable roles to
assist ECRs with IADLs and ADLs, as well as to manage the ECR’s symptoms, which may
impact caregivers’ ability to perform any other life tasks (Chan, 2005; Chatcheydang, 2005;
Given, 1995; NAC, 2009; Pinquart & Sorensen).
The expanded role caring for ECRs at home can place demands on caregivers’ physical
and mental health (Caffrey, 1992; Chaoum, Intarasombat, & Putwatana, 1996; Frias, Tuokko, &
Rosenberg, 2005) and can result in negative health outcomes for caregivers, including decreased
emotional and physical health and lower HRQOL (Barnes et al., 2006; Chatcheydang; Chung et
al.; Markowitz et al.; Morimoto et al.). Other studies revealed that HRQOL is influenced
significantly by various variables, such as age, ECR condition, physical performance, and health
behaviors (Casellas, Lopez-Vivancos, Casado, & Malagelada, 2002; Chung et al.; Kazis et al.,
1998; Sullivan, Kempen, Van Sonderen, & Ormel, 2000).
Physical performance has the strongest impact on HRQOL in the physical domain (Lai et
al., 2005). However, in Thailand, it remains largely unknown what most significantly influences
HRQOL levels for Thai elderly caregivers (Chatcheydang; Sasat, 2006) and how caregivers’
functional status influences their HRQOL. Sustaining caregiver HRQOL in the process of care is
a necessary factor in a caregiver’s psychological well-being, which, subsequently, may have an

45

effect on the quality of provided care (Chung et al.; Morimoto et al.; Subgranon & Lund, 2000).
Functional Status of Caregiver
The care recipient’s functional status or functional disability has been studied and shown
to relate to the caregiver’s health outcome, including HRQOL (e.g., Chung et al., 2007; Frias et
al., 2005; Given & Sherwood, 2006; Jones & Peters, 1992; Morimoto et al., 2003; Mui, 1995;
Northouse et al., 2002; Osse et al., 2006). Few investigators have studied the relationship of
caregivers’ functional status (Chung et al., 2010; Leidy, 1994; Newman, 1997; Spira et al.,
2010). Caring for a loved one experiencing chronic diseases for an extended time challenges and
disrupts family members’ usual pattern of daily living (Newman; Lu & Austrom, 2005; Spira et
al., 2010). Because of ECRs’ symptoms, behavioral problems, and personal needs, taking on the
caregiving role at home not only affects many family caregivers’ health and well-being, but also
increases their life tasks, limiting their participation in usual social, community, occupational,
and other life activities (Chung et al., 2010; Newman). The ability to complete life tasks and
other roles is considered necessary for caregivers of ECRs to provide long-term care and to meet
the needs of both the ECRs and themselves. Maintaining caregiver functional status through the
trajectory of the disease and the process of care is an important factor of the caregiver’s physical
well-being that may influence the quality of care the caregiver provides.
In this study, functional status was defined as “the person’s ability to perform activities of
daily living or the level of involvement in activities in multiple domains of function—physical,
psychological, social, and role” (Acton, 1994; Wilson & Cleary, 1995, p. 61). The functional
status assessment, originally invented in clinical rehabilitation practices for the purpose of
determining caregivers’ capacity to perform daily tasks in relation to expected performance, has
been used in studies with chronically ill elder patient samples (Chung et al., 2007; Knight, 2000;

46

Liedy, 1994; Moons, 2004).
The caregiving role for chronically ill elders is often physically demanding. To maintain
the caregiver’s ability to provide care, it is important to identify modifiable risk factors for
decline in the caregiver’s functioning (Chung et al., 2007; Chung et al., 2010). The changes in
the caregiver’s lifestyle result in physical activity and behaviorial changes (Spira et al., 2010).
While caregivers have to adapt their daily routines because of their new responsibilities—
including assisting the ECR with eating, exercising, and participating in recreational activities, as
well as managing their symptoms (Chung et al., 2007; Fredman et al. 2009)—they have to
maintain their functioning of their own ADLs.
Moreover, caregivers’ functional statuses may suffer from stress, anxiety, or strain caused
by expanded and unprepared caregiving roles that result from the enduring worsened conditions
of the ECRs and their behavioral problems (Caffrey, 1992; Chatcheydang, 2005; Chung et al.;
William, 1994). Long-term care for ECRs with chronic illnesses, which requires a commitment
of enormous energy, may lead to changes in physical functioning and/or psychological distress,
which can be observed in different physical symptoms–such as sleeplessness, weight loss,
headache, back pain, exhaustion, and lack of energy–and will impact caregivers’ functional
status and their ability to provide care for their elders (Belasco et al., 2006; Blanes et al., 2007;
Bull, 1990; Krach & Brooks, 1995; Teel, et al., 2001). For instance, some researchers found that
self-reported poor sleep in older adults has been linked to impairment in physical functioning and
impairment in ADLs (Byles, Mishra, Harris, Nair, 2003; Motivala, Levin, Oxman, & Irwin,
2006). Spira et al. (2010) reported that the time increase in caregivers’ total sleep was associated
with an improvement in their physical functioning.
Functional status of the caregiver has been studied in association with various aspects of

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caregiving situations, such as caregivers of patients with heart failure (Chung et al., 2010), of
adult patients with memory impairment (Spira et al., 2010), and of patients with Alzheimer’s
disease (Lu & Austrom, 2005). Some researchers found that depressed caregivers and caregivers
who spent more time and perceived difficulty in caregiving tasks had poor functional status
(Chung et al.; Lu & Austrom; Spira et al.). Moreover, changes in physical performance in female
caregivers were reported to associate with a high intensity (number of ADLs they performed for
the care recipients) of caregiver task of care in an osteoporotic fracture sample (Fredman et al.,
2009; Tong et al., 2002).
Multiple tasks of care resulting from ECRs’ disabilities and symptoms, as well as
dependency and needs, lead family caregivers to take more responsibilities in expanded roles,
including managing everyday living, helping with personal care, and monitoring and assisting
with symptoms management (Bakas et al., 2004; Bakas & Burgener, 2002; NAC, 2004; FTGRD,
2009). Such an increase in caregiving tasks may cause physical and psychological problems, as
well as health behaviors. Also, monitoring and assisting with an ECR’s symptoms was reported
as time consuming, and physically demanding, and exhausting (Chung et al., 2010; Newman,
1997), which may increase caregiving demands and tasks of care, resulting in a possible decrease
in the family caregiver’s ability to provide care. Caregiver functional status is considered to be
an important factor influencing a caregiver’s ability to perform ADLs or the level of involvement
in one’s own activities, as well as the ECR’s activities. There are few studies, particularly of
Thai family caregivers, investigating predictors of caregiver functional status in relation to
caregiver HRQOL.
Relationships between Caregivers’ HRQOL and Functional Status
HRQOL of a caregiver, interchangeably used with quality of life but similarly defined

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and measured by the same instrument, has been investigated in general samples of elders (Chung
et al., 2007; Jones and Peters, 1992) and in samples of elders with various specific chronic
diseases, such as stroke (Chatcheydang, 2005; Morimoto et al., 2003; Subgranon & Lund, 2000),
cancer (Given & Sherwood, 2006; Netchang et al., 2010; Northouse et al., 2002; Northouse et
al., 2005), dementia and Alzheimer’s (Arango-Lasprilla et al., 2010; Riedijk et al., 2006;
Markowitz et al., 2003), heart failure (Chung et al,. 2010), and multiple sclerosis (Buchanan &
Huang, 2011). Authors reported and recommended that caregiver HRQOL was one of the
essential components in a continuing caregiving situation, particularly in a home setting where
most of the caregiving for chronically ill elders takes place (Chatcheydang; Chung et al.; Riedijk
et al.; Subgranon). In addition, caregiver functional status, another caregiver health outcome
indicative of a caregiver’s ability to care for not only elderly relatives, but also themselves, is of
concern in caregiving studies (Fredman et al., 2009; Lu & Austrom, 2005; Newman, 1997; Spira
et al., 2010).
Caregiver’s functional status or performance ability may be a crucial factor in
accomplishing the caregiver role but has been discussed a result of long-term and physically
exhausting care activities (Chung et al., 2010; Lee, Colditz, Berkman, & Kawachi, 2003; Mui,
1995; Schulz & Beach, 1999). Caregiver’s functional status should be sustained in performing
effective care through the trajectory of the disease and the process of care. Also, caregiver’s
functional status is expected to be an essential factor influencing HRQOL of the caregiver, which
ultimately results in the continuous and desired care at home.
Most researchers have studied functional status as an ultimate outcome and have used it
interchangeably with HRQOL because each of the concepts has lacked a clear definition (Patrick
& Chiang, 2000; Siela, 2003; Wall, 2007). In this study, the functional status was explicitly

49

differentiated from HRQOL, and its relationships will be examined. There are no studies to date
that could be found which have examined the relationship between functional status and HRQOL
in Thai family caregivers of ECRs, particularly in rural settings and in the context of Buddhist
beliefs. It is challenging to support Thai family caregivers of ECRs in rural areas so that they
continue to provide care at home and have the optimal ability to perform care while maintaining
their own HRQOL.
In this proposed study, family caregivers’ functional status was measured to assess their
functioning pertaining to their abilities to perform daily activities in eight domains: physical
functioning, physical role functioning, bodily pain, general health, vitality, social functioning,
emotional role functioning, and mental health. In addition, the association between Thai family
caregivers’ functional status and their overall HRQOL was systematically examined. In a study
of 120 schizophrenic patients’ caregivers, the rewards of caregiving and length of caregiving
were suggested to influence the relationship between family caregiver functional status and
overall HRQOL (Lueboonthavatchai & Lueboonthavatchai, 2006). However, whether or not the
rewards of caregiving mediate the relationship of family caregiver functional status and overall
HRQOL, as well as how it mediates, has not yet been examined.
The findings from this study were therefore required for the identification of the
significance of the Buddhist-belief-related mediator, rewards of caregiving, enhancing overall
HRQOL in rural Thai family caregivers. Moreover, the results will lead to a new religion-related
model for assessing caregiving consequences and will provide guidelines for the development of
culturally appropriate intervention, including religious activities, as resources for heightened
caregiver rewards to enhance caregivers’ functional status, further resulting in improved
HRQOL. Caregiver functional status and HRQOL could be influenced by all preceding factors in

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caregiving situations, including the ECR’s symptoms and disability, caregiver task of care, as
well as a positive aspect: namely, rewards of caregiving. All these relevant factors and their
relationships will be discussed in the following sections.
Influences on Family Caregiver HRQOL
Family caregiver characteristics.
Age. Age refers to a family caregiver’s age in complete years. The literature has been
inconsistent with regard to the influence of age on family caregiver functional status (Lawang,
Sunsern, & Rodjarkpai, 2005; Serrano-Aguilar et al., 2006; Wongchantra, 1996). Previous
studies in Thailand have indicated that older family caregivers tend to consider the caring
situations as something less serious and to adapt themselves to better accept the caregiving role
than younger family caregivers do (Lawang et al.; Mui, 1995; Obert, et al., 1989; Sasat, 2006;
Wongchantra, 1996). However, since these types of family caregivers are older, their health may
more likely be affected, and they may suffer from underlying disease. Frais et al. (2005) and
Serrano-Aguilar et al. (2006) found that being older related to experiencing greater health
problems as family caregivers. As such, their health statuses during their provisions of care may
be affected, so it is unclear whether or not age affects caregivers’ performance during their
provisions of care. Therefore, age of family caregivers has been included in this study design.
Sex. The sex of family caregivers was included in this design because women are often
socialized to be family caregivers and may be better prepared than men for the family caregiver
role (Chaoum, 1996; Cheewapoonphon, 1998; Stoller, 1994). As a result, associations between
caregiving performance and health may be stronger in men than in women. Also, Mui (1995) and
Ekwall et al. (2004) found that the ECR’s functional impairments and the task of helping ECRs
with ADL related to a worse caregiver health and HRQOL for male family caregivers, but not

51

female caregivers. Simultaneously, male family caregivers may be more likely to seek social
support or to relinquish their family caregiver role when caregiving demands become too high
(Pinquart & Sorensen, 2007). Because of inconsistent and ambiguous results, sex will be
included in this study as a caregiver measure.
Relationship to ECR. The relationship to ECR is another relevant characteristic; most
previous research with Thai samples found that spouses are the primary family caregivers for
ECRs (Cheewapoonphon, 1998; Belasco et al., 2006; Heru & Ryan, 2004; Rashcick & IngersollDayton, 2004), and providing care tends to have ongoing negative effects on their health (Barnes
et al., 1992; Pinquart & Sorensen, 2007; Pinquart & Sorensen, 2011). Similar to age, a spousal
caregiver may report worse physical health than adult children do because they are usually older
and more likely to show age-associated physical declines. Still, spouses may show a weaker
relationship between family caregiver stressors and physical health of family caregivers because
caregiving for a spouse is more normative than caring for other frail persons and helps positively
appraise caregiving situation (Pinquart & Sorensen, 2007). Although Cantor (1983) and Barnes
et al. (1992) found poorer physical health in caregiving spouses and a greater risk for health
problems, Grasel (2002) demonstrated that health changes in family caregivers did not differ
between spouses and adult children. Because of the likely significance of this caregiver
characteristic associated with negative impact on caregivers’ health changes, it will be included
in this design.
Religious activities. The participation in religious activities is one of the internal
characteristics available to people to manage the demands of a stressful situation (Kramer &
Kipnis, 1995; Picot, 1997). The majority of Thais are Buddhist (94.5%;Wibulpolprasert, 2007).
For this study, most caregivers are assumed to be Buddhist. Buddhist Beliefs described by rural

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Thai family caregivers include karma, and the concepts of boon and babb, or merit and demerit,
respectively (Sethabouppha & Kane, 2005; Subgranon, 1999; Subgranon & Lund, 2000).
According to Buddhist beliefs, karma means action performed with intention. Karma can be
performed through three channels, including physical, verbal, and mental action. The law of
karma means that good acts will lead to good consequences and bad acts will lead to bad results
(Payomyong, 2000; Payutto, 1995, 1998). Thai Buddhist caregivers strongly believed that the
reason they had to care for their ill family members was the result of the law of karma in their
past and current lives. Some caregivers stated that, because of karma, they were repaying their
elderly ill family members for being hurtful to them in the past (Subgranon & Lund, 2000).
Accordingly, most of the caregivers performed boon or good deeds for their elderly ill family
members to achieve better lives in their next rebirth. Caregivers followed Buddhism in caring
for their chronically ill elders (Sethabouppha & Kane; Subgranon & Lund).
A religious activity, in this study, was conceptually defined as the behaviors that reflect
participation in religious activities, religious involvement, and subject reports of feelings of
religiosity (Levin et al., 1995; Picot et al., 1997). The participation in religious activities, one of a
caregiver’s resources, may impact positive caregiving experiences. Religious activity was added
in this design because it has been reported to lessen the effects of stress and heighten perceived
caregiver rewards (Picot et al.; Subgranon & Lund, 2000).
Household income. Household income was defined as the total income of family
caregivers and those living in the same place of residence (Chatcheydang, 2005; Pinquart &
Sorensen, 2007). It has been found that those who had higher household income levels were less
likely to be affected by patient caregiving demands and more likely to have a better overall
HRQOL (Chatcheydang; Ekwall et al, 2004; Lawang et al., 2005; Pinquart & Sorensen).

53

Similarly, the investigator found that lower household income levels in an American sample
ultimately correlate with caregiver HRQOL (Netchang, Corser, Given, Given, & Xie, 2010). In
addition, those caregivers with greater financial stability had more opportunities to seek other
things that benefit the ECR because they did not need to worry about earning their livings.
Caregivers with lower income levels frequently have to work harder to pay for their daily living
expenses (Chung et al. 2007; Lawang et al.). In addition, low-income family caregivers may
have less interest in finding helpful information to improve their caregiving practices or to take
care of their own health, which may result in a decline in their functional statuses and health
(Chung et al.; Ekwall et al., 2004; Sasat, 2006).
Chronic health conditions. A caregiver’s number of chronic health conditions was
identified as the total number of chronic health conditions that a family caregiver possesses, such
as high blood pressure, diabetes mellitus, stroke, cancer, heart disease, chronic bronchitis, low
back pain, arthritis, and so forth (Chatcheydang, 2005; Pinquart & Sorensen, 2007). The number
of chronic health conditions a caregiver possesses has been shown to affect the health status of
the family caregiver (Cheewapoonphon, 1998; Pinquart & Sorensen).
Studies have shown that many family caregivers experience one or more chronic
illnesses–such as hypertension, heart disease, low back pain, or arthritis–which have been shown
to affect their health status (Blanes et al., 2007; Frias et al., 2005). Barnes et al. (2006) found
that, when controlling for age, gender, and socioeconomic status, one of the significant
predictors associated with caregivers’ overall HRQOL is having two or more chronic health
conditions. In this study, the number of chronic health conditions will be measured as objective
indicators by using the number of medical and chronic illnesses, which will be counted in the
total.

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Characteristics of environments.
Social support. Social support was defined as the caregiver’s level of perceived social
support in regards to the current availability of functional supports, including (a) provision for
attachment or intimacy; (b) social integration—being an integral part of a group; (c) opportunity
for nurturance behavior; (d) reassurance of worth as an individual and in role accomplishments;
and (e) the availability of informational, emotional, and material assistance (Brandt & Weinert,
1981; Weinert, 1987; Weinert & Brandt, 1987). Park and Lee (2007) and Oka, Szuba,
Giacomini, and Cooke (2004) similarly found that social support is a potentially modifiable
factor associated with functional status, particularly physical levels in older family caregivers.
Moreover, social support may positively affect family caregivers’ HRQOL by reducing their
stressors, thereby enhancing their rewards of caregiving (Chappell & Reid, 2002; Cohen,
Colantonio, & Vernich, 2002; Northouse et al., 2002; Picot, 1995), and helping to develop more
effective forms of coping strategies, resulting in positive health behavior in relation to caregiving
performance (Losada et al., 2005; Tang & Chen, 2002).
In Thailand, Lueboonthavatchai and Lueboonthavatchai (2006) found that social support
was positively correlated to schizophrenic patient caregivers’ HRQOL. Also, Morissey and
colleagues (1990) and Uchino, Kiecolt-Glaser, and Cacioppo (1992) demonstrated that lower
levels of social support were associated with worse physical functioning of family caregivers, but
Mui (1995) did not find such a relationship. This study will include social support as one
preceding caregiving factor, which is expected to be one of the predictors of caregivers’
functional status.
ECR characteristics.
Age. Age refers to the ECR’s age in complete years. Age-associated changes in physical

55

and mental status and sensory deficits happen over time in elders (Jordhoy et al., 2007; Sasat,
2006). Thai elderly patients with chronic conditions have an appreciable decline in functioning
and frequently may need more help with personal ADLs (Choowattanapakorn, 1999; Jones &
Peters, 1992). Some researchers found that an older age of the care recipient was associated with
increased stress and age-related chronic diseases (Jones & Peters). However, the age of ECRs is
one important variable to measure in order to classify them into different disease, severity,
disability, limitation, or needs groups, which may help with studying the relationship of ECR age
and family caregivers’ functional status.
Sex. Sex of the ECRs was also included in this design because the differences between
sexes may result in differences in conditions, diseases, and overall well-being for ECRs
(Sobieszczyk, Knodel, & Chayovan, 2002). Also, among Thai elder populations, there is a higher
proportion of women than men with chronic disease (MSDHS, 2007). Such evidence might
further influence the dependencies and needs of ECRs that will affect caregivers’ performance to
meet ECRs’ needs. The associations between sex of ECRs and caregiver performance or
functioning are still knowledge gaps that need to be addressed.
ECR physical disability. ECR physical disability was defined as the limitation of
performing ADLs and is an indicator of the dependence and need of ECRs (Chatcheydang, 2005;
Pinquart & Sorensen, 2007). As ECRs experience more disabilities, family caregivers must
provide higher levels of care. Some studies have demonstrated a negative relationship between
levels of ECR disability and family caregiver’s HRQOL (Alshubaili et al., 2008; Chatcheydang).
However, Ekwall et al. (2004) proposed that family caregivers who reported that they helped
with more ADLs may have better physical status. Since the relationship between ECRs’ level of
physical disability and caregivers’ functioning remains unclear, it has been included in this study

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design for substantiating its impact in predicting a caregiver’s ability to perform life tasks.
ECR symptoms. Symptoms of ECRs were included in this study because the majority of
older people living with chronic disease experienced about 3.9 symptoms per day (Lorig, 1993;
Manton et al., 1997). ECRs’ symptoms experiences are the most important determinants of the
needs of care provided by family caregivers, resulting in caregiver tasks of care. Chronically ill
elders who have been discharged from the hospital still have some disabilities (Lausawatchaikul,
2001; Lawang et al., 2005; Periard & Ames, 1993; Sasat, 2006) and need regular care for IADLs,
ADLs, and age- and disease-related symptoms, including hearing loss, vision impairment,
weakness, pain, fatigue, nausea, vomiting, insomnia, difficulty breathing, diarrhea, coordination
problems, poor appetite, fever, cough, dry mouth, constipation, mouth sores, bed sores, inability
to concentrate, and so forth (Chung et al., 2007; NAC, 2004; FTGRD, 2009).
The symptoms of ECRs with chronic diseases are associated with the number of
caregiver tasks of care (Nijboer et al., 2000; Pinquart & Sorensen, 2003) and the degree of
assistance required from the caregiver (Given & Sherwood, 2006). In turn, the caregiver’s level
of involvement in providing care has been associated with the functional status of the caregiver
(Chung et al., 2010; Fredman et al., 2009). The ECRs’ symptoms have been included in this
study model to determine their effect on caregivers’ functional status.
Length of caregiving. Length of caregiving refers to the period of time in months or
years that a family caregiver has spent in the caregiver role. Changes in functional status
frequently occur over time in family caregivers with chronic physical illnesses (Liedy, 1994) and
might be associated with decreases in their overall HRQOL. Similar to Mui’s (1995) study, the
number of months of caregiving was correlated with decreased family caregiver health for
women (Sasat, 2006). Alshubaili et al. (2008) have proposed that the available national welfare

57

supports in Thailand were not sufficient to lift HRQOL levels of family caregivers caring for
patients with longstanding chronic illnesses because of the disproportions of elderly populations
and the budget limitations.
Some studies have demonstrated that changes in caregiving over time are not only caused
by the ECR’s continued aging but also affected by the trajectory of chronic illnesses (Leidy). On
the other hand, the longer family caregivers provide care, the more caregiving skills they may
attain (Choowattanapakorn, 1999; Sasat, 2006). Family caregivers might have positive or
negative feelings about caregiving that influence whether or not they are satisfied with their
functional statuses and HRQOL (Mui; Pinquart & Sorensen, 2007).The effect of length or
duration of caregiving on functional status is still questioned and has been included in this study
design to answer the research questions.
Caregiver tasks of care. Caregiver tasks of care for elders were defined as care activities
that often involve many aspects of care, dealing with the physical and psychological needs of an
elder patient (Bakas et al., 2001; Chung et al., 2007; Jones & Peters, 1992; Oberst, Thomas,
Gass, Ward, 1989; Sasat, 2006). Caregiver tasks of care included (a) managing IADLs; (b)
helping with ADLs; and (c) monitoring and assisting with the ECR’s symptoms experiences,
which can be challenging for family caregivers in home care situations (Given & Sherwood,
2006). Multiple caregiver tasks of care may result in decreased care ability of the family
caregiver (Bakas et al.; Caffrey, 1992; Chung et al.; Fredman et al., 2009; Oberst et al.).
Moreover, the number and difficulty of caregiving tasks have been reported to be associated with
caregiver burden in caregivers of patients with lung cancer (Bakas et al.; Chaoum et al., 1996)
and were one of the predictors of family caregivers’ HRQOL of chronically ill elderly
(Chatcheydang, 2005; Chung et al.). Caregiver tasks of care has been included in this study to

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examine whether or not multiple tasks of care will predict the caregiver’s ability to perform his
or her life tasks.
Rewards of caregiving. Rewards of caregiving refer to levels of the family caregivers’
overall sense of satisfaction associated with performing their caregiving roles (Raschick &
Ingersoll-Dayton, 2004; Sasat, 2006; Stewart & Archbold, 1997). Much of the earlier research on
family caregivers has focused on the negative consequences of caregiving (e.g., Morimoto et al.,
2003; Frias et al., 2005; Chatcheydang, 2005). However, caregiving for an older family member
can also be a satisfying and rewarding experience, despite the possible stress imposed from
managing one’s life (Davis, 2005; Kramer, 1997; Picot, 1995; Raschick & Ingersoll-Dayton).
Buddhist beliefs toward elders of Thai caregivers may impart a sense of obligation for them to
care for parents, and karma-based thought may create positive feelings from assuming the role of
family caregiver, such as the rewards of caregiving (Choowattanapakorn, 1999; Sasat, 2006;
Sethabouppha, & Kane, 2005). Similarly, Heru and Ryan (2004), Donprapeng (2006), and
Kasemkitwattana (2006) proposed that a caregiver’s warm and supportive attitude toward his or
her care recipient can sometimes help to cope with the caregiver role, which influences the
caregiver’s performance and overall HRQOL. This measure, therefore, will be a key in this study
to investigate its effect on caregivers’ functional status and HRQOL in Thai populations and
whether or not rewards of caregiving can moderate or mediate the relationship between those
two main caregiver outcomes: functional status and HRQOL.
Summary
Because of an increase in the number of elderly Thais with chronic, manageable illnesses,
more elderly Thais require assistance at home to care for age-related physical and mental
problems. Recently, more family members have been required to assume daily caregiver roles

59

for elderly relatives, particularly in rural areas (Chatcheydang, 2005; Subgranon, 1999). The
majority of family members in rural Thailand believe in Buddhism—that older family members
should receive obedience from the younger family members, parents should receive good care at
home, and kids have a sense of obligation to provide care—leading most Thais to refuse to let
elders or parents move into institutions. Buddhist beliefs have helped caregivers easily accept
caregiving situations and the caregiver role. Also, Buddhist beliefs have facilitated caregivers to
positively interpret and perceive the caring situation as rewards. These domains of benefit
finding in elder caregiving have been perceived by caregivers, and they are expected to be
associated with the caregivers’ ability to perform care and their overall HRQOL.
HRQOL measures have been developed to assess aspects of a family caregiver’s
subjective experience relating to health, disease, disability, and impairment. It is especially
important for nursing researchers to more rigorously examine the relationship of family
caregivers’ functional status to their HRQOL. As an ability of the caregiver to functionally
perform in daily life and to care for ECRs, functional status will be considered a very important
influence in fulfilling a caregiver role. In this study, the HRQOL of elderly Thai family
caregivers in rural settings was more rigorously explored to gain knowledge on how functional
status might affect their HRQOL. This study also examined how other family caregiver and ECR
factors are associated with HRQOL or functional status to fill the knowledge gap concerning the
most culturally appropriate interventions for rural Thai family caregivers to enhance
effectiveness and quality of their care for ECRs.
Even though Buddhist beliefs about elders in Thai family caregivers may create positive
feelings in the caregiver from assuming this role, other family caregiver characteristics should be
examined, such as age, sex, relationship to ECR, social support, and characteristics of ECRs. The

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results of the study will examine the relationship among those caregivers’ clinical outcomes,
functional status, and HRQOL which will further affect the continuum of caring for elders at
home. In addition, results will be particularly innovative in understanding how relevant
caregiving variables impact caregivers’ HRQOL in a rural, non-Western context.
Furthermore, the results of this study can be used to guide the future research trajectory
of caregiving for ECRs in the rural Buddhist context. The results also revealed the association of
caregivers’ participation in religious activities and their perceptions of rewards. Such results will
help create a new religion-related model of assessing caregiving consequences and provide
guidelines for the development of appropriate religious intervention to enhance caregivers’
ability to perform care for ECRs and themselves, which will impact on their HRQOL.

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Chapter 4
Methods
The purpose of chapter 4 is to present the methodology of the study. First, the design,
subjects, and settings of the study are introduced. Then, the study’s instrument operational
definitions and measurement of variables (see Appendices A and B for Study Instruments) are
presented. Finally, the proposed procedure of data collection, power and data analysis plan, data
management, protection of human subjects and inclusion of women are described.
Research Design
The cross-sectional, descriptive study was conducted from October 2011 to January 2012
by the investigator at two primary care units (PCUs) in two rural districts in the Uttaradit
province of northern Thailand. The two selected PCUs were responsible for all aspects of
population health in the small villages of each district. In every province of Thailand, the
standard was one PCU per district, which typically houses the club for elders. The club’s
members participate in activities provided by staff nurses and health care professionals once or
twice each month.
Purpose of the study. The purpose of this study was to examine which selected
variables–family caregiver characteristics (age, sex, religious activities, relationship to ECR,
chronic health conditions, household income, and social support), ECR characteristics (age, sex,
levels of physical disability, and ECRs’ symptoms), length of caregiving, rewards of caregiving,
caregiver tasks of care, and family caregiver functional status–significantly influence the
HRQOL levels of rural Buddhist Thai family caregivers caring for ECRs with one or more
chronic conditions and at least two ADL deficits.
Problem statement. Thai family caregivers frequently have physical difficulties from

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direct care dealing with chronically ill ECRs’ impairments and behavioral problems
(Chatcheydang, 2005). Assistance provided to elders with chronic diseases includes managing
IADLs, helping with ADLs, and monitoring age- and disease-related symptoms, any of which
may have a direct influence on the caregivers’ ability to care for elders and for themselves.
Caregivers’ functional status as an ability to perform their own daily self-care and household
activities will be considered an important variable in the caregiving role that may influence their
HRQOL and the continuation of the caregiving role at home. This study examined the following
research questions: What is the relationship between caregivers’ functional status and the
HRQOL of rural Thai family caregivers caring for chronically ill elders? Will the rewards of
caregiving exert a mediating effect on the relationship between rural family caregiver functional
status and overall caregiver HRQOL?
For the proposed study, the researcher hypothesized that Thai family caregivers, who care
for ECRs with physical disabilities, tend to have problems with caregiver functional status
because of the degrees of the ECRs’ disabilities, their age- and disease-related symptoms, and
increases in caregiver tasks of care. This was one of the first studies to explore those relevant
caregiving aspects to specifically understand caregivers’ functional status and HRQOL. The
results will demonstrate the relationship among those caregivers’ clinical outcomes affecting
functional status and HRQOL, which will further affect the sustainability of caring for elders in
the community.
Subjects
Sample respondents were community-dwelling, primary family caregivers of ECRs who
had one or more chronic conditions (e.g., stroke, hypertension, osteoarthritis, Alzheimer’s
disease, and dementia) and have needed assistance for two or more ADLs at home for at least

63

three months. Family caregivers were unpaid for caring for an ECR, which is defined as a family
member, such as a husband, wife, father, mother, son or daughter, sister or brother, and so forth.
All family caregivers taking care of chronically ill ECRs at home who met the inclusion criteria
were invited to enroll in the study.
According to the G*power for correlation and regression analyses and HRQOL outcome,
a total of 201 family caregivers were recruited through purposive sampling using the study
inclusion criteria. This minimal sample size of subjects provided an acceptable .80 power
analysis of medium effect size and an alpha level of significance of .05 (Buchner, Erdfelder, &
Faul, 1997; Faul et al., 2009; Walters et al., 2001).
The inclusion criteria for family caregiver eligibility included (a) being 18 years of age or
older and living in rural area, (b) caring for a chronically ill ECR 60 years of age or older for at
least three months, (c) acting as a primary caregiver at home and without pay for an ECR who
has two or more ADL deficits, (d) being fluent in the Thai language, and (e) being Buddhist. The
exclusion criteria included (a) being less than 18 years of age, (b) caring for elderly patients less
than 60 years of age, (c) being paid to care for a chronically ill ECR, and (d) not living in the
rural area (living in the municipal area).
Settings
Family caregivers in the study were recruited by the investigator from two PCUs in rural
regions of Northern Thailand. At each PCU, one elderly club provided monthly health-related
activities for elderly members. There, older people had access to ongoing support from the staff
of the PCU and engage in a wide-range of activities, such as praying, meditation, exercise, card
games, other recreational activities, and health examinations. The two PCUs in this study were
responsible for providing health care to residents of small villages where there is limited access

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to health care facilities. Elders undergoing health examinations at the PCU were asked by the
club staff if they are cared for by someone at home. Also, the caregivers accompanied the elders
to the club were questioned by the PCU health professionals using the inclusion criteria for
recruitment.
Sample Size
The required sample size was calculated based on G*power tests for correlation and
regression analyses (Faul, Erdfelder, Bucher, & Lang, 2009). The choice of the sample size
formulae depended on the way data will be analyzed, which, in turn, depended on specific
characteristics of the data analyzed (Walters, 2004). Sample size was critically dependent on the
purpose of the study, the outcome measure and how it is summarized, and the method of
calculating the test statistic (Machin, Campbell, Favers, & Pinol, 1997; Walters, Campbell, &
Lall, 2001).
Thus, according to the G*power for correlation and regression analyses and HRQOL
outcome, a minimal sample size of at least 150 subjects would provide an acceptable .80 power
analysis of medium effect size, with 15 predictors and an alpha level of significance of .05
(Buchner et al.,1997; Faul et al., 2009; Walters et al., 2001).
Instruments
Sociodemographic and clinical characteristics. Socio-demographic and clinical
characteristics were collected on the Thai study questionnaire developed by the investigator, as
well as from self-reported information on family caregivers’ characteristics: age in years, sex as
male and female, participation in religious activities—including the religion caregivers believe in
and activities they participated in, such as praying, meditating, offering food to monks, going to
the temple, and so forth.—relationship to ECR as the types of connections existing between

65

caregiver and ECR, household income as the total monthly income of the family caregiver, and
the chronic health conditions as the types and total number of the conditions that the family
caregiver possesses. Also, ECRs’ characteristics—age in years and sex as male and female—
were reported by the family caregivers. Length of caregiving or duration of assuming a family
caregiver role was measured using a question concerning the number of complete years as a
family caregiver.
Religious activities. Religion is the participation in religious-related activities—including
the activities they participated in, such as praying, meditating, offering food to monks, going to
the temple, donating to others, and doing other good things for themselves and others as reported
in previous religiosity-related literatures (Levin, Chatters, & Taylor, 1995; Picot et al., 1997).
Religious activity was measured using the religious activity grid to rate how often caregivers do
participate in those religious activities. Frequency scores were evaluated for each activity on 5point Likert-type scales, where caregivers selected 0 (not at all), 1 (less than once a month), 2
(once a month), 3 (once a week), or 4 (once a day). Responses to the religious activity grid were
summed such that high scores indicated a greater frequency of participating religious activities.
Participation in religious activities, one of a caregiver’s resources, may impact positive
caregiving experiences and has been reported to lessen the effects of stress and heighten
perceived caregiver rewards (Picot et al.; Subgranon & Lund, 2000).
All of the following instruments were used in many previous studies and were shown to
be reliable and acceptable psychometric characteristics as shown in Table 1.
HRQOL. Overall HRQOL was measured using the Thai translation of Quality of Life
Index (QLI; Ferrans, 2009; Petchprapai, 2007). The QLI was developed by Ferrans and Powers
to measure quality of life in terms of a person’s overall satisfaction with life (1985). The QLI

66

measures both satisfaction and importance regarding various aspects of life. The instrument
consists of two parts: The first measured satisfaction with various aspects of life, and the second
measures the importance of those same aspects. Scores were calculated for overall quality of life
in total and in four domains: health, psychological, social and economic, and family (Ferrans,
1996; Ferrans & Powers; Ferrans, 1990).
The total score came from the 33 items which each rated on a 6-point Likert-type scale.
Scores were calculated for HRQOL overall and in four domains: health and functioning,
psychological and spiritual, social and economic, and family (Ferrans, 1996; Ferrans & Powers,
1985; Ferrans, 1990). The total score of the QLI ranged from 0 to30; a higher score indicating a
better HRQOL. The instrument also had undergone formal psychometric testing for convergent

and divergent validity, test–retest reliability, and internal consistency. Test–retest reliability of
the measure is 0.87 with a 2-week interval and 0.81 with a 1-month interval and internal
consistency, as measured by Cronbach’s alpha, ranging from 0.73 to 0.99 (Ferrans & Powers,
1998; Katsuno, 2003) and 0.94 for the Thai version (Petchprapai, 2007).
Functional status. Caregiver functional status was measured using the 12-item Short
Form Survey (SF-12). The SF-12 (Ware, Kosinski, & Keller, 1996), derived from the Thaitranslated version of SF-36, had been demonstrated to be reliable and valid in clinical and
population-based applications (Hoffmann, 2005; Larson, 2002; Lim & Fisher, 1999; Lundberg,
Johannesson, Isacson, & Borgquist, 1999). To reduce the respondent burden and the time needed
for questionnaire administration, a short questionnaire had been used consisting of a single
instrument of 12 items and has been tested within both adult and adolescent groups (McHorney,
Ware, & Raczek, 1993; Nelson et al., 1994; Ware et al., 1995; Ware et al., 1996; Wasson et al.,
1994). The SF-12 survey contained 12 categorical questions that assess ability in performing
activities as a result of physical and emotional health and 3-, 5-, and 6-point Likert response
67

formats that assess limitations in physical activity and physical role functioning, pain, overall
health, mental health, vitality, and social functioning. Higher total scores indicate better
functioning status of caregivers.
All 12 items were used to calculate the physical- and mental-component summary scores
and total scores by applying a scoring algorithm empirically derived from the data of a U.S.
general population survey (Ware et al., 1995). Performance of the component summary scores
had been studied in nine languages, and it has been recommended that the U.S.-derived summary
scores, which yield a mean of 50 and a standard deviation of 10, be used in order to facilitate
cross-cultural comparison of results (Chariyalertsak, Sirisanthana, Saengwonloey, & Nelson,
2001; Chariyalertsak et al., 2011; Gandek et al., 1998; Kontodimopoulos, Pappa, Niakas, &
Tountas, 2007). Test-retest reliability coefficients greater than 0.70 were demonstrated (Resnick
& Parker, 2001). Validity, discriminatory power, correlation with other measures, construct, and
criterion had been rated as good (Larson et al., 2008; Lundberg et al.; Sanderson et al., 2001).
The sensitivity to change was reported as adequate (Luo et al., 2001; Muller-Nordhorn et al.,
2003). Similar to previous studies and some references to HRQOL measured by SF-36, a recent
study by the investigator has indicated acceptable psychometric properties of the measure
(Netchang et al., 2010). Moreover, many studies reported that the SF-12 summary measure
replicates well the SF-36 summary measure and shows similar responsiveness to changes over
time (Chariyalertsak et al. 2011; Lam et al., 2005; Larson; Muller-Nordhorn et al.; Wee, Davis,
& Hamel, 2008).
Caregiver tasks of care. Caregiver tasks of care were measured by the Oberst Caregiving
Burden Scale (OCBS; Carey, Oberst, McCubbin, & Hughes, 1991; Oberst, 1990; Oberst,
Thomas, Gass, & Ward, 1989), assessing caregivers’ perceptions of time and of difficulty

68

associated with tasks they performed in caring for their family members (Bakas et al., 2004;
Carey et al., 1991). Among others, such tasks included providing personal care, assisting with
medications, monitoring symptoms, managing the patient’s emotions and behaviors, dealing with
finances, and talking with health professionals. The time items on the OCBS were each rated on
a 5-point scale ranging from 1 (none) to 5 (a great amount), and the difficulty items are rated on
a 5-point scale ranging from 1 (not difficult) to 5 (extremely difficult). Total scores were
separately generated for time and for difficulty, which range from 15 to75; higher scores
represent more perceived time spent or more difficulty with tasks. The 15-item OCBS, as well as
the Thai-translated version, has shown evidence of internal consistency reliability,
unidimensionality, and content and construct validity in cancer, stroke, and heart failure
caregivers (Bakas et al., 2004; Bakas & Champion, 1999; Boonluk, 2005; Carey et al., 1991;
Chung et al., 2010; Oberst, 1990).
Social support. The social support questionnaire, Personal Resource Questionnaire 85
part II (PRQ85-II), was used for measuring social support. This instrument was developed by
Brandt and Weinert (1981) and was modified and translated into Thai by Puttapitukpol (2001).
The PRQ85- II is a 25-item questionnaire that measures the respondent’s level of perceived
social support (Brandt & Weinert; Weinert & Brandt, 1987). It includes five dimensions:
intimacy, social integration, nurturance, worth, and assistance. These items each use a 7-point
Likert rating scale, ranging from 1 (strongly disagree) to 7 (strongly agree) for positive
statements, and from 7 (strongly disagree) to 1(strongly agree) for negative statements. The
composite PRQ85-II score ranges from 25–175. The total scores were generated for this study;
higher scores indicate higher levels of social support. The internal consistency of the Thaitranslated version was tested by Cronbach’s alpha coefficient and was found to be good at 0.84

69

with the test-retest reliability shown to be 0.84 (Sreshthaputra, Sreshthaputra, & Vutyavanich,
2008; Tangkawanich, Yunibhand, Thanasilp, & Magilvy, 2008).
Rewards of caregiving. The rewards of caregiving were measured by the Thai-translated
version of Archbold and Stewart’s (1986, 1993) Rewards of Caregiving Form, which consisted
of 27 items including five aspects: reward of meaning, reward of learning, financial reward,
spiritual reward, and being there for the patient. This measure quantified levels of family
caregivers’ overall perceptions of reward from caring for the ECRs during the caring period.
Each statement has a 5-point Likert scale response, ranging from 0 (not at all) to 4 (a great deal).
Responses to the Thai-translated version were summed such that high scores indicate a greater
perceived reward of caregiving, with a range of 0 to 108 (Donprapeng, 2006; Kopachon, 2002;
Plaipetch, 2002). The overall Cronbach’s alpha of rewards of caregiving in previous studies
ranged from 0.77 to 0.94 (Archbold et al., 1995) and, it has been reported, in Thai studies ranged
from 0.80 to 0.93 (Chatcheydang, 2005; Donprapeng; Kopachon; Plaipetch; Subgranon & Lund,
2000).
ECR physical disability. The physical disability of the ECR was measured by the family
caregivers using the Barthel Index (BI; Mahoney, & Barthel, 1965). The BI was developed as a
measure to assess disability in patients and has been recommended by the Royal College of
Physicians for routine use in the assessment of older people (Sainsbury et al., 2005). The index
was an ordinal scale comprising of 10 ADLs: transferring, walking, stairs, toilet use, dressing,
feeding, bladder, bowel, grooming, and bathing. The scores range from 0 to 100; the healthy
score is 100, and lower scores indicate greater disability. Interrater reliability was reported as
high percentage agreement (> 0.70) for the total score. The reliability of the Thai version of the
BI has been investigated in the major clinical settings relevant to older people and has been

70

found to be reliable (> 0.80; Senanarong, et al., 2003).
ECR symptom. The symptom of the ECR was measured by the Memorial Symptom
Assessment Scale (MSAS;Portenoy et al., 1994). The MSAS was originally developed to
provide multidimensional information about a diverse group of common symptoms and first
tested in the cancer population. The MSAS consisted of subscales that describe (a) psychological
symptom distress (PSYCH), which includes feeling sad, worrying, feeling irritable, feeling
nervous, difficulty sleeping, and difficulty concentrating; (b) physical symptom distress (PHYS),
which includes lack of appetite, lack of energy, pain, feeling drowsy, constipation, dry mouth,
nausea, vomiting, change in taste, weight loss, feeling bloated, and dizziness; and (c) global
symptom distress (Global Distress Index; GDI). The GDI included the frequency scores for
feeling sad, worrying, feeling irritable, and feeling nervous, and it includes the distress scores for
lack of appetite, lack of energy, pain, feeling drowsy, constipation, and dry mouth. Severity,
frequency, and distress were evaluated for 24 symptoms, along with severity and distress for
eight symptoms, on 4- and 5-point Likert-type scales. Higher scores indicated more severity,
greater frequency, and higher distress. The scores range from 0 -128, with a score of zero
indicating the caregiver did not perceive that the ECR experienced the symptom in the past four
weeks. All reporting of symptoms was completed by caregivers, the individual symptom score
was the average of all the completed dimensions. The total MSAS score is the average of the
scores for all 32 symptoms. The scoring of the MSAS also yields three subscales.
Internal consistency was found to be moderate to high (0.58 - 0.88; Portenoy et al., 1994).
The MSAS was tested to determine whether or not it could serve as a feasible, reliable, and valid
tool for use in assessing family caregivers on the symptoms experiences of advanced cancer
patients. The author found that the internal consistency was high in the PHYS (α = 0.84),

71

PSYCH (α = 0.82), and GDI (α = 0.84) subscales (Lobchuk, 2003). The Thai-translated version
of MSAS was reported as high (0.78 - 0.91) in cancer patients (Malangpoothong et al., 2009;
Sumdaengrit, 2008; Suwisith, 2007).
Procedure for Data Collection
The rights of the caregiver subjects enrolled in this study were respected by the
investigator throughout the study period through various measures. Also, the study was guided
by principles of the Health Insurance Portability and Accountability Act (HIPAA) of 1996
(HIPAA, 1996). After the Institutional Review Boards (IRB) of Michigan State University
(MSU) approved the study (see Appendix D for IRB Approval Letter), the investigator contacted
the PCU directors, who had already completed training in research ethics and human rights. The
investigator explained the objectives and procedures of the study to the PCU nurses and asked
for their assistance in identifying eligible family caregivers. Each of the PCUs provided a letter
of approval allowing the investigator to conduct the study at the facility. Then, information was
gathered using the following steps (see Figure 3):
1. Screening for eligible subjects was first completed by the club staff nurses at the PCUs
based on the specified inclusion criteria. The ECRs had been diagnosed for their conditions and
diseases by the specialists at Uttaradit hospital once they were admitted to or visited the
emergency department.
2. All eligible subjects were approached by the investigator after they asked to obtain
more information about the study. Eligible subjects were asked to provide their informed consent
(see Appendix C for Study Consent Form) after the investigator had explained the study
objectives, the data collection processes, and the subject’s right to not participate in the study.
3. Separate from the ECRs, the investigator asked consented family caregivers to

72

complete a questionnaire at the elderly club in approximately 45 to 60 minutes. The investigator
read the questionnaires for those family caregivers who requested assistance or reported having
difficulty completing the questionnaires.
Figure 3 shows the sequence that was used for collecting data. This study was conducted
by the investigator at the PCUs and elderly clubs in two rural districts in the Uttaradit province
of Northern Thailand. Eligible family caregivers were first identified by the club staff, who
searched census registration lists and patient records. At the PCUs, participants attending health
examinations and elderly club activities were asked by club staff whether they are care for elders
in need of assistance for two or more ADLs. A total of 127 family caregivers were recruited from
the initial contact at PCUs, and a total of 74 family caregivers were recruited from census
searching. The investigator approached family caregivers at the PCU who agreed to receive more
information on the study. Participants who were not caring for an elderly family member at home
or did not intend to participate in the study were thanked for answering before they left. Few
family caregivers refused participation in this study because their elders needed no help with two
or more ADLs. Family caregivers who agreed to talk with the investigator were provided
information about the study objectives, along with a copy of the informed consent form.
After consent was obtained by the investigator, the investigator administered the
translated questionnaires (see Appendix A) to family caregivers at the elderly clubs. Using the
study questionnaire, the investigator collected study data from enrolled family caregivers
regarding all study variables: family caregiver and ECR sociodemographic and clinical
characteristics, length of caregiving, caregiver tasks of care, rewards of caregiving, family
caregiver functional status, and overall HRQOL.

73

-Club staff searched census
registration or patient records for
elders with one or two chronic
health conditions
-Club staff questioned if they were
taken care of by someone at home
(N = 74)

Initial contact at PCUs
-Participants attending health examinations and
elderly club activities were asked by club staff if
they are caring for elders in need of assistance
for two or more ADLs (N = 127)

No

Yes

Attended the health
services, then left

The investigator explained
study objectives and
obtained informed consent

Yes

No

Thanked for
answering, and then
left

The translated questionnaires
were administered by the SI to
assess caregivers and ECRs at
the PCU.
-Caregiver characteristics
-ECR characteristics
-Length of caregiving
-Social support
-Caregiver tasks of care
-Caregiver functional status
-Rewards of caregiving
-Overall HRQOL of caregiver
(N=201)
Figure 3. Data collection flowchart. PCU = primary care unit; ADL = activity of daily living;
ECR = elderly care recipient; HRQOL = health related quality of life.

Plan for Data Management
A total of 201 family caregivers were asked to complete a questionnaire by the SI at the
PCU, and the SI read the questionnaires for those family caregivers who requested assistance or
report having difficulty completing the questionnaires. The questionnaires included family
caregivers’ and ECRs’ sociodemographic and clinical characteristics, QLI, SF-12, PRQ85-II, BI,
74

MSAS, OCBS, and rewards of caregiving. All completed study questionnaires were kept
confidentially by the investigator and housed separately from the signed consent form. The data
were entered daily by only the investigator using the Predictive Analytics Software 18 (PASW
18.0) in the SI’s personal computer and saved in a password-protected file. A codebook was
developed that linked the study variables to variable names in PASW.
The codebook was used as a guide for entering, cleaning, checking, and analyzing all the
data. The questionnaires were coded anonymously by a designated study ID number, which
corresponded with the subject ID variable in the PASW data set. Missing data were to be
carefully coded and managed to prevent an analysis error as planned, but there were no missing
data because the investigator was at the PCU to answer all the questions the caregivers asked
when experiencing problems completing the study questionnaire. Also, every questionnaire was
carefully checked right after the caregiver returned it to the investigator. The investigator asked
the caregiver to review and complete the questionnaire if there were any incomplete items.
Random checks were made to ensure that data was entered completely and correctly by the
investigator.
Only the investigator, major professor, and study statistician were allowed to access the
information. All study questionnaires were stored in a locked cabinet at the investigator’s office
in Thailand or at West Fee Hall on MSU’s campus, and the electronic data were kept in a
password-protected file on the investigator’s personal computer. The investigator’s personal
computer had a backup file system to restore data, had any problems arisen with the hard drive,
and the data were kept separately in a password-protected external hard drive. Because the
electronic data were kept in the investigator’s personal computer and external hard drive, the
personal computer and the external hard drive were carried in a backpack kept by the

75

investigator’s side when traveling internationally.
Plan for Data Analysis
Data from all participants were analyzed by the investigator using the PASW 18.0
Statistic for Windows (IBM SPSS Statistics, 2010). The specific analysis plan for each aim is
outlined in the following section.
Descriptive statistics were calculated for the categorical variables of sociodemographic
and clinical characteristics of family caregivers and ECRs, including frequencies and
percentages. The mean, range, and standard deviation of the continuous variables’ scores for
family caregivers and ECR sociodemographic and clinical characteristics, length of caregiving,
caregiver tasks of care, rewards of caregiving, family caregiver functional status, and overall
HRQOL of family caregivers were computed.
A series of Pearson’s product moment correlation procedures was used to explore
relationships between family caregiver and ECR characteristics, as well as other selected
caregiving-related variables for rural Thai family caregiver functional status (Specific Aim 1).
Correlation tests of the associations among study variables were executed by setting the
significance level at .05.
Multiple regression procedures were used to examine the relationships between family
caregiver and ECR characteristics, length of caregiving, caregiver tasks of care, rewards of
caregiving, family caregiver functional status, and overall HRQOL of family caregivers (Specific
Aims 2 and 3), setting the significance level at .05 (Tabachnick, & Fidell, 2007; see Figure 3).
Analyses to determine the mediating effect of the rewards of caregiving on the relationship
between family caregiver functional status and HRQOL of family caregiver were based on the
principles published by Baron and Kenny (1986). To test a potential mediating effect of rewards

76

of caregiving on the relationship between caregiver functional status and HRQOL, three
regression equations were performed, controlling for other family caregiver and ECR
characteristics. The three regression equations were (a) caregiver functional status as a
significant predictor of rewards of caregiving, (b) caregiver functional status as a significant
predictor of overall HRQOL, and (c) caregiver functional status and rewards of caregiving
entered simultaneously with the overall HRQOL.
Hypotheses of the study were that:
1. That the limitation of rural family caregivers’ functional status would have a negative
influence on their overall HRQOL.
2. That the rewards of caregiving would exert a mediating effect on the relationship
between rural family caregivers’ functional status and caregivers’ overall HRQOL.
Human Subjects Protection
The rights of the caregiver subjects who were enrolled in this study were respected by the
investigator throughout the study period. Also, the study was guided by principles of HIPAA of
1996 (HIPAA, 1996). After the study had been approved by the IRB of MSU and the PCUs, the
investigator contacted the PCUs’ nurse director and department heads who had already
completed training in research ethics and the protection of human subjects. The investigator
explained the objectives and procedures of the study to four PCU nurses and asked for their
assistance in identifying eligible family caregivers. Eligible family caregivers were first
identified by the club staff, who searched census registration lists and patient records. The
investigator approached family caregivers at the PCU who had agreed to receive more
information about the study. Only the investigator enrolled family caregivers.
Family caregivers who agreed to talk with the investigator were informed of the study via

77

an information sheet and were provided with a consent form. The consent form included
information about the study, study objectives, rights of participants, and contact information for
the investigator and IRB. A consent form and an information sheet were translated and back
translated by a PhD-educated translator in Thailand to ensure that the study materials were
equivalent in Thai and English. Family caregivers read and signed the consent form prior to
answering the questionnaires. If family caregivers were unable to read, the investigator is applied
for a waiver of documentation of written consent to the MSU IRB.
After consent was obtained by the investigator, the investigator administered translated
questionnaires—QLI, SF-12, PRQ85-II, BI, MSAS, OCBS, and rewards of caregiving—to
family caregivers at the PCUs or their homes. They had the right to stop participating in the
study at any time. No study data were collected before IRB and PCU permission approval.
Participants were asked to complete the study questionnaire, which contained no
identifiers, such as names or phone numbers. Data–including family caregivers’ and ECRs’
sociodemographic and clinical characteristics, QLI, SF-12, PRQ85-II, BI, MSAS, OCBS, and
rewards of caregiving–then were entered daily by only the investigator using PASW 18.0. All
completed study questionnaires were kept confidential and separate from the signed consent
forms. The data were coded anonymously by a designated study ID number. The research
findings did not associate subjects with specific questionnaires or findings. Only the investigator,
major professor, and study statistician were allowed to access the family caregivers’ information.
All study questionnaires were stored in a locked cabinet at the investigator’s office in Thailand
or at Fee Hall on MSU’s campus, and the electronic data were kept in a password-protected file
on the investigator’s personal computer. The hard copies of consent forms and the electronic data
were brought separately and confidentially to MSU’s College of Nursing for potential audit.

78

Because the electronic data were kept in the investigator’s personal computer and external hard
drive, the personal computer, the external hard drive, and consent forms were separately carried
in the investigator’s locked carry-on luggage and the backpack and kept with the investigator
when traveling from Thailand back to the United States.
Women and Minority Inclusion in Clinical Research
As the National Institutes of Health (NIH) policy and guidelines on the inclusion of
women and minorities as subjects in clinical research—amended October, 2001—require, female
and minority (if there are any) caregivers were recruited representing the subjects of the
proposed study. A breakdown in sex and religious activities in the dataset for the proposed
research was expected, and descriptive statistics regarding sex and religious activities are
reported in chapter 5.
The purpose of this chapter was to present the design and methods that were used for this
study, as well as human subject protection and data safety. Chapter 5 will describe the result of
the study analyses. Chapter 6 will present contributions to science and implications for policy,
clinical practice and research.

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Table 1
Summary of Study Measures
Measure

Number
of items

Data
source

Admin.

Time
(min.)

Psychometric property
Reliability

Validity

Thaitranslated
version

Sensitivity
to change
Acceptable

Responsiveness
Demonstrated

Yes

Demonstrated

Yes

Overall QOL:
QLI

33 Family
caregiver

Selfadministered

10

0.73 - 0.99 High

Functional
status: SF-12

12 Family
caregiver

Selfadministered

5

> 0.76 Good

Adequate

Social
support:
PRQ85-II

25 Family
caregiver

Selfadministered

10

0.84 High

Adequate

Yes

Rewards of
caregiving

27 Family
caregiver

Selfadministered

2

Acceptable

Yes

Physical
disability : BI

10 Family
caregiver

5

0.80, 0.89 High

Adequate

ECR
symptoms:
MSAS

32 Family
caregiver

Selfadministered/
interviewed
Selfadministered/
interviewed

10

0.78 - 0.91 High

Adequate

Caregiver
tasks of care:
OCBS

15 Family
caregiver

5

> 0.80 High

Adequate

Selfadministered

> 0.80 Moderate

80

High

Yes

Yes

Demonstrated

Yes

Table 1 (cont’d)
Measure

Number
of items

Data
source

Admin.

Time
(min.)

Psychometric property
Reliability

Family
caregiver
sociodemographic
& clinical
characteristic

7 Family
caregiver

Selfadministered

5

Validity

Sensitivity
to change

Responsiveness

Thaitranslated
version
Yes

ECR socio3 Family
Self5
Yes
demographic
caregiver administered/
& clinical
interviewed
characteristic
Note. Admin. = method of administration; QOL = quality of life; QIL = Quality of Life Index; SF-12 = 12-item Short Form Survey;
PRQ85-II = Personal Resource Questionnaire 85 part II; BI = Barthel Index; ECR = elder care recipient; MSAS = Memorial Symptom
Assessment Scale; OCBS = Oberst Caregiving Burden Scale.

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Chapter 5
Results
The primary purpose of this study was to examine which selected variables–family
caregiver characteristics (age, sex, religious activities, relationship to ECR, chronic health
conditions, household income, and social support), ECR characteristics (age, sex, levels of
physical disability, and ECRs’ symptoms), length of caregiving, perceived rewards of
caregiving, caregiver tasks of care, and family caregiver functional status–significantly influence
the HRQOL levels of rural Buddhist Thai family caregivers caring for ECRs with at least two
ADL deficits. This study sought to address the following specific aims, to examine:
1. The relationships among family caregiver characteristics (age, sex, religious activities,
relationship to ECR, chronic health conditions, household income, social support), ECR
characteristics (age, sex, levels of physical disability, ECRs’ symptoms), length of caregiving,
rural Thai family caregiver tasks of care, rewards of caregiving, and functional status.
2. The relationships among family caregiver characteristics (age, sex, religious activities,
relationship to ECR, chronic health conditions, household income, social support), ECR
characteristics (age, sex, levels of physical disability, ECRs’ symptoms), length of caregiving,
rewards of caregiving, caregiver tasks of care, family caregiver functional status, and overall
HRQOL of rural Buddhist Thai family caregivers.
3. Whether the relationship between family caregiver functional status and overall
HRQOL of family caregivers is mediated by the rewards of caregiving, controlling for all other
variables.
The following sections will present the results from this study. Sample characteristics
and descriptive analyses will be presented. In addition, reliability of study instruments and

82

scoring information will be presented. Interpretation and discussion of the results and
implications will be presented in chapter 6.
Study Measures
Operational definitions for all study variables were provided in chapter 4. The following
section will discuss the actual measurement, scoring, and descriptive analyses results of the
sample response to study variables. Reliability coefficient for each of the study instruments will
be presented. Reliability data for each instrument for this study can be found in Table 2.
Predictors/Covariates
Caregiver characteristics.
Age. Each caregiver reported his or her age in years based on the age at the date of
enrollment into the study and treated as a continuous variable for analysis.
Sex. Each caregiver self-reported his or her sex as either male or female. They were
scored as 1 for male and 2 for female in PASW 18.0. Sex was treated as a categorical variable
for analysis.
Religion. Each caregiver was asked to select the category which best fit his or her
religion. Categories were Buddhist, Christian, Islam, and other. Religion was treated as a
categorical variable for analysis.
Religious activities. Each caregiver was asked to report the frequency of participation in
religious-related activities, which were, praying, meditating, going to the temple, offering food
and things for monks, donating for others and other. Participation in religious activities was
measured using the religious activity grid to rate how often caregivers do participate in those
religious activities. Frequency scores were evaluated for each activity on 5-point Likert-type
scales, in which participants selected 0 (not at all), 1 (less than once a month), 2 (once a month),

83

3(once a week), or 4 (once a day). A total score of the religious activity was developed by
summing all activities with total number for other, such that higher scores indicate a greater
frequency of participating religious activities. This variable was treated as a continuous variable
analysis.
Relationship to ECR. Each caregiver was asked to report his or her relationship to the
ECR. They were instructed to choose the category best described the particular type of
connection existing between the caregiver and ECR. Categories were wife, husband, daughter,
son, niece, nephew, sister (younger), brother (younger), son-in-law, daughter-in-law, and other
relatives. Relationship to ECR was treated as a categorical variable for analysis.
Chronic health conditions. Caregivers were asked to respond “yes” or “no” when
questioned whether they possessed chronic health conditions. Chronic health conditions included
hypertension, diabetes mellitus, heart disease, chronic obstructive pulmonary disease, back pain,
arthritis, and others. Each condition was coded 1 (yes) or 0 (no). For the other category, the study
investigator reviewed what was written to ensure that the participant reported a chronic condition
different from what had already been reported in the list. A score for chronic health conditions
was developed by summing all chronic health conditions. This variable was treated as a
continuous variable for analysis.
Household income. Income was a self-reported variable. Caregivers were asked to select
the total household income which best reflected them. Income was divided into four different
categories ranging from less than or equal to 2000 Baht ($65) per month to greater than or equal
to 10,000 Baht ($325) per month. Income was treated as a categorical variable for analysis.
Elderly care recipient characteristics.
Age. Each caregiver was asked to report the age in completed years of the elderly

84

recipient in the individual’s care. The ECR’s age in years was based on the age at the date of
caregiver enrollment into the study and treated as a continuous variable for analysis.
Sex. Each caregiver was asked to report the ECR’s sex either male or female. They were
scored as 1 (male) or 2 (female) in SPSS. Sex of the ECR was treated as a categorical variable
for analysis.
Levels of physical disability. The BI (Mahoney, & Barthel, 1965) was used to measure
the limitation of performing ADLs as an indicator of the dependence and need of the ECR. This
instrument was described in chapter 4. This instrument was administered by the individual
caregiver reporting the ADLs limitation of the ECR. The index is an ordinal scale comprising of
10 ADLs: transferring, walking, stairs, toilet use, dressing, feeding, bladder, bowel, grooming,
and bathing. Each caregiver was asked to rate the limitation with scores ranging from 0 to100.
The highest score is 100, indicating no disability, and lower scores indicate greater disability.
The mean scores of 51-75 were reported as moderate disability in the previous study (Supervia,
Aranda, Marquez, Aguirre, Skaf, & Cutierrez, 2008). The limitation score for each index was
summed to create a total ADL limitation score for each ECR. A level of physical disability was
treated as a continuous variable for analysis. A Cronbach’s alpha for this instrument was
administered and determined to be .82. This is consistent with the reported reliability of the
instrument both in English and Thai-translated version of the BI (Sainsbury et al., 2005;
Senanarong, et al., 2003).
ECRs’ symptoms. The MSAS (Portenoy et al., 1994) was used to collect data on 32
different symptoms common in elders. This instrument was described in chapter 4. To administer
the MSAS, Individual caregivers selected the frequency, severity, and distress for symptoms.
Severity, frequency, and distress were evaluated and reported for 24 symptoms, as were severity

85

and distress for 8 symptoms, on 4- and 5-point Likert-type scales. Higher scores indicated more
severity, greater frequency, and higher distress. All symptoms were reported by caregivers. The
individual symptom score was the average of all the completed two or three dimensions
(frequency, severity, and distress) divided by the number of dimensions for each item. The total
dimension scores for each item were summed to create a total symptom score. The scores range
from 0 -128, with a score of zero indicating the caregiver did not perceive the ECRs’ symptoms
in the past four weeks. The score of each dimension was reported as low when it was lower than
14.8 in the previous study (Portenoy et al., 1994). The variable, ECRs’ symptoms, was treated as
continuous for analysis. A Cronbach’s alpha for this instrument was administered and
determined to be .81. This is consistent with the reported reliability of the instrument both in
English and Thai-translated version of the MSAS (Portenoy et al.; Suwisith, 2007).
Environmental characteristics.
Social support. The PRQ85-II (Brandt & Weinert, 1981) was used for measuring social
support. This instrument was described in chapter 4. Caregivers were asked to rate their levels of
perceived social support regarding provision for attachment or intimacy, social integration,
opportunity for nurturance behavior, reassurance of worth as an individual and in role
accomplishments, and the availability of informational, emotional, and material assistance. These
items each use a 7-point Likert rating scale, ranging from 1 (strongly disagree) to 7 (strongly
agree) for positive statements and from 7 (strongly disagree) to 1 (strongly agree) for negative
statements (item numbers 4, 7, 10, 16, and 24). For this study, all items were summed to create a
total social support score for each caregiver. The total score ranges from 25–175; higher scores
indicate higher levels of social support. The score of social support was reported as high in the
previous study when it was higher than 120 (Sreshthaputra, Sreshthaputra, & Vutyavanich,

86

2008). Social support was treated as a continuous variable for analysis. A Cronbach’s alpha for
this instrument was administered and determined to be .91. This is consistent with the reported
reliability of the instrument both in English and Thai-translated version of the PRQ85-II (Brandt
& Weinert, 1981; Sreshthaputra et al., 2008).
Length of caregiving. The total number of caregiving months was determined by
computing the total number of months from the caregiver’s start in the role of primary caregiver,
to the month caregiver enrolled into the study. The length of time of caregiving was reported in
total months, and was treated as a continuous variable for analysis.
Rewards of caregiving. The Rewards of Caregiving Form (Archbold & Stewart, 1986,
1993) was used to measure rewards of caregiving. This instrument was described in chapter 4.
The instrument consisted of 27 items which assessed the levels of family caregivers’ overall
perceptions of the rewards of caregiving for the ECRs during the caring periods. It is scored by
using a 0 to 4 response scale response, and then all items are summed for a total score ranging
from 0 to 108 such that high scores indicate a greater perceived reward of caregiving. Rewards
of caregiving scores were reported as high above the cut-off point of 70 in Kopachon’s (2002)
and Plaipetch’s (2002) studies. Rewards of caregiving were treated as a continuous variable for
analysis. A Cronbach’s alpha for this instrument was administered and determined to be .97.
This is consistent with the reported reliability of the instrument both in English and Thaitranslated version of the Rewards of Caregiving Form (Archbold et al., 1995; Chatcheydang,
2005).
Caregiver tasks of care. The OCBS (Carey, Oberst, McCubbin, & Hughes, 1991; Oberst,
1990; Oberst, Thomas, Gass, & Ward, 1989) was used to assess caregivers’ perceptions of time
and difficulty associated with tasks they performed in caring for their ECRs. This instrument was

87

described in chapter 4. Tasks included were providing personal care, assisting with medications,
monitoring symptoms, managing the patient’s emotions and behaviors, dealing with finances,
and talking with health professionals. Caregivers were asked to rate the time spent on these tasks
ranging from 1 (none) to 5 (a great amount), and the difficulty of these tasks ranging from 1 (not
difficult) to 5 (extremely difficult). Total scores were generated separately for time and for
difficulty, which ranged from 15-75; higher scores represent more perceived time spent or more
perceived difficulty with tasks. Both the time spent on and the difficulty of tasks were reported
as low when the scores were less than 35 in previous studies (Boonluk, 2005; Carey et al., 1991).
Caregiver tasks of care were treated as a continuous variable for analysis. A Cronbach’s alpha
for this instrument was administered and determined to be .96. This is consistent with the
reported reliability of the instrument both in English and Thai-translated version of the OCBS
(Bakas et al., 2004; Boonluk, 2005). Reliability coefficients were also calculated for the
instrument subscales of time and difficulty. The time and difficulty subscale was the same (α =
.95).
Family caregiver functional status. The SF-12 (Ware, Kosinski, & Keller, 1996) was
used to calculate total scores of physical and mental components by applying a scoring
algorithm. This instrument was described in chapter 4. The SF-12 survey contains 12 categorical
questions that assess limitations in performing activities as a result of physical and emotional
health. Caregivers were asked to rate the items in 3-, 5-, and 6-point Likert response formats to
assess limitations in physical activity and physical role functioning, pain, overall health, mental
health, vitality, and social functioning. The instrument was scored in two steps. First, the
response for each item was recoded with a value from 0 to 100. Second, an average value was
calculated for all items scored by each individual caregiver, which ranged from 0-100. Higher

88

total scores indicate better functioning status of caregivers. Functional status scores reported
higher than the standard mean scores (50) indicated good abilities to perform daily activities
(Chariyalertsak et al., 2011; Ware, Kosinski, & Keller, 1996). Caregiver functional status was
treated as a continuous variable for analysis. A Cronbach’s alpha for this instrument was
administered and determined to be .89. This is consistent with the reported reliability of the
instrument both in English and Thai-translated version of the SF-12 (Resnick & Parker, 2001;
Chariyalertsak et al.).
Dependent Variable
Caregiver overall HRQOL. Overall HRQOL was measured with the QLI (Ferrans &
Powers, 1985; Ferrans, 2009; Petchprapai, 2007). The QLI was developed to measure quality of
life in terms of a person’s overall satisfaction with life. The QLI measures both satisfaction and
importance regarding various aspects of life. This instrument was described in chapter 4. This
instrument consisted of 33 items which measure satisfaction and importance. Responses were
scored by recoding the satisfaction raw score in order to center the scale at zero, done by
subtracting 3.5 for each item and then weighting it by multiplying with the importance raw score.
The weighted scores were summed to generate the preliminary total score. To prevent bias due to
missing data, the primary investigator divided each sum-obtained score by the number of items
answered by individual caregiver. Lastly, to eliminate negative numbers for the final score, 15
were added to every score; this produced the final overall total QLI score which ranged from 1 to
30. The total score ranged from 0 to30; a higher score indicating a better HRQOL. Caregivers were
reported as having slightly satisfied HRQOL when the QLI scores were lower or equal to 20 in some
previous studies (Katsuno, 2003; Petchprapai, 2007). Overall HRQOL was treated as a

continuous variable for analysis. A Cronbach’s alpha for this instrument was administered and
determined to be .98. This was consistent with the reported reliability of the instrument both in
89

English and Thai-translated version of the QLI (Ferrans & Powers, 1998; Petchprapai).
Table 2
Reliability Coefficients for Study Instruments
Instrument

N of items

μ

SD

α

Quality of Life Index (QLI)

33

20.71

3.75

.98

12-item Short Form Survey (SF-12)

12

64.36

14.73

.89

Personal Resource Questionnaire
(PRQ85-II)

25

122.47

15.05

.91

Rewards of Caregiving Form

27

74.85

16.27

.97

Memorial Symptom Assessment
Scale (MSAS)

32

10.33

7.14

.81

15
15

33.86
28.23

9.97
9.31

.95
.95

Barthel Index (BI)
10
75.10
Note. μ = mean; SD = standard deviation; α = Cronbach’s alpha.

13.87

.82

Oberst Caregiving Burden Scale
(OCBS)
Time
Difficulty

Sample
Once IRB approval was obtained from MSU (see Appendix C for IRB approval letter) a
total of 201 family caregivers who met the inclusion criteria were enrolled in this study. A
criteria checklist was used to ensure that subjects were Buddhist primary caregivers who were
not being paid to care for a chronically ill ECR and who were not living in the municipal area, in
alignment with the specific objectives of this study.
Sociodemographic characteristics of caregivers (N = 201) and elders are presented in
Table 3. Of the caregivers who were eligible and enrolled in the study, 61.7% (n = 124) were
female and 39.3% (n = 79) were daughters, and there was mean age of 40 years old (SD = 13). A

90

full 100% were Buddhist who pray (chant) daily (52.2%, n = 105), offer food and things for
monks each day (33.3%, n = 67), and go to the temple monthly (39.8%, n = 80; see Table 4). The
majority had moderate to high household incomes of 5,001-10,000 baht per month (54.7%, n =
110). Most of the caregivers had no chronic health conditions (55.7%, n = 112), and some
caregivers reported one chronic health condition (25.9%, n = 52). Family caregivers were found
to have some chronic health conditions, such as back pain (30.3%, n = 61), hypertension (20.4%,
n = 41), arthritis (12.4%, n = 25), and diabetes mellitus (7%, n = 14; see Table 5).
For ECRs, the majority were female (62.7%, n = 126), with the mean age of 71.65 (SD =
7.67) and with an average of two chronic health conditions (48.8%, n = 98). Most chronic health
conditions reported in ECRs included hypertension (72.1%, n = 145), diabetes mellitus (53.2%, n
= 107), arthritis (18.9%, n = 38), stroke (7.5%, n = 15), and congestive heart failure (7.5%, n =
15). In addition, the averages of ECR symptoms were reported as low in three dimensions of the
MSAS included frequency, severity, and distress. ECRs had an average physical disability score
of 75.07 (SD = 14.06) indicating a moderate physical disability of the ECRs in performing ADLs
(see Table 6).
Moreover, Tables 6 and 7 present further sample information, the means and standard
deviations for continuous variables, which included total religious activities, length of
caregiving, social support (PRQ85-II), rewards of caregiving, caregiver tasks of care (OCBS),
caregiver functional status (SF-12), and caregiver overall HRQOL (QLI).
Caregivers had an average of three years (mean = 38.56 months, SD = 39.9 months) in
taking the role of caregiving, but they reported the amount of time mean score of 33.86 (SD =
9.97) and the difficulty mean score of 28.22 (SD = 9.31). That is, caregivers in this study
reported low total scores representing low perceived time spent and low perceived difficulty with

91

tasks. Also, caregivers reported the mean social support score of 122.47 (SD = 15.05) and mean
rewards of caregiving score of 74.85 (SD = 16.27) indicating caregivers perceived social support
and rewards of caregiving as high. Although most of the caregivers had relatively good
functional status with the mean scores of 64.36 (SD = 14.93), some older caregivers reported
lower scores indicating poor functional status (see Table 7). However, caregivers reported a
slightly satisfied HRQOL (20.71, SD = 3.75; see Table 6 and 7).
Table 7 shows that male caregivers reported higher functional status than female
caregivers did, with mean scores of 65.55 and 63.61 (SD = 13.49 and 15.76), respectively.
However, female caregivers reported slightly higher HRQOL than male caregivers did, with the
mean scores of 21.05 and 20.16 (SD = 3.95 and 3.36), respectively. For age of caregivers, older
caregivers were more likely to report worse functional status, but they were more satisfied their
lives than younger caregivers. In the relation to age, spousal caregivers reported lower functional
status than younger daughters, sons, and others did.

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Table 3
Sample Characteristics of Caregivers and Elderly Care Recipients, N and % for Categorical
Variables
Characteristic
Caregiver
Sex

Variable

Male
Female

N

%

77
124

38.3
61.7

13
7
79
42
23
21
16

6.5
3.5
39.3
20.9
11.4
10.4
8

Relationship to elderly
care recipient

Wife
Husband
Daughter
Son
Niece
Nephew
Others

Household income
(reported in Baht)

Less than 2000
2,001-5,000
5,001-10,000
10,001 or more

5
59
110
27

2.5
29.4
54.7
13.4

Male
Female

75
126

37.3
62.7

Elderly care recipient
Sex

Table 4
Caregiver Religion and Religious Activities, N and %
Characteristic

Variable

N

%

Religion

Buddhist

201

100

Religious activities

Praying
Meditating
Going to the temple
Offering food and things for monks
Donating

105
17
80
67
97

52.2
8.5
39.8
33.3
48.3

93

Table 5
Clinical Characteristics of Caregivers and Elderly Care Recipients, N and % for Categorical
Variables
Characteristic
Caregiver
Chronic health condition

Variable

No
Hypertension
Diabetes mellitus
Heart diseases
Back pain
Arthritis
Others

Total chronic health conditions

%

112
41
14
1
61
25
3

55.7
20.4
7.0
.5
30.3
12.4
1.5

0
1
2
3

109
52
27
13

54.2
25.9
13.4
6.5

Hypertension
Diabetes Mellitus
Arthritis & gouty arthritis
Cardiovascular accident
Congestive heart failure
Back pain
Alzheimer’s
Hyper-lipidemia
Others
1
2
3

145
107
38
15
15
7
4
4
8
81
98
22

72.1
53.2
18.9
7.5
7.5
3.5
2.0
2.0
4.0
40.3
48.8
10.9

Total chronic health conditions

Elderly Care Recipient
Diagnosis (chronic health condition)

N

94

Table 6
Sample Characteristics of Caregivers and Elderly Care Recipients (ECRs), μ, and SD for Continuous Variables (N=201)
Variable
Caregiver
Age
Religious activities

Description

Range

Age of caregiver
Total number of religious
activities of caregiver

0-20

Min.

Max.

μ

SD

18
1

80
15

40.70
7.74

13.00
3.66

ECR
Age

Age of elderly care recipient

60

92

71.65

7.67

Length of caregiving

Caregiving period in months

2

252

38.56

39.9

BI

Elder physical disability

0-100

10

90

75.07

14.06

PRQ85-II

Social support of caregiver

25-175

84

169

122.47

15.05

Rewards of caregiving

Rewards of caregiving

0-108

36

108

74.85

16.27

MSAS
Frequency
Severity
Distress

Elder symptom
Symptom frequency
Symptom severity
Symptom distress

0-128
0-96
0-128
0-128

1.20
1.00
1.00
1.60

36.20
43.00
33.00
36.80

10.33
8.88
9.42
11.62

7.14
6.12
6.68
8.01

OCBS time

Caregiver task of care: Time
spent in caregiving

15-75

15

61

33.86

9.97

95

Table 6 (cont’d)
Variable

Description

Range

Min.

Max.

μ

SD

OCBS difficulty

Caregiver task of care:
Difficulty of caregiving

15-75

15

58

28.22

9.31

SF-12

Caregiver functional status

0-100

25

93.75

64.36

14.93

QLI
Caregiver overall HRQOL
1-30
12.89
28.98
20.71
3.75
Note. μ= mean; SD = standard deviation; BI = Barthel Index; PRQ85-II = Personal Resource Questionnaire 85 part 11; MSAS =
Memorial Symptom Assessment Scale; OCBS = Oberst Caregiving Burden Scale; SF-12 = 12-item Short Form Survey; QLI = Quality
of Life Index; HRQOL = health-related quality of life.

96

Table 7
Categorical Sociodemographic Characteristics of Caregivers, Caregiver Functional Status, and
Overall HRQOL
Caregiver
functional status
μ (SD)

N
Sex
Male
Female
Age
18-24
25-34
35-49
50-64
65+

Caregiver
overall HRQOL
μ (SD)

77
124

65.55 (13.49)**
63.61 (15.76)

20.16 (3.36)
21.05 (3.95)

13
61
77
37
13

74.78 (8.88)**
65.96 (13.38)
68.63 (12.58)
56.19 (15.42)
44.32 (11.69)

21.40 (3.01)
19.85 (3.32)
20.73 (3.45)
20.81 (4.58)
23.57 (4.28)*

Relationship to elder
Wife
13
45.96 (17.07)
24.10 (4.09)**
Husband
7
57.66 (12.52)
23.35 (4.06)
Daughter
79
65.41 (14.60)
20.72 (3.79)
Son
42
67.44 (13.34)
20.10 (3.17)
Niece
23
70.83 (11.89)
20.80 (3.41)
Nephew
21
68.02 (11.38)
19.78 (2.45)
Others
16
54.86 (13.27)
19.39 (4.77)
Note. HRQOL = health-related quality of life; μ= expected value; SD = standard deviation.
*p < .05. **p < .01

Results and Analysis
Specific Aim 1. As stated previously, Aim 1 was to examine the relationships among the
following variables: family caregiver characteristics (age, sex, religious activities, relationship to
ECR, chronic health conditions, household income, social support), ECR characteristics (age,
sex, levels of physical disability, ECRs’ symptoms), social support, length of caregiving, rural
Thai family caregiver tasks of care, and functional status.
Correlation analysis was utilized to determine if the caregiver’s and ECR individual
characteristics and other independent factors were either positively or negatively related to the
97

caregiver’s functional status. A series of Pearson’s product moment correlation procedures were
used to explore relationships among family caregiver and ECR characteristics, as well as other
selected caregiving-related variables, and their associations with rural Thai family caregiver
functional status. Correlation tests of the associations among study variables were executed by
setting the significance level at .05 (see Table 8 for correlation results). Caregiver age, caregiver
chronic health conditions, length of caregiving, elder chronic health conditions, elder symptoms,
and caregiver task of care were all negatively correlated with caregiver functional status. As
caregiver age, caregiver chronic health conditions, length of caregiving, elder chronic health
conditions, elder symptoms, and caregiver task of care increased, the caregiver functional status
decreased. Simultaneously, social support, rewards of caregiving, and elder’s physical disability
were all positively correlated with caregiver functional status. As social support, rewards of
caregiving, and elder’s physical ability increased so did the caregiver functional status.
A linear regression model was also run to assess for possible significant predictors of
caregiver functional status. In order to run this model, categorical variables (sex of caregiver and
elder, and relationship to elder) were recoded to dummy variables (male = 1 and female = 0;
daughter = 1 and others = 0) and all selected variables were entered. The highest nonsignificant
probability variable in each iteration was trimmed until the model was stable with a highest
correlation coefficient. A total of eight iterations were completed before the final model was
achieved. The final model had a correlation coefficient (R) of .797, correlation coefficient
2

squared (R ) of .635, correlation coefficient squared change of .635, and an F distribution of
29.735 with a probability of .000. That is, all final variables included caregiver age, sex, chronic
health conditions, and elder symptoms significantly influenced caregiver functional status with
the p-value less than .001. The adjusted correlation coefficient squared for the final model was
98

.614, indicating that the model explained approximately 61% of the variance. Caregiver age, sex,
chronic health conditions, and elder symptoms were noted to be significant predictors of
caregiver functional status (see Table 9 for regression coefficients). Younger male caregivers
with few chronic health conditions who were taking care of ECRs with fewer symptoms were
most likely to have better functional status than those who were older female with more chronic
health conditions who were taking care of elders with more symptoms.
Table 8

Caregiver age
Caregiver chronic
health condition
Length of caregiving
Elder chronic health
condition
Social support

1 .757** .326** .228** -.083 .127
1

.205** .235** -.086 .077
1

Caregiver
functional status

Caregiver task of
care (Difficulty)

Elder symptoms

Elder disability

Social support
Rewards of
caregiving

Elder chronic
health condition

Length of
caregiving

Characteristics

Caregiver age
Caregiver chronic
health condition

Correlation Estimates of Caregivers’ and Elderly Care Recipients’ Characteristics and
Caregiver Functional Status (N = 201)

-.256** .294** .443** -.451**
-.297** .284** .369** -.419**

.136

.051 .063

-.102

.170* .134

1

-.032 .084

-.174*

.212** .195** -.199**

1 .567** .094

Rewards of
caregiving
Elder physical
disability
Elder symptoms

1

.090
1

-.040

-.099

.334**

-.036

-.009

.157*

.576** .299** .170*
1

Caregiver task of care
(Difficulty)
Caregiver functional
status
* p < .05. **p < .01.

-.138*

.436** -.213**
1

-.239**
1

99

Table 9
Coefficients for Final Linear Regression Model Indicating Significant Predictors of Caregiver
Functional Status

Predictor

Constant

Unstandardized Standardized
coefficient
coefficient
Beta Std. error
Beta
75.967

9.548

Caregiver age

-.493

.087

Caregiver sex; male

4.378

Relationship to ECR; daughter
Household income

t

Significance

7.956

.000

-.415

-5.653

<.001

1.742

.138

2.513

.013

2.409

1.700

.076

1.417

.158

1.429

1.075

.064

1.330

.185

-4.130

1.152

-.248

-3.584

<.001

.019

.019

.049

1.012

.313

-.447

.114

-.206

-3.923

<.001

Caregiver tasks of care (difficulty)
-.141
.091
Note. Std. error = standard error; t = t distribution.

-.085

-1.548

.123

Caregiver chronic health condition
Length of caregiving
Elder symptoms

Specific Aim 2. The purpose of Aim 2 was to examine the relationships between the
following variables: family caregiver characteristics (age, sex, religious activities, relationship to
ECR, chronic health conditions, household income, and social support), ECR characteristics
(age, sex, levels of physical disability, and ECRs’ symptoms), length of caregiving, rewards of
caregiving, caregiver tasks of care, family caregiver functional status, and overall HRQOL of
rural Buddhist Thai family caregivers.
Correlation analysis was utilized to determine if the caregiver’s and ECR’s individual
characteristics and other independent factors were either positively or negatively related to the
caregiver overall HRQOL. A series of Pearson’s product moment correlation procedures were
used to explore relationships between family caregiver and ECR characteristics, as well as other
selected caregiving related variables, and their associations with rural Thai family caregiver

100

overall HRQOL, setting the significance level at .05 (see Table 10 for correlation results).
Caregiver age, religious activities, household income, social support, rewards of
caregiving, and caregiver functional status were all positively correlated with caregiver overall
HRQOL. As caregiver age, religious activities, household income, social support, rewards of
caregiving, and caregiver functional status increased, so did the caregiver’s overall HRQOL.
Simultaneously, relationship to elder was negatively correlated with caregiver overall HRQOL.
When caregivers were not daughters, but were spouses or others, caregiver overall HRQOL was
higher
A linear regression model was also run to determine what predictors contributed
significantly to caregiver overall HRQOL (see Table 11 for regression coefficients). In order to
run this model, categorical variables (sex of caregiver and elder and relationship to elder) were
recoded to dummy variables (male = 1 and female = 0; daughter = 1 and others = 0), and all
selected variable were entered. The highest nonsignificant probability variable in each iteration
was trimmed until the model was stable with a highest correlation coefficient. A total of 12
iterations were completed before the final model was achieved. The final model had a correlation
coefficient of =.857, a correlation coefficient squared of .735, a correlation coefficient squared
change of .735, an F distribution of 47.54 with a probability of .000. That is, all final variables
included caregiver age, total religious activities, relationship to elder, caregiver chronic health
condition, social support, rewards of caregiving, and caregiver functional status significantly
influenced caregiver overall HRQOL with the p-value less than .001.

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Table 10

Religious activities

-.083

.127

1

-.451** .183*

.202** .466** .807** .037

Household income

1

Social support

.244** .186** .138
1

Rewards of caregiving

.735**
.255**

.567** .334** .582**
1

Caregiver functional status

Overall HRQOL

Rewards of caregiving

.351** -.076

Caregiver functional
status

Social support

1

Household income

Caregiver age

Religious activities

Characteristics

Caregiver age

Correlation Estimate of Caregivers’ and Elderly Care Recipients’ Characteristics, Other
Selected Caregiving Factors, and Overall HRQOL (N=201)

.157*
1

.801**
.250**

Overall HRQOL

1

Note. HRQOL = health-related quality of life.
*p < .05. **p < .01.
The adjusted correlation coefficient squared for the final model was .719, indicating that
the model explained approximately 72% of the variance. Caregiver age, total religious activities,
relationship to elder, caregiver chronic health condition, social support, rewards of caregiving,
and caregiver functional status were noted to be significant predictors of caregiver overall
HRQOL. Older, nondaughter (spouses and others) caregivers participating in more religious
activities, who had few chronic health conditions and better functional status and perceived
higher social support and higher rewards of caregiving, were most likely to have the greatest
overall HRQOL. Simultaneously, younger daughter caregivers participating in fewer religious
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activities, who had more co-morbid conditions and worse functional status and perceived lower
levels of social support and rewards of caregiving, tended to have a low overall HRQOL.
Table 11
Coefficients for Final Linear Regression Model Indicating Significant Predictors of Caregiver
Overall HRQOL
Unstandardized
coefficient
Predictor
Constant

Beta

Std. error

-.949

.018

Caregiver sex; male

-.190

Religious activities

Beta

2.049

.064

Standardized
coefficient
t

Significance

-.463

.644

.221

3.518

.001

.367

-.025

-.517

.806

.203

.075

.198

2.695

.008

-.648

.295

-.085

-2.200

.029

.303

.218

.056

1.391

.166

Caregiver chronic health condition

-.475

.239

-.117

-1.986

.048

Length of caregiving

-.002

.004

-.024

-.589

.557

Social support

.034

.012

.137

2.796

.006

Rewards of caregiving

.117

.017

.509

7.057

<.001

-.025

.023

-.047

-1.072

.285

Caregiver age

Relationship to elder; spouse
Household income

Elder symptoms

Caregiver functional status
.042
.012
.165 3.564
<.001
Note. HRQOL = health-related quality of life; Std. error = standard error; t = t distribution.
Specific Aim 3. The purpose of Aim 3 was to determine whether the relationship
between family caregiver functional status and overall HRQOL of family caregivers is
moderated or mediated by the rewards of caregiving, controlling for all other variables.
Analyses to determine the mediating effect of the perceived reward of caregiving on the
relationship between family caregiver functional status and HRQOL of family caregiver was
based on the principles proposed by Baron and Kenny (1986). To test a potential mediating
effect of rewards of caregiving on the relationship between caregiver functional status and
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HRQOL, three regression equations were performed, controlling for other family caregiver and
ECR characteristics. Three regression equations were (a) caregiver functional status as a
significant predictor of rewards of caregiving, (b) caregiver functional status as a significant
predictor of overall HRQOL; and (c) caregiver functional status and rewards of caregiving
entered simultaneously with the overall HRQOL.
To test rewards of caregiving as a potential mediating variable, the three regression
equations were completed for caregiver functional status (see Table 12, 13, and 15 and Figure 4).
The analyses indicated a partial mediating influence of rewards of caregiving on caregiver
overall HRQOL. Data from the first equation showed that, when controlling for other variables,
caregiver functional status influenced (p < .05) rewards of caregiving, meaning that caregivers
who had greater functional status tended to report higher perceptions of rewards of caregiving.
Table 12
Coefficients for Linear Regression Model Indicating Caregiver Functional Status as a
Significant Predictor of Rewards of Caregiving
Unstandardized
Coefficient
Predictor

Beta

Constant

63.867

Std. Error

Standardized
Coefficient
Beta

5.040

Caregiver functional status
.171
.076
Note. Std. error = standard error; t = t distribution.

t

Significance

12.673
.157

.000

2.236

.026

The second equation showed that caregiver functional status positively influenced
caregiver overall HRQOL (p < .01; see Table 13). That is, caregivers who had better functional
status were most likely to have greater overall HRQOL.

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Table 13
Coefficients for Linear Regression Model Indicating Caregiver Functional Status as a
Significant Predictor of Overall HRQOL
Unstandardized
Coefficients
Predictor
Constant

Beta
16.668

Std. Error

Standardized
Coefficients
Beta

1.140

Caregiver functional status .063
.017
Note. Std. error = standard error; t = t distribution.

t

Significance

14.624
.250

.000

3.640

.000

The final test for mediation was to enter both rewards of caregiving and caregiver
functional status into a regression equation and evaluate whether: (a) rewards of caregiving was a
significant influence on caregiver overall HRQOL and (b) the strength of the relationship
between caregiver functional status and caregiver overall HRQOL decreased when rewards of
caregiving was included. When both caregiver functional status and rewards of caregiving were
included as predictors of caregiver overall HRQOL, controlling for all other variables, the model
had a correlation coefficient of .811, a correlation coefficient squared of .658, a correlation
coefficient squared change of .658, and an F distribution of 190.459 with a probability of .000
(see Table 14). The adjusted correlation coefficient squared for the final model was .655,
indicating that the model explained approximately 65% of the variance. Caregiver functional
status (p = .003) and rewards of caregiving (p = .000) were noted to be significant predictors of
caregiver overall HRQOL, satisfying the first criterion as a mediating influence (see Table 15).

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Table 14
Model Summary for Multiple Regression Indicating the Variance of Caregiver Functional Status
and Rewards of Caregiving in Predicting Caregiver Overall HRQOL
Change Statistics
R

R
.811

2

.658

Adjusted
2
R
.655

SE

2

R Change

2.20635

F
Change

df1

.658 190.459

df2
2

198

Sig. F
Change
.000

2

Note. HRQOL = health-related quality of life; R = multiple correlation; R = multiple correlation
squared; SE = standard error of the estimate; F = F distribution; df = degrees of freedom; Sig. F
Change = significance F distribution change
Table 15
Coefficients for Multiple Regression Model Indicating Caregiver Functional Status and Rewards
of Caregiving as Significant Predictors of Overall HRQOL
Unstandardized
Coefficients
Predictors
Constant
Caregiver functional status

Beta

SE

Standardized
Coefficients
Beta

5.156

.928

.032

.011

t

Significance

5.557
.128

.000

3.030

.003

Rewards of caregiving
.180
.010
.781 18.568
.000
Note. HRQOL = health-related quality of life; SE = standard error; t = t distribution.
Considering the second criterion, the t-value representing the relationship between
caregiver functional status and caregiver overall HRQOL decreased (see Figure 4) when rewards
of caregiving was included. Sobel’s test to determine whether this change was statistically
significant was performed, and the results (p = .02) indicated a significant difference. The effect
of caregiver functional status on caregiver overall HRQOL, however, did not disappear when
rewards of caregiving was entered into the model, indicating that a partial mediation effect had
occurred. Therefore, rewards of caregiving appears to have significantly, partially mediated the
relationship between caregiver functional status and overall HRQOL.

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Rewards of
caregiving

Caregiver
functional
status

t2 = 3.03*
t1 = 3.64

Caregiver
overall
HRQOL

Figure 4. Summary model of the partial mediation of rewards of caregiving in the relationship
between caregiver functional status and overall health-related quality of life (HRQOL). t1 = t
distribution of the relationship between solely caregiver functional status and caregiver overall
HRQOL; t2 = t distribution of the relationship between caregiver functional status and caregiver
overall HRQOL when rewards of caregiving was simultaneously entered in the model.
Additional Analysis
As shown in the findings, the relationship between family caregiver functional status and
overall HRQOL of family caregivers was partially mediated by the rewards of caregiving. In
order to assess influences associated with rewards of caregiving, correlation analysis was utilized
to determine if any of the caregiver’s and ECR’s individual characteristics and other independent
factors were either positively or negatively related to rewards of caregiving. Furthermore,
whether or not behaviors reflecting participation in religious activities were shown to associate
with family caregivers’ perceived rewards had been tested. Religious activities were praying,
meditating, going to the temple, offering food and things for monks, or donation of money, food
and things for others.
Pearson’s product moment correlation procedures was used to explore relationships
between family caregiver and ECR characteristics, as well as other selected caregiving related
variables, and their associations on rewards of caregiving. Correlation tests of the associations
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among study variables were executed by setting the significance level at .05 (see Table 16 for
correlation results and Table 17 for the mean of rewards of caregiving in each categorical group).
Caregiver sex, religious activities, household income, and social support were all
positively correlated with rewards of caregiving. If the caregivers were female, as religious
activities, household income, and social support increased, so did the rewards of caregiving.
Simultaneously, relationship to elder was negatively correlated with rewards of caregiving.
When the caregivers were spouses, rewards of caregiving were reported as higher than other
kinds of relationship to elder with the mean score of 86.85 (SD = 16.18) in wives and the mean
score of 90.00 (SD = 8.12) in husbands. Mean rewards of caregiving for each sex and
relationship to elder are shown in Table 17, which indicates that female caregivers reported
higher rewards of caregiving and spousal caregivers reported higher rewards of caregivers than
the others. .
Table 16

Total religious activities

1

Rewards of
caregiving

Total
religious
activities

Household
income

Characteristic

Social
support

Correlation Estimate of Significant Caregiver’s Characteristic, Other Selected Caregiving
Factor,s and Rewards of Caregiving (N = 201)

.202**

Rewards of caregiving

.244**

.186**

1

Social support

.807**

1

Household income

.466**

.567**
1

**p < .01

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Table 17
Categorical Sociodemographic Characteristics of Caregivers and Rewards of Caregiving

Characteristic
Sex
Male
Female

N

Rewards of caregiving
μ (SD)

77
124

71.61 (16.11)
76.86 (16.10) *

Relationship to elder
Wife
13
Husband
7
Daughter
79
Son
42
Niece
23
Nephew
21
Others
16
Note. μ = mean; SD = standard deviation.
*p < .05. **p < .01

86.85 (16.18)
90.00 (8.12)
77.18 (14.82) **
68.90 (14.84)
77.00 (11.11)
72.62 (14.74)
62.85 (23.19)

A linear regression model was also run to assess for possible significant predictors of
rewards of caregiving. In order to run this model, categorical variables (sex of caregiver and
elder and relationship to elder) were recoded to dummy variables (male = 1 and female = 0;
daughter = 1 and others = 0) and all selected variable were entered. The highest nonsignificant
probability variable in each iteration was trimmed until the model was stable with a highest
correlation coefficient. A total of two iterations were completed before the final model was
achieved. The final model had a correlation coefficient of .840, a correlation coefficient squared
of .705, a correlation coefficient squared change of .705, an F distribution of 93.351 with a
probability of .000. The adjusted correlation coefficient squared for the final model was .698,
indicating that the model explained approximately 69.8% of the variance. Total religious
activities, social support, and relationship to elder were noted to be significant predictors of
rewards of caregiving (see Table 18 for regression coefficients). Daughter caregivers who
participated in more religious activities and perceived greater social support were most likely to
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have higher perception of rewards of caregiving than those who were not a daughter, but were
participating in few religious activities and perceiving lower social support.
Table 18
Coefficients for Final Linear Regression Model Indicating Significant Predictors of Rewards of
Caregiving
Unstandardized
Coefficients
Predictors
Constant

Standardized
Coefficients

Beta
16.358

Std. error
5.684

Beta

t
Significance
2.878
.004

Caregiver sex; male

2.518

1.594

.075

1.580

.116

Religious activities

3.116

.202

.702

15.455

.000

Relationship to elder;
daughter
Household income

3.259

1.553

.098

2.099

.037

-.411

.941

-.018

-.436

.663

Social Support
.272
.048
Note. Std. error = standard error; t = t distribution

.251

5.612

.000

Power
A post hoc analysis utilized the program G*power (Faul, Erdfelder, Bucher, & Lang,
2009) in order to determine the study’s power. This analysis was run for the linear regression
model predicting caregiver functional status and overall HRQOL and determining rewards of
caregiving as a potential mediating variable. The linear regression model revealed an effect size
of .35 and a power (1- error probability) of .99. Because the required sample size has been
calculated based on G*power Tests for correlation and regression analyses, this sized sample
provided an acceptable power analysis of a large effect size.
Summary
This chapter presented the results from quantitative analysis. Based on the results, some

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caregiver sociodemographic characteristics, health condition, and elder symptoms had an impact
on caregiver abilities to perform ADL and functional status. Moreover, religious activities
caregiver participate in and other positive aspects in caregiving–such as social support and
rewards of caregiving–are noted significantly influence caregiver overall HRQOL. Rewards of
caregiving were found to have a partial mediating effect in the relationship between caregiver
functional status and overall HRQOL. Finally, family caregivers’ rewards of caregiving were
found to be significantly predicted by religious activities–such as praying, meditating, going to
the temple, offering food and things for monks, or donation for others– as well as social support,
and relationship to elder. Further interpretation and discussion of these results will be presented
in chapter 6.

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Chapter 6
Discussion & Implications
The focus of this study was on the relationship among individual caregivers’ elders’
clinical characteristics, positive and negative caregiving aspects, family caregiver functional
status, and overall HRQOL of rural Buddhist Thai family caregivers caring for chronically ill
ECRs. A discussion of the results with interpretation, as well as how they support or differ from
existing research literature, and limitations of the study will be presented in this chapter. Also,
this final chapter will present the implications for nursing practice, research, and policy.
Discussion of Sample
The study results of sociodemographic characteristics of caregivers as female and
daughters were consistent with the previous reports and other caregiver studies in Thailand
(Chatcheydang, 2005; Lawang et al., 2006). The majority of the caregivers were female (61.7%,
n = 124) and daughters (39.3%, n = 79), a caring situation whereby one generation cared for the
other. Social belief and the Thai culture inculcated the expectation that the role of primary care
was a female function. Daughters assumed this role to show gratitude to their parents because
they have concern for their loved ones and a good attitude toward care through the love, bonding,
and closeness with the patients, including fathers, mothers, grandfathers, and grandmothers
(Chatcheydang; Sethabouppha & Kane, 2005; Subgranon & Lund, 2000).
Most of the caregivers had no chronic health conditions (55.7%, n = 112); because the
mean age of caregivers was 40, perhaps they were middle-aged adults who had no occurrence of
many chronic health conditions. Studies have shown that many older family caregivers
experience one or more chronic illnesses, such as hypertension, heart disease, low back pain, or
arthritis (Chatcheydang, 2005; Blanes et al., 2007; Frias et al., 2005).

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For ECRs, the majority were female (62.7%, n = 126), the mean age was 71.65, and
roughly half had two chronic health conditions (48.8%, n = 98), which included hypertension,
diabetes mellitus, and so forth. The results were consistent with the report of the Ministry of
Social Development and Human Security (MSDHS, 2007) and other studies that report that the
number of older Thai people is projected to increase, female elders have longer life expectancies,
and most of these people experience chronic health problems (Caffrey, 1992; Chan, 2005; Sasat,
2006; Subgranon, 1999; Subgranon & Lund, 2000).
The study results serve to clarify the associations between family caregiver
characteristics, ECR characteristics, caregiving-related independent variables, caregiver
functional status, and caregivers’ overall HRQOL. A discussion of the results with interpretation
for each aim, as well as the additional results, will be presented in the following sections.
Discussion of Results for Specific Aim 1
Specific Aim 1. The purpose of Specific Aim 1 was to examine the relationships among
the following variables: family caregiver characteristics (age, sex, religious activities,
relationship to ECR, chronic health conditions, household income, and social support), ECR
characteristics (age, sex, levels of physical disability, and ECRs’ symptoms), social support,
length of caregiving, rural Thai family caregiver tasks of care, and functional status.
Initially, correlations were computed, and caregiver age, caregiver chronic health
conditions, length of caregiving, elder chronic health conditions, elder symptoms, and caregiver
task of care were found to be negatively correlated with caregiver functional status. Also, social
support, rewards of caregiving, and elder’s physical disability were found to be positively
correlated with caregiver functional status. That is, caregiver functional status was expected to
decrease when caregivers get older, have more chronic health conditions, spend more time in the

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caregiving role, and have more care tasks, as well as when elders have more chronic health
conditions and more symptoms. Simultaneously, caregiver functional status is assumed to
increase when caregivers perceive higher social support and rewards of caregiving, and when
elders have more physical disability.
A linear regression model was also computed. Caregiver age, sex, chronic health
conditions, and elder symptoms were found to be predictors of caregiver functional status.
Younger male caregivers with few chronic health conditions and caring for elders with few
symptoms were found to have better functional status.
Age. The younger caregivers were, the more they were to perform their daily activities
and tasks. Previous studies have also noted age to be a predictor of caregiver functional status
(Lawang et al, 2005; Serrano-Aguilar et al., 2006; Wongchantra, 1996). Wongchantra and
Lawang et al. noted that older caregivers’ functioning may be deteriorating and older caregivers
may suffer from their underlying disease more than younger caregivers. This causes the older
caregiver to experience decreased ability to perform daily tasks compared to the younger
caregiver. However, the mean age of caregivers in the present study was 40, which shows that
caregivers were mid-adult and most likely have an above average functional status (64.36, SD =
14.93).
Sex. For sex of caregivers, being male predicted a higher score of functional status. The
study results show that male caregivers reported slightly higher scores of functional status than
did female caregivers (65.55 and 63.61, respectively). Although women are often socialized to
be family caregivers and may be better prepared than men for the family caregiver role,
associations between performing their daily tasks and caregiving may be physically stronger in
men than in women (Chaoum, 1996; Cheewapoonphon, 1998; Pinquart & Sorensen, 2007;

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Stoller, 1994). The male caregivers may have more physical strength than female caregivers and,
in relation to age, the mean age of male caregivers in current study is 38.66 (SD = 11.70) years
old, which shows that male caregivers were likely younger than their female counterparts.
Chronic health conditions. Caregivers with few chronic health conditions are more
likely to have better functional status because they have fewer physical and mental symptoms
and limitations related to those chronic health conditions. Although the study results show that
caregivers are middle-age adults with few instances of chronic health conditions (1 condition;
25.9%, n = 52), the number of chronic health conditions was still found to be one of the
significant predictors of caregiver functional status. The results were similar to the previous
studies, which have shown that many family caregivers experience one or more chronic illnesses,
such as hypertension, heart disease, low back pain, or arthritis. These chronic conditions have
been shown to affect a caregiver’s ability to perform daily tasks (Blanes et al., 2007;
Cheewapoonphon, 1998; Chatcheydang, 2005; Frias et al., 2005; Pinquart & Sorensen 2007).
More chronic health conditions may negatively impact the physical and mental health status of
caregivers, leading the caregivers to perform fewer abilities in their life tasks.
ECRs’ symptoms. Caregivers who are taking care of elders with fewer symptoms were
more likely to have better functional status than those who were taking care of elders with more
symptoms. The results of this study are consistent with previous studies that have shown that the
symptoms of ECRs with chronic diseases are associated with the number of caregiver tasks of
care (Girgis et al., 2011; Osse et al., 2006; Nijboer et al., 2000; Pinquart & Sorensen, 2003,
2007) and the degree of assistance required from the caregiver (Given & Sherwood, 2006). In
turn, the level of involvement in providing care has been associated with the functional status of
the caregiver (Chung et al., 2010; Fredman et al., 2009). ECRs with more symptoms required

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caregivers to perform more tasks, which, consequently, worsen caregivers’ functional status in
achieving their own daily tasks.
Interpretation based on the finding for Specific Aim 1. Caregivers who were younger,
male, have few chronic health conditions, and taking care of elders with fewer symptoms are
more likely to have greater functional status. That is, the older caregivers’ functioning may have
been deteriorating, and older caregivers may have suffered from their own comorbid diseases.
Because they may be physically weaker than male caregivers, the female caregiver’s functioning
may decrease, especially as it’s associated to age. Moreover, consistent with the earlier literature
(Chatcheydang, 2005; Frias et al., 2005; Pinquart & Sorensen 2007), caregivers’ possessing more
chronic health conditions negatively influence caregivers’ health and ability. In addition, ECRs
who had more symptoms require more time, more difficult care which in turn interferes with
caregivers’ functioning. Nurses and other health care providers who are caring for chronically ill
elders need to understand this relationship and pay more attention to these caregiving factors in
order to assist caregivers and elders in caring. The younger male with few chronic health
conditions may have a better functional status, but he may need more supportive information and
skills to continually care at home for an elder with more symptoms. The symptom management
or extra support for managing symptoms and treatment of elders should be of concern.
Discussion of Results for Specific Aim 2
Specific Aim 2. The purpose of Aim 2 was to examine the relationships among the
following variables: family caregiver characteristics (age, sex, religious activities, relationship to
ECR, chronic health conditions, household income, and social support), ECR characteristics
(age, sex, levels of physical disability, and ECRs’ symptoms), length of caregiving, rewards of
caregiving, caregiver tasks of care, family caregiver functional status, and overall HRQOL of

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rural Buddhist Thai family caregivers.
A correlation analysis and linear regression model were computed to determine the
relationship among caregivers’ and ECRs’ individual characteristics, as well as other
independent factors that were related to the caregiver overall HRQOL. The results show that
caregiver age, religious activities, household income, social support, rewards of caregiving, and
caregiver functional status are positively correlated with caregivers’ overall HRQOL. Also,
relationship to elder is negatively correlated with caregivers’ overall HRQOL.
Age. Older caregivers are more likely to be happy and satisfied with their lives as a
whole. Although older caregivers reported lower functional status, they reported higher overall
HRQOL. Previous studies in Thailand have indicated that older family caregivers tend to
consider the caring situations as something less serious and to adapt themselves to better accept
the caregiving role than do younger family caregivers, because older caregivers could more
readily accept the changes of elders’ condition (Lawang et al., 2005; Mui, 1995; Obert, et al.,
1989; Sasat, 2006; Wongchantra, 1996). In other words, when caregivers are older, they had
experienced many life events, which enabled them to solve caregiving problems more
effectively. The caregivers would be able to make decisions and cope with problems and would
possess the skills necessary in providing care to elders. This is unlike Frais et al. (2005) and
Serrano-Aguilar et al. (2006) findings that being older relates to greater health problems,
possibly worsening older caregivers’ physical health and their overall HRQOL more so than
younger caregivers.
Religious activities. Caregivers who participated in more religious activities were more
likely to have a greater overall HRQOL. The mean of total religious activities was 7.74,
indicating a moderate to high level of caregiver religious participation. As religion in this study

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was conceptually defined as the behaviors that reflect participation in religious activities, religion
is expected to be the one of a caregiver’s resources that may impact positive caregiving
experiences. In this study, 100% of family caregivers were Buddhists who believed in the law of
karma. The law of karma means that good acts will lead to good consequences (Payomyong,
2000; Payutto, 1995, 1998); caregivers perform good deeds for their elderly ill family members
to achieve better lives in their next rebirths. Caregivers followed Buddhism in caring for their
chronically ill elders (Sethabouppha & Kane, 2005; Subgranon & Lund, 2000). Consistent with
Picot et al.’s (1997), Sethabouppha and Kane’s, and Subgranon’s studies, caregivers’ overall
HRQOL is predicted by a positive resource, religion, as total of religious activities. The more
religious activities caregivers participate in, the more positive resources and benefit finding they
perceive, which further affects their happiness or satisfaction of life as a whole, and thus a effects
higher overall HRQOL.
Relationship to ECR. Spousal and other kinds of relationships to elders are more likely
to associate with higher overall HRQOL then daughter-caregiver relationships. Although most of
the caregivers in this study are daughters and they have greater functional status than spousal
caregivers, daughters report lower overall HRQOL than husbands and wives do (20.72, 23.35,
and 24.10, respectively). This is unlike previous studies with Thai samples, which found that
spouses are the primary family caregivers for ECRs (Cheewapoonphon, 1998; Belasco et al.,
2006; Heru & Ryan, 2004) and that providing care tends to have ongoing negative effects on
their health (Barnes et al., 1992; Pinquart & Sorensen, 2007; Pinquart & Sorensen, 2011).
However, this study focuses on the overall HRQOL as a subjective aspect related to how happy
or satisfied the caregiver is with life as a whole, which may differ from other studies using
physical health measures. Consequently, spousal relationships may show stronger associations

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with overall HRQOL of family caregivers because caregiving for a spouse is more normative
than caring for other persons and helps caregivers positively appraise caregiving situations
(Pinquart & Sorensen, 2007).
Chronic health conditions. Similar to the relationship to functional status, caregivers
who have fewer chronic health conditions are more likely to have better overall HRQOL. Many
family caregivers reported experiencing one or more chronic illnesses, which has been shown to
affect their health and might worsen their overall HRQOL (Blanes et al., 2007; Frias et al.,
2005). Similarly, Barnes et al. (2006) found that, when controlling for age, gender, and
socioeconomic status, one of the significant predictors associated with caregivers’ overall
HRQOL is having two or more chronic health conditions. Also, the physical conditions were
reported to have the strongest impact on HRQOL in Lai et al.’s study (2005). Caregivers’
physical health may be deteriorating and interfering with daily life, because of their underlying
diseases or chronic health conditions as mentioned above. Besides, because caregivers are
middle-aged adults, they may have some chronic health conditions and may not be able to take
appropriate care of the elders for long, or they may face more barriers in performing as a care
provider because of their own health status limitation. All of these reasons may lead a caregiver
to appraise his or her life as one of not being satisfied.
Social support. Social support was one predictor of greater overall HRQOL. In this
study, perceived social support is defined as the level of support currently available to the
caregiver. Also, others have conceptualized social support as a resource that may positively
affect family caregivers’ HRQOL (Chappell & Reid, 2002; Lueboonthavatchai and
Lueboonthavatchai, 2006). Social support may have positively affected family caregivers’
overall HRQOL by reducing their stressors, enhancing their rewards of caregiving (Chappell &

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Reid, 2002; Cohen, Colantonio, & Vernich, 2002; Northouse et al., 2002; Picot, 1995), and
helping them to develop more effective forms of coping strategies, all of which result in positive
health behaviors in relation to caregiving performance (Losada et al., 2005; Tang & Chen, 2002).
However, functional status was not predicted by social support. This is unlike the studies of Park
and Lee (2007), and Oka et al. (2004), which found that social support was a modifiable factor
associated with functional status, particularly physical levels, in family caregivers. More
caregiver support from family, friends, and others positively affects caregiver satisfaction. Even
though they have to deal with difficult caring situations, caregivers perceive those circumstances
with the happiness needed to continue their caregiving roles when they have more resources and
support.
Rewards of caregiving. Rewards of caregiving was a significant predictor of caregiver
overall HRQOL. Caregivers who perceive higher rewards are more likely to have high overall
HRQOL while taking care of chronically ill elders. Similar to Karmer’s (1997) and Davis’s
(2005) studies, caregiving for an older family member can also be a rewarding experience,
despite the possible stress imposed from managing one’s life. Buddhist beliefs toward elders of
Thai caregivers may have imparted a sense of obligation to care for parents, and karma-based
thoughts may create positive feelings and rewards from assuming the role of family caregiver
(Sethabouppha, & Kane, 2005). The positive experience of caregiving, its rewards, and its
relation to Buddhist beliefs might have helped caregivers understand and accept their roles.
Moreover, rewards of caregiving can be explained as the positive perceptions of caregivers, as
well as their willingness to care for ECRs with chronic illness, which may impact the caregivers’
appreciation to perform caregiving roles. Besides, Heru and Ryan (2004), Donprapeng (2006),
and Kasemkitwattana, (2006) found that a caregiver’s warm and supportive attitude toward the

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care recipient can sometimes help him or her cope with the caregiver role, which influences the
caregiver’s performance and overall HRQOL. In this study, caregivers reported the high rewards
of caregiving with the mean score of 74.85 (SD = 16.27; ranged from 0-108), and 100% are
Buddhist. It is assumed that caregivers positively perceive experiences of care as the happiness
in their lives as a whole.
Caregiver functional status. Caregiver functional status was another predictor of
caregivers’ overall HRQOL. In this study, caregivers with greater functional status are more
likely to have higher overall HRQOL. As relation to age, some older caregivers reported poor
functional status but they were found to perceive higher overall HRQOL. In this study, the
relationship of caregiver functional status and overall HRQOL was found to be mediated by
rewards of caregiving, which might explain the high overall HRQOL in the poor functional
status caregivers. Similar to some previous studies (Bakas & Burgener, 2002; Chung et al., 2010;
NAC, 2004; FTGRD, 2009), HRQOL levels might also be influenced by various caregivingrelated factors experienced in the current caring situations. Multiple tasks of care for ECRs, as
well as dependency and needs of ECRs, lead the family caregiver to take more responsibility in
expanded roles (Bakas et al., 2004; Bakas & Burgener, 2002; NAC, 2004; FTGRD, 2009). Such
an increase in caregiving tasks may cause physical and psychological problems, as well as
problematic health behaviors. Moreover, monitoring and assisting with an ECR’s symptoms was
reported as time consuming, physically demanding, and exhausting (Chung et al., 2010;
Newman, 1997), which may increase caregiving demands and tasks of care, resulting in a
possible decrease in the family caregiver’s ability to perform his or her own life tasks and to
provide care. An ability to perform daily tasks of care may be a crucial factor in accomplishing
the caregiver role, which can influence the caregiver’s overall HRQOL as shown in the study

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results, consistently with some previous studies (Chung et al., 2010; Fredman et al., 2009; Lee et
al., 2003; Lu & Austrom, 2005; Spira et al., 2010).
Interpretation based on the finding for Specific Aim 2. Older spouses and other
caregivers participated in more religious activities, who have few chronic health conditions and
better functional status have higher levels of overall HRQOL. Furthermore, caregivers who
perceive higher social support and rewards of caregiving have greater overall HRQOL. Positive
aspects of caregiving–including religious activities, social support, and rewards of caregiving–
and functional status are significant predictors which may be enhanced by nurses and health care
teams either in hospitals or communities. Moreover, caregiver’s functional status should be
sustained in performing effective care through the trajectory of the disease and the process of
care. Caregiver’s functional status can be expected to be an essential factor influencing HRQOL
of the caregiver, which ultimately results in the continuous and desired care at home. In other
words, caregivers will be more happy or satisfied with their lives as a whole when they are able
to perform daily life tasks even during caregiving periods.
Discussion of Results for Specific Aim 3
Specific Aim 3. The purpose of Aim 3 was to determine whether the relationship
between family caregiver functional status and overall HRQOL of family caregivers is mediated
by the rewards of caregiving, controlling for all other variables.
To test rewards of caregiving as a potential mediating variable, the three regression
equations were performed for caregiver functional status. The analyses indicated a partial
mediating influence of rewards of caregiving on the relationship of caregiver functional status
and his or her overall HRQOL. Results from the first equation show that, when controlling for
other variables, caregiver functional status influences rewards of caregiving, meaning that

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caregivers who have greater functional status tended to report higher perceptions of the rewards
of caregiving.
Rewards of caregiving in this study were defined as levels of family caregivers’ overall
sense of satisfaction toward the experiences of caring with a positive attitude during the periods
of care (Raschick & Ingersoll-Dayton, 2004; Sasat, 2006; Stewart & Archbold, 1997). Most of
the caregivers in this study report relatively high scores of functional status (56 -74), which were
higher than the standard mean scores (50), indicating that most caregivers have good abilities to
perform their daily activities. Due to age-related physical changes, older caregivers were found
to report lower scores of functional status, which mean they had poorer abilities to perform their
life tasks, particularly in the group of above 65-year-old caregivers (44). Although much of the
earlier research on family caregivers has focused on the negative consequences of multiple tasks
of care (e.g., Morimoto et al., 2003; Chatcheydang, 2005), caregiving for an older family
member can also be a rewarding experience, despite the physical and psychological stress
imposed from managing one’s life (Davis, 2005; Kramer, 1997; Picot, 1995; Raschick &
Ingersoll-Dayton, 2004). The results of this study initially showed that a reward of caregiving
was significantly predicted by a greater functional status of caregivers. This finding will be
useful for further investigating the relationship between physical and psychological aspects of
caregiving.
The second equation shows that caregiver functional status positively influenced
caregiver overall HRQOL. That is, caregivers who have better functional status are most likely to
have greater overall HRQOL. As discussed in Specific Aim 2, caregiver overall HRQOL was
influenced by caregiver functional status. Caregivers with greater abilities to perform their daily
life tasks are more likely to be happier or more satisfied with their lives as a whole. Although

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caregivers take more responsible in expanded roles of caring (Bakas et al., 2004; Bakas &
Burgener, 2002; NAC, 2004; FTGRD, 2009), including monitoring and assessing ECRs’
symptoms (Chung et al., 2010; Newman, 1997), their overall HRQOL are not worsened if they
can maintain good functional status.
The results are consistent with some previous studies (Chung et al., 2010; Fredman et al.,
2009; Lee et al., 2003; Lu & Austrom, 2005; Spira et al., 2010) revealing that an ability of
caregivers to perform daily tasks is a crucial factor influencing their overall HRQOL. That is,
caregivers are more satisfied with their life and are happier if they can complete their daily life
activities, even though they also have expanded roles caring for chronically ill elders at home.
The final test for mediation was to enter both rewards of caregiving and caregiver
functional status into a regression equation and evaluate whether: (a) rewards of caregiving was a
significant influence on caregiver overall HRQOL and (b) the strength of the relationship
between caregiver functional status and caregiver overall HRQOL decreased when rewards of
caregiving was included. When both caregiver functional status and rewards of caregiving were
included as predictors of caregiver overall HRQOL controlling for all others related variables,
the model accounted for 65% of variance in predicting caregiver overall HRQOL. Both caregiver
functional status and rewards of caregiving were significant influences on caregiver overall
HRQOL, satisfying the first criterion as a mediating influence. Sobel’s test was performed to
determine the statistically significant changes of the t-value. The t-value representing the
relationship between caregiver functional status and caregiver overall HRQOL decreased when
the rewards of caregiving was included, satisfying the second criteria as a partial mediating
influence. Rewards of caregiving significantly, partially mediate the relationship between
caregivers’ functional status and their overall HRQOL. That is, functional status still appears to

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have a positive impact on overall HRQOL, but the degree of the effect decreases when a reward
of caregiving takes its role to affect overall HRQOL. Caregivers are satisfied with their lives
when they are able to complete their own daily life tasks. Caregivers would be much happier if
they also positively perceived their caregiving role as a reward, similarly reported in Lu and
Austrom’s (2005) and Spira et al.’s (2010) studies.
The results show a partial mediation: both a direct effect of caregiver functional status on
caregiver overall HRQOL and an indirect effect through rewards of caregiving. An ability to
perform life tasks has a direct positive impact on caregivers’ happiness and still has influences
on overall HRQOL when the caregivers have positive appraisals of caregiving. Concerning the
indirect effect, caregiver functional status leads to higher rewards of caregiving, which further
leads to higher overall HRQOL in caregivers. As discussed above, a caregivers who has a good
functional status is more likely to perceive positive or reward experiences (Davis, 2005; Kramer,
1997; Picot, 1995; Raschick & Ingersoll-Dayton, 2004) and tends to have a better overall
HRQOL (Chung et al., 2010; Fredman et al., 2009; Lee et al., 2003; Lu & Austrom, 2005; Spira
et al., 2010). Not only does caregiver functional status need to be enhanced, but caregivers’
overall sense of satisfaction toward the experiences of caring with a positive attitude could also
be increased. That is, the happier the life of a caregiver, overall HRQOL, is encouraged by both
better physical capability and superior mental appraisal. In other words, caregivers’ overall
HRQOL results from both their physical and emotional factors of caregiving.
Interpretation based on the finding for Specific Aim 3. In summary, Specific Aim 3
examined whether the relationship between family caregiver functional status and overall
HRQOL of family caregivers is mediated by the rewards of caregiving, controlling for all other
variables. Interpretively, rewards of caregiving not only highly correlated to caregiver overall

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HRQOL, but also partially mediated the relationship between caregiver functional status and
overall HRQOL. That is, caregivers who had e the capacity to complete their life tasks are more
likely to be happy or satisfied with their lives as a whole, increasing overall HRQOL. Caregivers
would be even happier if they also positively perceived their caregiving roles as rewards.
However, comparing caregiver overall HRQOL between groups with low and the high functional
status when both groups have had high rewards of caregiving is of further concern. The results of
such comparison would lead nurses and health care providers to assess how rewards of
caregiving can improve overall HRQOL in the group with low functional status. The appropriate
interventions or programs for enhancing rewards of caregiving, such as improving caregiver
overall HRQOL, are needed.
Discussion of Additional Analysis
As the findings show, rewards of caregiving significantly, partially mediates the
relationship between family caregiver functional status and overall HRQOL of family caregivers.
The results also reveal that rewards of caregiving is a crucial factor influencing caregiver overall
HRQOL. In order to assess influences associated with rewards of caregiving, correlation analysis
was performed among caregivers’ and ECRs’ individual characteristics, other independent
factors, and rewards of caregiving. Furthermore, whether the number of religious activities–such
as praying, meditating, going to the temple, offering food and things for monks, or donation for
others–positively associate with family caregivers’ rewards of caregiving has been tested.
The mean scores of rewards of caregiving indicate that female caregivers report higher
rewards of caregiving and spousal caregivers report higher rewards of caregivers than did other
elder relations. Caregiver sex, religious activities, household income, and social support are
positively correlated with rewards of caregiving. Rewards of caregiving increase for female

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caregivers and as caregivers participate in religious activities, report higher household income,
and perceive more social support. Simultaneously, caregivers’ relationship to elder negatively
correlated with rewards of caregiving. If the caregivers were spouses, rewards of caregiving
scores were higher than daughter caregivers’ scores. Rewards of caregiving are the positive
resources or benefit findings for caregivers, and appear to have an encouraging impact on overall
HRQOL, as discussed above. Such results help pave the way to improve caregivers’ HRQOL
through supporting constructive perception in caring situations, such as motivating or
encouraging participation in the desired religious activities. A private room with a Buddha image
for praying, chanting, or meditating is a simple way to support and enhance some religious
activities could be created by nurses in a ward.
Some previous studies in Thailand (Chaoum, 1996; Chatcheydang, 2005;
Cheewapoonphon, 1998; Stoller, 1994) have revealed that women are often socialized to be
family caregivers and may be better prepared than men for the family caregiver role. Similarly,
the results in this study show that female caregivers experience higher rewards of caregiving.
The results in Aim 3 show that caregivers who have better functional status tend to perceive
higher rewards of caregiving and better HRQOL. Such findings may support the association
between caregiving performance and health in men, which is stronger for men than for women.
However, Pinquart and Sorensen (2007) found that male family caregivers had some positive
attitudes in caregiving because they may be more likely to seek social support for their family
caregiver roles when caregiving demands become too high. Even though sex correlates with
rewards of caregiving, it is not a significant predictor of rewards of caregiving when entered into
the linear regression model. That is, although male caregivers may have been stronger and able
to complete more tasks than females can, female caregivers may have positive feelings about

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caregiving. Female caregivers may be more prepared for caring roles and may report higher
perceptions of positive view points. So, sex is not considered to have a significant impact on
rewards of caregiving in this study.
Caregiver household income was found to be correlated with rewards of caregiving in
this study. Similar to previous studies, those with higher household income levels are less likely
to be affected by patient caregiving demands and more likely to have positive experiences of
caregiving (Chatcheydang, 2005; Ekwall et al, 2004; Lawang et al., 2005; Pinquart & Sorensen,
2007). Caregivers with lower income levels frequently have to work harder to pay for their daily
living expenses and tend to perceive caregiving as a burden (Chung et al. 2007; Lawang et al.;
Sasat, 2006). Although, in this study, caregiver household income correlated with rewards of
caregiving, it is not a significant predictor of rewards of caregiving when entered into the
regression model. Higher household income may have helped caregivers perceive caregiving
roles positively; however, their financial status alone does not impact rewards of caregiving in
this study. This might be due to the fact that because most of caregivers in this study (68.1%, n =
137) have moderate to high household income.
When performing a linear regression model to assess for possible significant predictors of
rewards of caregiving, total religious activities, social support, and relationship to elder were
found to be significant predictors of rewards of caregiving. Daughter caregivers participating in
more religious activities and perceiving greater social supports are more likely to have higher
perceptions of rewards of caregiving.
Religious activity. Religious activity has the highest correlation with rewards of
caregiving (see Table 16) and is the most significant predictor (see Table 18) of rewards of
caregiving. The results show that all of the caregivers in the study were Buddhist. Buddhist

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beliefs dictate that older Thais should be offered a high status, respect, and obedience from
children and younger members of society. Children have an obligation to provide good care for
their elders at home. Moreover, Thai people believe in the law of karma, meaning that good acts,
words, or thoughts affect their future lives, and they wish to receive good care in return when
they are older (Payomyong, 2000; Payutto, 1995, 1998; Sethabouppha, & Kane, 2005). Buddhist
beliefs toward elders may impart a sense of obligation on caregivers to care for parents, and
karma-based thought may create positive feelings, such as the rewards of caregiving, from
assuming the role of family caregiver (Sethabouppha, & Kane, 2005). Following the law of
karma, caregivers reported moderate to high religious activities, and the findings reveal that
caregivers participated in more activities are more likely to perceive higher rewards of
caregiving. That is, the caregivers who believe in Buddhism and the law of karma participate in
good activities and responsibly care for their elders, easily accepting their roles and positively
appraising their caregiving role as a one with rewards.
Relationship to ECR. Daughters comprised the majority of caregivers in this study, and
daughter-elder relationships significantly predict rewards of caregiving. Inconsistently, previous
research both in Thailand and other countries revealed that most of the caregivers of chronically
ill elders were spouses of the patients (Chatcheydang, 2005; Joolamate, 1997; Kasemkitwattana,
2006; Sasat, 2006; Pinquart & Sorensen, 2007). In Thailand, an estimated 90% of elders live
with their children or relatives at home in rural areas (MSDHS, 2007; Subgranon & Lund, 2000)
because of these Buddhist belief-related reasons mentioned above (Sethabouppha, & Kane,
2005). As females, daughters are often socialized to be family caregivers and may be better
prepared than men for the family caregiver role, as found in some previous studies (Chaoum,
1996; Chatcheydang, 2005; Cheewapoonphon, 1998; Stoller, 1994). Similarly, in Raschick and

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Ingersoll-Dayton’s (2004) study, they assessed the association between caregiver relationship
and gender, and the costs and rewards of caregiving in a national sample of 978 spouse and child
caregivers of older family members. Results supported studies’ hypotheses that women, whether
wives or daughters, experience more caregiving costs than men, and that adult children
experience more rewards than spousal caregivers. For this study, daughters, the majority of
caregivers (61.7%, n = 124), have positive rewards of caregiving because of generational caring
situations, resulting from social beliefs and Thai culture which inculcates that the expected role
of primary care is a female function. Daughters are taught to assume this role to show gratitude
to their parents, and because daughters have more concern and better attitudes of care through
the love, strong bonds, and closeness with the elders.
Social support. Perceived Social support, one of the most important resources for family
caregivers, significantly predicts rewards of caregiving. Many caregivers could identify positive
aspects of caregiving, such as rewards (Picot, 1995; Picot et al., 1997), gratifications (Motenko,
1989), or gains (Kramer, 1997) through support from family members, friends, and others.
Similar to Chappell and Reid’s (2002) study, social support was conceptualized as the
caregivers’ perceptions of support and resources from others and was found to positively affect
rewards of caregiving (Chappell & Reid, 2002). Park and Lee (2007) and Oka et al. (2004)
similarly found that social support might be a potentially modifiable factor associated with
positive aspects in caregiving, particularly psychological levels in older family caregivers.
Moreover, social support has been found to positively affect family caregivers’ HRQOL by
reducing their stressors and enhancing their rewards of caregiving (Chappell & Reid, 2002;
Cohen, Colantonio, & Vernich, 2002; Northouse et al., 2002; Picot, 1995). Nurses and health
care providers should appropriately assess caregivers’ needs and help support and provide

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sufficient resources required to enhance confidence in knowledge and skills for caregiving roles.
As social support also included the provision for attachment, the social integration, and the
availability of informational, emotional, and material assistance, training programs and discharge
plans are needed to develop caregivers’ knowledge and to build caregiving skill for enhancing
caregivers’ perceived social support. Nurses can offer and support some parts of the
informational, emotional, and material assistance regarding elder conditions or diseases and their
needs with those conditions and caregiving skills to perform care with those specific conditions.
Having sufficient knowledge and skills would lead caregivers to assertively comprehend their
roles as rewarding and benefit finding.
In conclusion, a reward of caregiving was a crucial factor influencing HRQOL and
partially mediates the relationship between caregivers’ functional status and their overall
HRQOL.
Interpretation for additional results. Greater rewards of caregiving are significantly
influenced when caregivers participate in more religious activities, perceive higher levels of
social support, and have a daughter-elder relationship. Even though the relationship to elder can’t
be changed, other relations can be motivated to have higher perceptions of rewards of caregiving.
Also, religious activities and social support are important caregiver resources which can be
enhanced and promoted by nurses and health care providers both in hospitals and communities.
Nurses and health care providers not only provide knowledge and skills in caring to enhance
caregivers’ resources, but also maintain and increase positive perceptions of rewards by
supporting and encouraging caregivers to join religious activities.
Study Limitations
This study may have been subject to some limitations which related to threats to validity.

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Threats to validity are reasons the conclusion or the inference of the study might be incorrect
(Trochim & Donnelly, 2007). First, there may have been an inadequate number of relevant
factors in the model or too many overlapping components of each concept to explore the full
impact on caregiver overall HRQOL or predict it. Second, a relatively small convenience sample
of rural Thai family caregivers and ECRs were enrolled; the generalizability of the study results
to other Thai or Asian settings may be limited. Third, the cross-sectional study design limits the
interpretation of study findings to the relationships among selected variables over time. That is,
the descriptive nature of the design does not allow for a strong causal relationship between study
measures. Because subjects were not selected randomly and the inclusion criteria were relatively
broad, the findings cannot be generalized. Nonprobability sampling (convenience and purposive
sampling) of the subjects and the fact that the study only applies to Buddhist also somewhat limit
the heterogeneity of the sample characteristics.
Finally, although measures used in the study were self-administered questionnaires, the
researcher read the questionnaires for those family caregivers who requested assistance or
reported having difficulty completing the questionnaires. Thus, a social threat of researcher
expectancy bias may exist. But the investigator carefully, informally communicated with the
caregivers, so as not to create stressful situations, which might have made caregivers answer with
the desired outcomes for study. In addition, the bias may have occurred if the caregivers’ desired
to look good, and might have lead them to react or respond in a very good way. This may be
especially true with the rewards of caregiving; a bias may have caused high levels of rewards for
some individuals. However, a mono-method bias in the future may be caused by using the same
method, self-report, for all operationalization.

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Implications for Nursing Practice
The results of this study show that, in general, caregivers of ECRs reported good
functional status and moderate to high rewards of caregiving, as well as overall HRQOL.
However, this does not mean that caregivers were not vulnerable in their caregiving roles. Based
on the relationships between variables found in this study, nurses and health care providers are
able to maintain and enhance caregiver functional status by improving caregivers’ abilities and
skills to effectively deal with all of the elders’ symptoms, even though they cannot reduce those
symptoms. Older caregivers should have regular health checks and receive appropriate
treatments if they have chronic health conditions. A caregiver’s functional status as the ability to
perform daily life tasks should be sustained in performing effective care through the trajectory of
the disease and the process of care at home and in the community.
Moreover, findings show that older caregivers participating in more religious activities,
had few chronic health conditions and better functional status, and perceived greater social
support and rewards of caregiving have greater overall HRQOL. Positive aspects of caregiving–
including religious activities, social support, and rewards of caregiving–as well as functional
status are of concern for nurses and health care providers. Caregivers require not only physical
ability and support in caregiving situation, but also sufficient positive or psychological support.
Hospital and/or community health care providers may be able to improve caregivers’ overall
HRQOL by offering desired information and caregiving skills suited to their elders’ conditions.
In addition, in wards or primary care units, there could be a private room with the Buddha image
for praying or chanting and meditating, where caregivers can participate in religious activities
when their elders are admitted.
Also based on results from mediation testing, increasing the rewards of caregiving will

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further enhance caregiver functional status, which positively impacts caregiver overall HRQOL.
Nurses can help maintain and encourage caregivers’ functional status by providing sufficient
knowledge and training for the specific skills each caregiver needs, such as transferring elders
and assisting with exercising, preparing meals, rehabilitating, or providing transportation. When
caregivers are confident in caring and perform appropriate and effective care, they are not
exhausted and do not negatively appraise their caring situations. In doing so, caregivers have
better functional statuses and are empowered to positively perceive caring situations as rewards.
Combined with additional results, the more religious activities caregivers participated in, the
higher they appraised the rewards of caregiving. Nurses and health care providers can also offer
more than a private room with the Buddha image. On the occasion of important days of
Buddhism, monks could be invited to the hospital or care unit to give the Dharma talk, at which
time the caregivers are able to offer food and things for monks, or to donate some money if they
so desire. Developing a special unit in the community would help to counsel caregivers to
manage all the symptoms and problems they experience at home if they cannot go to the hospital
in the city. Training programs or discharge plans for caregivers of chronically ill elders are
needed to support all the above mentioned issues, and to promote caregivers’ functional status,
which is expected to maintain and improve their HRQOL.
Implications for Research
Measuring HRQOL of the Thai family caregivers taking care of ECRs over time would
be incredibly advantageous in order to reveal the effect of caregiving on caregiver overall
HRQOL over time and to provide nursing interventions relevant to longitudinal experiences
based on empirical findings. This study provided results of factors influencing caregiver overall
HRQOL of chronically ill elders. It would be more useful in developing knowledge of family

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caregivers if it investigated overall HRQOL of Thai caregivers taking care of elders with certain
chronic diseases, such as cancer, stroke, dementia, or Alzheimer’s disease. In future research, the
negative aspect of caregiving or psychological health– such as depressive symptoms, anxiety,
worry, or burden–of caregivers may be included to predict overall HRQOL. For example, the
research question could be, “what is the relationship between worry of caregiving and overall
HRQOL in caregivers of elder stroke survivors?” Whether or not rewards of caregiving are
mediated, the relationship between worry of caregiving and overall HRQOL is of concern.
Whether the rewards of caregiving can mediate the relationship between a negative aspect and
overall HRQOL should be examined. Also, if the rewards of caregiving will be negatively or
positively influence those relationships should also be investigated.
Moreover, this study highlights the need for further research to investigate the
relationship between other negative consequences of caregiving and overall HRQOL. Some
researchers have examined HRQOL and its influences on caregivers of elders with chronic
illnesses and have found some negative health outcomes from providing long-term care at home,
such as anxiety, stress, depression, and fatigue. All those negative outcomes should be added to
predict HRQOL of caregivers of chronically ill elders. The rewards of caregiving should also be
tested as a mediating effect in those relationships.
As a multidimensional outcome, nursing interventions for overall HRQOL might be
approached in various ways. Also, HRQOL is defined as a subjective life quality related to how
happy or satisfied someone is with his or her life as a whole, and is measured as subjective or
psychosocial-related outcome. Therefore, because psychosocial variables have been linked to
morbidity and mortality, the examination of non-pharmacological nursing interventions that
guide clinical practice and improve patient outcomes are of interest and should be a focus.

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Before conducting the intervention research, much more correlational and causal research,
including longitudinal studies, is needed to confirm certain predictors, such as caregiver sex,
functional status, social support, or religious activities, and the relationship between those
existing predictors and caregiver HRQOL, cause and effect, and relevant influences of HRQOL,
such as caregiver age and religious activities. Previous intervention research was conducted to
maintain and improve patients’ HRQOL in a variety of diseases, and such research should be
developed for caregivers of those patients as well.
Implications for Policy
This study provided results which highlight the need for the development of policies and
protocols to improve outcomes for caregivers of chronically ill elders. The increase in the
chronically ill elderly population in Thailand has had a significant impact on families with ECRs
and has resulted in worsening physical and mental health of many family caregivers. Currently,
in Thailand all of the policy focuses on the patients, not the caregivers. As the results in this and
previous studies show, caregivers should be taken care of in the same way. Caregivers are key
persons continuing to take on the roles of caring for their chronically ill elders at home. The aim
of caring for elders with chronic illnesses is not only to maintain health and delay death of ECRs,
but also to maintain or improve HRQOL of their caregivers. In doing so, government and the
Ministry of Public Health should promote policies that expand the elderly care workforce and
policies to provide adequate funding for programs that assist family caregivers.
The concept of HRQOL has frequently been discussed as a key element of nursing
practice and clinical outcome criteria. The evaluation of caregivers’ overall HRQOL of
chronically ill patients may enable health care providers to evaluate the impact of medical and
nursing interventions on caregivers’ lives and, ultimately, to produce information that may

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improve health care and the quality of the population’s lives. However, HRQOL is a complex
concept that does not have a universal definition or a standard for its measurement. It must be
defined clearly in order for it to be clinically useful, especially in HRQOL measurement. In
Thailand, the Ministry of Public Health may propose the identification of key stages in HRQOL
measurement for policy decisions, included selecting the salient descriptive characteristics
relevant to health; choosing an operational definition and categorization of the selected
characteristics; and standardizing an appropriate type of measurement. These stages would guide
researchers to conduct productive research properly using HRQOL as an outcome. For this part,
the Ministry of Public Health should request an annual budget and fund educational institutes of
nursing for research not only on elders but also on family caregivers. Moreover, in a nursing
student courses that focus on the elderly, the content of caregivers’ problems and needs should
not be ignored. Thus, funding would be provided for creating appropriate training programs to
assist caregivers in continuing their home care with sufficient knowledge and skills supported
and managing by nurses and health care providers.
The conceptual model of this study was based on the revised Wilson and Cleary model
for HRQOL by Ferran et al. (2005). The results of this study did show that some of caregivers’
and elders’ characteristics and selected caregiving aspects were related to and had an influence
on caregiver functional status and their overall HRQOL. The model worked well in predicting
caregiver overall HRQOL, however, due to the small sample size and the low levels of elders'
symptoms, disabilities, and caregiver tasks of care, it may possibly not detect all relationships as
revealed in the model. More research for testing the model with more caregiving-related
variables, including positive and negative aspects, should be done to confirm the significant
factors influencing caregiver overall HRQOL.

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Conclusion/Summary
The primary purpose of this study was to examine factors which may influence overall
HRQOL levels of rural Buddhist Thai family caregivers caring for ECRs aged 60 and older who
had one or more chronic conditions and at least two ADL deficits. Additionally, rewards of
caregiving was tested to determine whether it exerts a mediating effect on the relationship
between rural family caregiver functional status and overall caregiver HRQOL. Caregiver age,
total religious activities, relationship to elder, caregiver chronic health conditions, social support,
rewards of caregiving, and caregiver functional status were significant influences of better
caregiver overall HRQOL. This is in comparison to younger caregivers who participated in fewer
religious activities, were not daughters of the ECRs, had more chronic health conditions,
experienced less social support, perceived lower rewards of caregiving, and reported worse
functional status. Moreover, rewards of caregiving partially mediated the relationship between
family caregiver functional status and overall HRQOL.
Additional analysis was performed in order to examine factors which may influence
rewards of caregiving. Greater rewards of caregiving were significantly predicted by more
religious activities in which the caregivers participated, higher social support, and daughter-elder
relationships. Rewards of caregiving is one important resources predicting HRQOL and can be
enhanced by those factors which relate to religious activities. This study contributes to the
science by adding knowledge regarding what can make caregivers perceive more positive
aspects, rewards, in Thai family caregiving which ultimately impacts overall HRQOL.
Supportive protocols and interventions need to be developed and provided in order to improve
care for caregivers of chronically ill elders, done by improving caregivers’ overall HRQOL.

138

APPENDICES

139

APPENDIX A

Study Instrument (Thai-Translated Version)

140

่
ข้อมูลสวนบุคคลของผูดแล
้ ู
่
่
โปรดตอบคำถำมข ้อมูลสวนบุคคลต่อไปนี้ โดยเติมคำในชองว่ำงและทำเครืองหมำยกำกบำท
่
หน ้ำข ้อควำมทีเหมำะสมกับท่ำน
่
1. อำยุของผู ้ดูแล_______ปี (เติมตัวเลขอำยุเป็ นปี )
2. เพศของผู ้ดูแล (เลือกหนึงคำตอบ) ___ชำย
่

___หญิง

3. ศำสนำ (เลือกหนึงคำตอบ)
่
___พุทธ
___คริสต์
___อิสลำม
___อืนๆ (โปรดระบุ)_______________
่
มีรำยกำรกิจกรรมทำงศำสนำให ้ท่ำนอ่ำนและพิจำรณำว่ำทีผำนมำท่ำนได ้ปฏิบัตกจกรรมเหล่ำนี้
่ ่
ิ ิ
่ ่
่
ิ่ ่ ่
หรือไม่ ถ ้ำปฏิบัต ิ บ่อยครังเพียงใด โปรดใสเครืองหมำยกำกบำทในชองทีตรงกับสงทีทำนได ้ปฏิบัต ิ
้
่
จริง
Table A1
Caregiver Religious Activities Questions (Thai)
กิจกรรมทำงศำสนำ

วันละ
ครัง
้

ั
สปดำห์
ละครัง
้

เดือน
ละครัง
้

น ้อยกว่ำ
หนึงครัง
่
้
ต่อเดือน

สวดมนต์ไหว ้พระ (เลือกหนึง
่
คำตอบ)
นั่งสมำธิ (เลือกหนึงคำตอบ)
่
ไปทำบุญทีวด (เลือกหนึงคำตอบ)
่ ั
่
ตักบำตรทำบุญ (เลือกหนึงคำตอบ)
่
ิ่
บริจำคสงของ (เลือกหนึงคำตอบ)
่
อืนๆ (โปรดระบุ)
่
ั
4. ควำมสมพันธ์กับผู ้สูงอำยุ (เลือกหนึงคำตอบ)
่
___คูสมรส (ภรรยำ/สำมี)
่
___บุตรสำว /ชำย
___หลำนสำว /ชำย
___พีสำว/ชำย น ้องสำว/ชำย
่
___บุตรเขย /สะใภ ้
___ญำติ (โปรดระบุ)___________
5. รำยได ้ของครอบครัว (บำท/เดือน) (เลือกหนึงคำตอบ)
่
___ตำกว่ำ 2000
่
___2001-5000
___5001-10000
___10000 และมำกกว่ำ
6. โรคประจำตัว (จำนวนโรคทีเป็ นทังหมด) (เลือกทุกคำตอบทีเกิดขึน)
่
้
่
้
___ไม่ม ี
___ควำมดันโลหิตสูง
___เบำหวำน
___โรคหัวใจ
141

ไม่เคย
ปฏิบัต ิ
เลย

___โรคหลอดลมอักเสบเรือรัง
้
___ปวดหลัง
ื่
___โรคกระดูกเสอม
___(อืนๆ) โปรดระบุ______________________
่
7. ระยะเวลำในกำรดูแลผู ้สูงอำยุ_____________เดือน (เติมตัวเลขระยะเวลำเป็ นเดือน)
8. อำยุของผู ้สูงอำยุ_______ปี (เติมตัวเลขอำยุเป็ นปี )
ื่
9. โรคทีเป็ น___________________________ (เติมชอโรคทีผู ้ป่ วยได ้รับกำรวินจฉั ย)
่
่
ิ
10. เพศของผู ้สูงอำยุ (เลือกหนึงคำตอบ)
่

___ชำย

___หญิง

แบบว ัดความสามารถในการปฏิบ ัติกจกรรมของผูดแล
ิ
้ ู
แบบส บ
บส
บ
ส
แ
ส
แ
แ
 ลงหน ้ำข ้อควำมทีตรงกับควำมสำมำรถของท่ำนมำกทีสด
่
่ ุ
1.โดยทั่ว ๆ ไปสุขภำพของท่ำนเป็ นอย่ำงไร
____ดีมำกทีสด (1)
่ ุ
____ดีมำก (2)
____ดี (3)
____พอใช ้ (4)
____แย่ (5)
่
กรุณำอ่ำนข ้อควำมต่อไปนีแล ้วพิจำรณำว่ำภำวะสุขภำพของท่ำนในปั จจุบันสงผลให ้ท่ำนมีข ้อจำกัด
้
ในกำรทำกิจกรรมต่อไปนีหรือไม่ ถ ้ำใช ่ จำกัดมำกน ้อยเพียงใดโดยทำ เครืองหมำย ลง
้
่
หน ้ำข ้อควำมทีตรงกับระดับควำมจำกัดของท่ำน
่
่
2.กิจกรรมทีออกแรงปำนกลำง เชน เลือนโต๊ะ, กวำดบ ้ำน, ถูบ ้ำน
่
่
____ใช ่ จำกัดมำก (1)
____ใช ่ จำกัดเล็กน ้อย (2)
____ไม่จำกัดเลย (3)
ั้
3.เดินขึนบันไดหลำยขัน (1 ชนหรือมำกกว่ำ)
้
้
____ใช ่ จำกัดมำก (1)
____ใช ่ จำกัดเล็กน ้อย (2)
____ไม่จำกัดเลย (3)
่
กรุณำอ่ำนข ้อควำมต่อไปนี้ แล ้วพิจำรณำว่ำในชวง 1 เดือนทีผำนมำ ท่ำนมีปัญหำเกียว กับกำร
่ ่
่
ึ่
ทำงำนหรือกำรปฏิบัตกจวัตรประจำวันซงเป็ นผลมำจำกสุขภำพกำยของท่ำนหรือไม่ถ ้ำมีบอยครัง
ิ ิ
่
้
เพียงใดโดยทำเครืองหมำยลงหน ้ำข ้อควำมทีตรงกับ ระดับปั ญหำ ของท่ำน
่
่
4.ทำงำนหรือปฏิบัตกจวัตรประจำวันได ้สำเร็จน ้อยกว่ำทีอยำกทำ
ิ ิ
่
____ตลอดเวลำ (1)
่
____เป็ นสวนมำก (2)
____เป็ นบำงครัง (3)
้
____นำนๆครัง (4)
้
____ไม่เลย (5)

142

5.ถูกจำกัดชนิดของงำน หรือ ทำกิจกรรมบำงทีสำมำรถทำได ้
่
____ตลอดเวลำ (1)
่
____เป็ นสวนมำก (2)
____เป็ นบำงครัง (3)
้
____นำนๆครัง (4)
้
____ไม่เลย (5)
่
กรุณำอ่ำนข ้อควำมต่อไปนีแล ้วพิจำรณำว่ำ ในชวง 1 เดือนทีผำนมำสภำพทำงด ้ำนอำรมณ์ ของท่ำน
้
่ ่
่
ึ ึ
เชนรู ้สกซมเศร ้ำหรือกังวลทำให ้ท่ำนมีปัญหำเกียวกับกำรทำงำน หรือกำรปฏิบัตกจวัตรประจำวัน
่
ิ ิ
บ่อยครังเพียงใด ให ้ทำเครืองหมำยลงหน ้ำข ้อควำมทีตรงกับระดับปั ญหำของท่ำน
้
่
่
6.ทำงำนหรือทำกิจวัตรประจำวันได ้สำเร็จน ้อยกว่ำทีทำนอยำกจะทำ
่ ่
____ตลอดเวลำ (1)
่
____เป็ นสวนมำก (2)
____เป็ นบำงครัง (3)
้
____นำนๆครัง (4)
้
____ไม่เลย (5)
7.ทำงำนหรือกิจกรรมอืนๆ ด ้วยควำมระมัดระวังน ้อยกว่ำปกติ
่
____ตลอดเวลำ (1)
่
____เป็ นสวนมำก (2)
____เป็ นบำงครัง (3)
้
____นำนๆครัง (4)
้
____ไม่เลย (5)
่
8.ในชวง 1เดือนทีผำนมำ ท่ำนมีอำกำรเจ็บปวดในร่ำงกำย มำกน ้อยเพียงใด
่ ่
____ไม่มเลย (1)
ี
____เล็กน ้อย (2)
____ปำนกลำง (3)
____มำก (4)
____มำกทีสด (5)
่ ุ
ึ่
ึ
ิ่ ่
่
กรุณำอ่ำนข ้อคำถำมต่อไปนี้ ซงถำมเกียวกับควำมรู ้สกของท่ำนและสงทีเกิดขึนใน ชวง 1 เดือนที่
่
้
ึ
ผ่ำนมำ แล ้วทำเครืองหมำย ลงในหนำข ้อควำมทีตรงหรือใกล ้เคียงกับควำมรู ้สกของท่ำนให ้มำก
่
่
ทีสด
่ ุ
ึ
9.ท่ำนมีควำมรู ้สกสงบและเป็ นสุข
____ตลอดเวลำ (1)
่
____เป็ นสวนมำก (2)
____เป็ นบำงครัง (3)
้
____นำนๆครัง (4)
้
____ไม่เลย (5)
10.ท่ำนมีพละกำลังเป็ นอย่ำงมำก
____ตลอดเวลำ (1)
่
____เป็ นสวนมำก (2)
____เป็ นบำงครัง (3)
้
____นำนๆครัง (4)
้
____ไม่เลย (5)

143

ึ
ึ
11.ท่ำนรู ้สกท ้อแท ้ใจและซมเศร ้ำ
____ตลอดเวลำ (1)
่
____เป็ นสวนมำก (2)
____เป็ นบำงครัง (3)
้
____นำนๆครัง (4)
้
____ไม่เลย (5)
่
12.ในชวง 1 เดือนทีผำนมำ ปั ญหำทำงสุขภำพและอำรมณ์ของท่ำนเป็ นอุปสรรคในกำรทำกิจกรรม
่ ่
ั
่
ทำงด ้ำนสงคม เชน ไปเยียมเพือน/ ญำติ มำกน ้อยเพียงใด
่
่
____ตลอดเวลำ (1)
่
____เป็ นสวนมำก (2)
____เป็ นบำงครัง (3)
้
____นำน ๆ ครัง (4)
้
____ไม่เลย (5)
SF-12® Health Survey © 1994, 2002 by Medical Outcomes Trust and Quality Metric
Incorporated. All Rights Reserved
SF-12® is a registered trademark of Medical Outcomes Trust

144

่
แบบประเมินการได้ร ับการสน ับสนุนสวนบุคคล
ี้
คำชแจง ข ้อควำมต่อไปนี้ บำงท่ำนอำจจะเห็นด ้วย บำงท่ำนอำจจะไม่เห็นด ้วย โปรดอ่ำน ข ้อควำม
ในแต่ละข ้อ และวงกลมในข ้อทีทำนเห็นว่ำเป็ นข ้อทีตรงกับควำมคิดเห็นของท่ำน มำกทีสด ไม่ม ี
่ ่
่
่ ุ
คำตอบถูกหรือผิด
Table A2

่
ไม่เห็นด ้วยอย่ำงยิง
145

่
ค่อนข ้ำงทีจะไม่เห็น
ด ้วย

เฉยๆ

ค่อนข ้ำงเห็นด ้วย

เห็นด ้วย

่
เห็นด ้วยอย่ำงยิง

ึ
ิ
ึ่
ึ
1.ฉั นมีคนทีฉันรู ้สกใกล ้ชดสนิทสนมซงทำให ้ฉั นรู ้สก
่
อบอุนปลอดภัย
่
ึ่
ึ
2.ฉั นมีกลุมเพือนหรือเพือนบ ้ำนซงทำให ้ฉั นรู ้สกว่ำฉั นมี
่
่
่
ควำมสำคัญในกลุม
่
3.คนรอบข ้ำงหรือเพือนร่วมงำนบอกหรือแสดงให ้ฉันรู ้ ว่ำ
่
ฉั นทำงำนได ้ดี (งำนบ ้ำนหรือทีทำงำน)
่
่
4.ฉั นไม่สำมำรถพึงพำญำติและเพือนทีจะชวยเหลือฉั น
่
่
่
เมือฉั นมีปัญหำ
่
ึ
5.ฉั นรู ้สกว่ำฉั นเป็ นคนมีคำสำหรับญำติและหรือเพือนๆ
่
่
้
6.ฉั นใชเวลำพูดคุยหรือทำกิจกรรมร่วมกับคนทีมควำม
่ ี
สนใจในเรืองคล ้ำยๆกัน
่
่
7.ฉั นไม่คอยได ้เป็ นผู ้ให ้ หรือชวยเหลือผู ้อืน
่
่
8.คนรอบข ้ำงหรือเพือนๆ แสดงให ้ฉั นรู ้ว่ำเขำชอบทีได ้
่
่
ทำงำนร่วมกับฉั น
่
้
9.ถ ้ำฉั นต ้องกำรควำมชวยเหลือทีต ้องใชเวลำนำนพอ
่
่
สมควร มีคนพร ้อมทีจะสละเวลำชวยเหลือฉั น
่
ึ
10.ฉั นไม่รู ้จะระบำยควำมรู ้สกกับใครเมือฉั นมีปัญหำ
่
หรือไม่สบำยใจ
่
ึ่
11.ฉั นและเพือนจะชวยเหลือซงกันและกัน
่
่
่
12.ฉั นได ้มีสวนชวยให ้เพือนหรือคนรู ้จักสำมำรถทำงำนได ้
่
ดีขน
ึ้
13.ครอบครัวของฉั นแสดงให ้ฉั นทรำบว่ำฉั นมีควำม
สำคัญกับเขำ

ไม่เห็นด ้วย

Personal Resource Questionnaire Part II (PRQ85-II; Thai)

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1
1

2
2

3
3

4
4

5
5

6
6

7
7

1
1

2
2

3
3

4
4

5
5

6
6

7
7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1
1

2
2

3
3

4
4

5
5

6
6

7
7

1

2

3

4

5

6

7

146

ไม่เห็นด ้วย
่
ค่อนข ้ำงทีจะไม่เห็นด ้วย

เฉยๆ

ค่อนข ้ำงเห็นด ้วย

เห็นด ้วย

่
เห็นด ้วยอย่ำงยิง

่
14.ฉั นมีญำติหรือเพือนทีพร ้อมทีจะชวยเหลือฉั นถึง แม ้ว่ำ
่
่
่
ฉั นจะไม่สำมำรถตอบแทนเขำได ้
ึ
ิ ่
15.เมือฉั นรู ้สกไม่สบำยใจฉั นมีคนใกล ้ชดทีเข ้ำใจฉั น และ
่
ึ
ทำให ้ฉั นรู ้สกเป็ นตัวของตัวเอง
ึกว่ำไม่มใครมีปัญหำมำกเท่ำฉั น
16.ฉั นรู ้ส
ี
ึ
ิ่
17.ฉั นรู ้สกมีควำมสุขทีจะทำสงพิเศษเล็กๆน ้อยๆ ทีทำให ้
่
่
ผู ้อืนพอใจ
่
ึ
ื่
18.ฉั นรู ้สกว่ำมีคนชนชมฉั น
19.ฉั นมีคนทีรักและห่วงใยฉั น
่
20.ฉั นมีเพือนทีจะคุย เทียว หรือทำอะไรด ้วยกัน
่
่
่
่
21.ฉั นมีควำมรับผิดชอบในกำรชวยเหลือผู ้อืน
่
่
22.ถ ้ำฉั นต ้องกำรคำแนะนำ มีคนพร ้อมทีจะชวยฉั น
่
ึ
23.ฉั นมีควำมรู ้สกว่ำฉั นเป็ นทีต ้องกำรของเพือน ญำติ หรือ
่
่
คนทีรู ้จัก
่
24.มีคนคิดว่ำฉั นไม่ได ้เป็ นเพือนทีดอย่ำงทีฉันควรจะเป็ น
่
่ ี
่
25.ถ ้ำฉั นป่ วย มีคนทีจะให ้คำแนะนำฉั นในกำรดูแลตนเอง
่

่
ไม่เห็นด ้วยอย่ำงยิง

Table A2 (cont’d)

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1
1

2
2

3
3

4
4

5
5

6
6

7
7

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

4
4
4
4
4
4

5
5
5
5
5
5

6
6
6
6
6
6

7
7
7
7
7
7

1
1

2
2

3
3

4
4

5
5

6
6

7
7

แบบว ัดรางว ัลทีได้ร ับจากการดูแล (Rewards of Caregiving)
่
จำกหัวข ้อแต่ละหัวข ้อต่อไปนี้ โปรดพิจำรณำเลือกคำตอบทีบงชถงระดับควำมคิดเห็น ของท่ำนต่อ
่ ่ ี้ ึ
สถำนกำรณ์กำรดูแลผู ้สูงอำยุด ้ำนต่ำงๆ คำตอบแต่ละข ้อไม่มควำมหมำยว่ำ ถูกหรือผิดอย่ำงแท ้จริง
ี
ึ
หำกคำตอบทีมไม่ตรงกับควำมรู ้สกของท่ำนทีเดียว กรุณำวงกลม ตัวเลขทีใกล ้เคียงกับระดับควำม
่ ี
่
คิดเห็นของท่ำนมำกทีสดและโปรดตอบข ้อคำถำมทุกข ้อ
่ ุ
Table A3
Rewards of Caregiving (Thai)
ไม่
เลย
่
ึ
1.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนรู ้สกว่ำท่ำนได ้ทำควำมดี
มำกน ้อยเพียงใด
่
2.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนเข ้ำใจตัวท่ำนเองเมือ
่
ต ้อง เจ็บป่ วยมำกน ้อยเพียงใด
่
ึ
3.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนรู ้สกว่ำท่ำนได ้สร ้ำงกุศล
ผลบุญมำกน ้อยเพียงใด
่
ึ
ิ่
4.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนรู ้สกว่ำท่ำนได ้ทำในสงที่
มี ควำม สำคัญมำกน ้อยเพียงใด
่
ึ
5.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนรู ้สกปลืมปิ ตมำกน ้อย
้
ิ
เพียงใด
่
ึ
6.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนรู ้สกว่ำเป็ นกำรแสดง
ควำม กตัญญู/ร่วมทุกข์รวมสุขต่อผู ้ป่ วยมำกน ้อย
่
เพียงใด
่
ี ิ ่ ี
7.ท่ำนคิดว่ำกำรดูแลผู ้ป่ วยชวยให ้ท่ำนมีชวตทีดใน
ชำติ นีหรือชำติหน ้ำมำกน ้อยเพียงใด
้
่
8.กำรดูแลผู ้ป่ วยชวยฐำนะทำงกำรเงินของท่ำนโดย
่
ทีไม่ คำดคิดมำก่อน เชน ได ้รับมรดกหรือเงินรำงวัล
่
จำกญำติ ทีมำเยียม
่
่
่
ึ ่ ี ่
9.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนมีควำมรู ้สกทีดตอตัวท่ำน
เอง มำกน ้อยเพียงใด

147

เล็ก
น ้อย

ปำน
กลำง

มำก
ทีสด
่ ุ

2

ค่อน
ข ้ำง
มำก
3

0

1

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

4

Table A3 (cont’d)
ไม่
เลย
่
11.กำรดูแลผู ้ป่ วยชวยให ้ผู ้อืนเห็นควำมสำคัญของ
่
กำร ดูแลมำกน ้อยเพียงใด
่
ี ิ
11.กำรดูแลผู ้ป่ วยชวยให ้ชวตของท่ำนมีควำมหมำย
มำกขึนมำกน ้อยเพียงใด
้
่
12.กำรดูแลผู ้ป่ วยทีบ ้ำนชวยให ้ท่ำนมีควำมคล่องตัว
่
ด ้ำน กำรเงินมำกกว่ำกำรให ้ผู ้ป่ วยไปอยูโรงพยำบำล
่
หรือสถำน พยำบำลมำกน ้อยเพียงใด
่
13.กำรดูแลผู ้ป่ วยชวยให ้คนในครอบครัวของท่ำน
ิ
ใกล ้ชด สนิทสนมกันมำกน ้อยเพียงใด
่
ึ
14.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนรู ้สกประสบควำมสำเร็จ
ในบทบำทของกำรเป็ นผู ้ดูแลมำกน ้อยเพียงใด
่
ึ
15.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนรู ้สกว่ำได ้ตอบแทน
บุญคุณ ผู ้ป่ วยมำกน ้อยเพียงใด
่
ึ
่
ี ิ
16.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนรู ้สกว่ำท่ำนได ้ชวยชวต
ของผู ้ป่ วยให ้ดีขนมำกน ้อยเพียงใด
ึ้
ึ
17.ท่ำนรู ้สกภูมใจมำกน ้อยเพียงใดทีทำนเป็ นคนหนึง
ิ
่ ่
่
ทีให ้กำรดูแลผู ้ป่ วย
่
18.กำรดูแลผู ้ป่ วยเป็ นประสบกำรณ์ททำนพึงพอใจ
ี่ ่
มำก น ้อยเพียงใด
19.กำรดูแลผู ้ป่ วยทำให ้ท่ำนมีควำมสุขมำกน ้อย
เพียงใด
่
ึ
21.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนรู ้สกว่ำท่ำนมี
คุณประโยชน์ ต่อผู ้ป่ วยมำกน ้อยเพียงใด
่
21.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนและผู ้ป่ วยมีควำม
ิ
ใกล ้ชด สนิทสนมกันมำกขึนมำกน ้อยเพียงใด
้
่
22.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนเรียนรู ้เกียวกับกำรดูแล
่
สุขภำพมำกน ้อยเพียงใด

148

เล็ก
น ้อย

ปำน
กลำง

มำก
ทีสด
่ ุ

2

ค่อน
ข ้ำง
มำก
3

0

1

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

4

Table A3 (cont’d)
ไม่
เลย
่
23.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนปรับตัวเองไปในทำงทีด ี
่
่น ใจเย็นมำกขึน ,อดทนมำกขึน ,มีควำม
ขึน เช
้
้
้
อ่อนโยนมำกขึน มำกน ้อยเพียงใด
้
ื่
24.กำรทีผู ้ป่ วยหรือบุคคลอืนแสดงควำมชนชมหรือ
่
่
ึ้ ่ ่
ซำบซงทีทำนให ้กำรดูแล ถือเป็ นรำงวัลสำหรับท่ำน
มำกน ้อยเพียงใด
่
ึ
25.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนรักหรือรู ้สกดีกับผู ้ป่ วย
มำกน ้อยเพียงใด
่
26.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนดูแลสุขภำพของตนเอง
ดีขนมำกน ้อยเพียงใด
ึ้
่
ื่
27.กำรดูแลผู ้ป่ วยชวยให ้ท่ำนชนชมหรือภำคภูมใจคน
ิ
ในครอบครัวมำกน ้อยเพียงใด

149

เล็ก
น ้อย

ปำน
กลำง

มำก
ทีสด
่ ุ

2

ค่อน
ข ้ำง
มำก
3

0

1

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

4

แบบประเมินสมรรถภาพผูสงอายุ
้ ู
จำกหัวข ้อแต่ละกิจกรรมต่อไปนี้ โปรดพิจำรณำเลือกคำตอบทีบงชถงระดับควำมสำมำรถของ
่ ่ ี้ ึ
่
่
ผู ้สูงอำยุในกำรปฏิบัตกจกรรมนันๆ โดยใสตัวเลข (0, 5, 10, หรือ 15) ลงในชองว่ำง
ิ ิ
้
กิจกรรม
คะแนนการประเมิน
การร ับประทานอาหาร
0 = ทำไม่ได ้เลย
่
่
5 = ทำได ้แต่ต ้องกำรควำมชวยเหลือบำงสวน หรือต ้องกำรอำหำรพิเศษ/ อำหำรเฉพำะโรค
10 = ทำได ้เอง
______
การอาบนา
้
0 = ทำไม่ได ้เลย
่
่
5 = ทำได ้แต่ต ้องกำรควำมชวยเหลือบำงสวน
______
่
การดูแลสุขล ักษณะสวนต ัว
่
่
0 = ต ้องกำรควำมชวยเหลือในกำรดูแลสุขลักษณะสวนตัว
5 = ทำได ้เอง (ล ้ำงหน ้ำ หวีผม แปรงฟั น โกนหนวด โดยมีผู ้เตรียมอุปกรณ์ให ้)
______
่ ื้
การใสเสอผ้า
0 = ทำไม่ได ้เลย
่
่
5 = ทำได ้แต่ต ้องกำรควำมชวยเหลือบำงสวน
ิ
ื
10 = ทำได ้เอง (รวมถึงกำรติดกระดุม, รูดซบ, ผูกเชอกรองเท ้ำ และอืนๆ) _____
่
การควบคุมการข ับถ่ายอุจจาระ
0 = ควบคุมกำรขับถ่ำยอุจจำระไม่ได ้ (หรือต ้องกำรกำรสวนอุจจำระ)
5 = ควบคุม/กลันอุจจำระไม่ได ้เป็ นบำงครัง
้
้
10 = ควบคุมกำรขับถ่ำยอุจจำระได ้
______
การควบคุมการข ับถ่ายปัสสาวะ
่
0 = ควบคุมกำรขับถ่ำยปั สสำวะไม่ได ้ (กลันไม่ได ้) หรือใสสำยสวนปั สสำวะค ้ำงไว ้
้
5 = ควบคุม/กลันปั สสำวะไม่ได ้เป็ นบำงครัง
้
้
10 = ควบคุมกำรขับถ่ำยปั สสำวะได ้
______
้ ้
การใชหองนา
้
0 = ทำไม่ได ้เลย
่
่
5 = ทำได ้ด ้วยตัวเองแต่ต ้องกำรควำมชวยเหลือบำงสวน
10 = ทำได ้ด ้วยตัวเอง (เปิ ดและปิ ด, แต่งตัว, ทำควำมสะอำด)
______
้
การเคลือนย้าย (ระหว่างเตียงและเก้าอี)
่
0 = ทำไม่ได ้เลย, ไม่สำมำรถนั่งได ้
่
่
5 = สำมำรถนั่งได ้, ต ้องกำรควำมชวยเหลือเป็ นสวนใหญ่ (ต ้องกำรผู ้อืนชวยในระหว่ำงกำร
่ ่
เคลือนย ้ำย)
่
่
10 = ต ้องกำรควำมชวยเหลือเล็กน ้อย (มีผู ้คอยระวังเพือควำมปลอดภัย)
่
15 = สำมำรถเคลือนย ้ำยได ้ด ้วยตัวเอง
่
______
การเคลือนที่ (เคลือนทีในแนวราบ)
่
่
่
0 = ไม่สำมำรถเคลือนทีได ้ด ้วยตัวเอง หรือได ้น ้อยกว่ำ 45 เมตร
่
่
5 = สำมำรถเข็นรถเข็นนั่ งเองได ้ รวมทังเข็นรถเลียวได ้, เคลือนทีได ้มำกกว่ำ 45 เมตร
้
้
่
่
่
10 = เดินได ้ด ้วยตนเองมำกกว่ำ 45 เมตรแต่ต ้องกำรผู ้ชวยเหลือ 1 คน

150

่
15 = เดินได ้ด ้วยตนเองหรือร่วมกับอุปกรณ์ชวยเดินโดยไม่ต ้องมีผู ้ดูแลได ้มำกกว่ำ 45 เมตร
______
้
การขึนลงบ ันได
0 = ไม่สำมำรถขึนลงบันไดได ้เลย
้
่
5 = สำมำรถขึนลงบันไดได ้แต่ต ้องกำรควำมชวยเหลือ
้
10 = สำมำรถขึนลงบันไดได ้เอง
้
______
คะแนนรวม (0–100):
______

สนับสนุนโดยศูนย์ผู ้ป่ วยโรคหลอดเลือดสมองทำงคอมพิวเตอร์ - www.strokecenter.org

151

แบบประเมินอาการของผูสงอายุ (MSAS)
้ ู
่
สวนที่ 1. มีอำกำรทังหมด 24 อำกำรให ้ท่ำนอ่ำนและพิจำรณำว่ำในหนึงเดือนทีผำนมำผู ้สูงอำยุม ี
้
่
่ ่
อำกำรเหล่ำนีหรือไม่ ถ ้ำมี เกิดขึนบ่อยครังเพียงใด รุนแรงเพียงใด และอำกำรเหล่ำนีรบกวนผู ้สูงอำยุ
้
้
้
้
มำกน ้อยเพียงใด โปรดวงกลมตัวเลขทีเหมำะสมกับอำกำรทีเกิดขึน ถ ้ำไม่เกิดขึนให ้ทำเครืองหมำย
่
่
้
้
่
่
X ลงในชอง “ไม่มอำกำร”
ี
Table A4
Memorial Symptoms Assessment Scale – Section 1 (Thai)

บ่อย

่
เกือบจะสมำเสมอ

เล็กน ้อย

ปำนกลำง

รุนแรง

รุนแรงมำก

ไม่รบกวน

รบกวนเล็กน ้อย

รบกวนปำนกลำง

รบกวนค่อนข ้ำงมำก

รบกวนมำก

ถ ้ำมี
อำกำรทีเกิดขึน
่
้
รบกวนผู ้สูงอำยุ
มำกน ้อยเพียงใด

้
เป็ นบำงครัง

มีปัญหำในกำรมุงจุด
่
ิ่
ิ่
สนใจทำสงใดสงหนึง
่
ควำมเจ็บปวด
หมดกำลัง, อ่อนเพลีย
ไอ
ประหม่ำ/กระวนกระวำย
ปำกแห ้ง
คลืนไส ้
่
ึ
ื่
ึ
รู ้สกเซองซม
ชำมือและเท ้ำ
มีปัญหำในกำรนอนหลับ
อึดอัดแน่นท ้อง
มีปัญหำกำรขับถ่ำย
ปั สสำวะ
อำเจียน
ั้
หำยใจสน
ี
ท ้องเสย
ึกเศร ้ำ
รู ้ส
เหงือออกมำก
่
วิตกกังวล

ถ ้ำมี
อำกำรรุนแรง
เพียงใด

้
แทบจะไม่เกิดขึน

ผู ้สูงอำยุมอำกำรเหล่ำนี้
ี
เกิดขึนหรือไม่?
้

ี
ไม่มอำกำร

ระหว่ำงหนึงเดือนทีผำน
่
่ ่
มำ

ถ ้ำมี
เกิดขึนบ่อย
้
เพียงใด

1

2

3

4

1

2

3

4

0

1

2

3

4

1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4

1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4

0
0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

4
4
4
4
4
4

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

4
4
4
4
4
4

0
0
0
0
0
0

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

4
4
4
4
4
4

152

Table A4 (cont’d)

บ่อย

่
เกือบจะสมำเสมอ

เล็กน ้อย

ปำนกลำง

รุนแรง

รุนแรงมำก

ไม่รบกวน

รบกวนเล็กน ้อย

รบกวนปำนกลำง

รบกวนค่อนข ้ำงมำก

รบกวนมำก

ถ ้ำมี
อำกำรทีเกิดขึน
่
้
รบกวนผู ้สูงอำยุ
มำกน ้อยเพียงใด

้
เป็ นบำงครัง

มีปัญหำเกียวกับกำรมี
่
ั
เพศสมพันธ์
อำกำรคัน
ควำมอยำกอำหำรลดลง
ี
เวียนศรษะ
กลืนลำบำก
ึ
รู ้สกหงุดหงิดโมโหง่ำย

ถ ้ำมี
อำกำรรุนแรง
เพียงใด

้
แทบจะไม่เกิดขึน

ผู ้สูงอำยุมอำกำรเหล่ำนี้
ี
เกิดขึนหรือไม่?
้

ี
ไม่มอำกำร

ระหว่ำงหนึงเดือนทีผำน
่
่ ่
มำ

ถ ้ำมี
เกิดขึนบ่อย
้
เพียงใด

1

2

3

4

1

2

3

4

0

1

2

3

4

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

153

่
สวนที่ 2. มีอำกำรทังหมด 8 อำกำรให ้ท่ำนอ่ำนและพิจำรณำว่ำในหนึงเดือนทีผำนมำผู ้สูงอำยุม ี
้
่
่ ่
อำกำรเหล่ำนีหรือไม่ ถ ้ำมี อำกำรเหล่ำนันรุนแรงเพียงใดและรบกวนผู ้สูงอำยุมำกน ้อยเพียงใด โปรด
้
้
่
วงกลมตัวเลขทีเหมำะสมกับอำกำรทีเกิดขึน ถ ้ำไม่มอำกำร ให ้ทำเครืองหมำย X ลงในชอง “ไม่ม ี
่
่
้
ี
่
อำกำร”
Table A5
Memorial Symptoms Assessment Scale – Section 2 (Thai)

1 2 3 4 0 1 2 3
แผลในปำก
1 2 3 4 0 1 2 3
กำรรับรสอำหำรเปลียนแปลง
่
1 2 3 4 0 1 2 3
น้ ำหนักลด
1 2 3 4 0 1 2 3
ผมร่วง
1 2 3 4 0 1 2 3
ท ้องผูก
1 2 3 4 0 1 2 3
แขนหรือขำบวม
1 2 3 4 0 1 2 3
ึ
“ฉั นรู ้สกไม่ชอบตัวเอง”
1 2 3 4 0 1 2 3
มีกำรเปลียนแปลงของผิวหนัง
่
่
ถ ้ำผู ้สูงอำยุมอำกำรอืนๆ ในระหว่ำงหนึงเดือนทีผำนมำ โปรดเติมลงในชองด ้ำนล่ำง
ี
่
่
่ ่
และระบุวำ อำกำรเหล่ำนั นรบกวนผู ้สูงอำยุมำกน ้อยเพียงใด
่
้
0 1 2 3
อำกำรอืนๆ:
่
0 1 2 3
อำกำรอืนๆ:
่

154

รบกวนมำก

รบกวนค่อนข ้ำงมำก

รบกวนปำนกลำง

รบกวนเล็กน ้อย

รุนแรงมำก

รุนแรง

ปำนกลำง

เล็กน ้อย

ผู ้สูงอำยุมอำกำรเหล่ำนีเกิดขึน
ี
้
้
หรือไม่?

ี
ไม่มอำกำร

ระหว่ำงหนึงเดือนทีผำนมำ
่
่ ่

ถ ้ำมี
อำกำรทีเกิดขึนรบกวน
่
้
ผู ้สูงอำยุมำกน ้อย
เพียงใด

ไม่รบกวน

ถ ้ำมี
อำกำรรุนแรง
เพียงใด

4
4
4
4
4
4
4
4

4
4

แบบประเมินภาระหน้าทีในการดูแล (OCBS)
่
คำถำมเหล่ำนีถำมเกียวกับภำระหน ้ำทีและกิจกรรมทีทำนทำเพือชวยเหลือผู ้สูงอำยุ ในแต่ละข ้อ
้
่
่
่ ่
่ ่
้
คำถำมให ้ท่ำนระบุวำท่ำนใชเวลำในกำรทำกิจกรรมเหล่ำนั นมำกน ้อย เพียงใด และกำรปฏิบัตแต่ละ
่
้
ิ
กิจกรรมมีควำมยำกมำกน ้อยเพียงใด
้
เวลำ 5 = ใชเวลำมำกทีสด
่ ุ
ควำมยำก
5 = ยำกมำกทีสด
่ ุ
้
4 = ใชเวลำค่อนข ้ำงมำก
4 = ยำกมำก
้
3 = ใชเวลำปำนกลำง
3 = ยำกปำนกลำง
้
2 = ใชเวลำเล็กน ้อย
2 = ยำกเล็กน ้อย
้
1 = ใชเวลำไม่มำก
1 = ไม่ยำก
Table A6
Oberst Caregiving Burden Scale (Thai)
เวลำทีใช ้
่

ไม่มำก

เล็กน ้อย

ปำนกลำง

ค่อนข ้ำงมำก

่ ุ
มำกทีสด

ไม่ยำก

ยำกเล็กน ้อย

ยำกปำนกลำง

ยำกมำก

่ ุ
ยำกมำกทีสด

ควำมยำก

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

ภำระหน ้ำทีและกิจกรรมทีทำนทำเพือ
่
่ ่
่
่
ชวยเหลือผู ้สูงอำยุ:

1. กิจกรรมกำรรักษำทำงกำรแพทย์และกำร
พยำบำล (ให ้ยำ, ดูแลผิวหนัง, ทำแผล
ฯลฯ):
่
2. กิจกรรมสวนบุคคล (อำบน้ ำ, ขับถ่ำย,
แต่งตัว, ให ้อำหำร, ฯลฯ):
่
3. ชวยเหลือในกำรเดิน ลุกออกและ กลับ
เข ้ำเตียง, ออกกำลังกำย, ฯลฯ:
4. กำรสนับสนุนด ้ำนอำรมณ์, กำรอยูกับ
่
ผู ้สูงอำยุ:
5. เฝ้ ำดูและรำยงำนอำกำรของผู ้สูงอำยุ,
เฝ้ ำดูวำเป็ นอย่ำงไร และดูควำมก ้ำวหน ้ำ
่
ของอำกำรต่ำงๆ:
่
6. ชวยเหลือในกำรเดินทำงหรือร่วมทำ
กิจกรรม (ขับรถ, ขีจักรยำนด ้ว ้ยกัน, กำร นั ด
่
หมำย และขับรถให ้ในงำนทีผู ้สูงอำยุขอ:
่
้
7. จัดกำรเกียวกับค่ำใชจ่ำยเกียวกับ ควำม
่
่
เจ็บป่ วยของผู ้สูงอำยุ:
ั
8. งำนในบ ้ำนอืนๆ (ซกผ ้ำ, ทำอำหำร, ทำ
่
่
ควำมสะอำด, ทำสวน, ซอมบ ้ำน, ฯลฯ):

155

Table A6 (cont’d)
เวลำทีใช ้
่

ไม่มำก

เล็กน ้อย

ปำนกลำง

ค่อนข ้ำงมำก

่ ุ
มำกทีสด

ไม่ยำก

ยำกเล็กน ้อย

ยำกปำนกลำง

ยำกมำก

่ ุ
ยำกมำกทีสด

ควำมยำก

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

ภำระหน ้ำทีและกิจกรรมทีทำนทำเพือชวย
่
่ ่
่ ่
เหลือผู ้สูงอำยุ:

ื้
ื้
9. งำนนอกบ ้ำนอืน (ซออำหำรและเสอผ ้ำ,
่
ไปธนำคำร, จัดกำรงำนอืนๆทีร ้องขอ, ฯลฯ:
่
่
10. วำงแผนเกียวกับกิจกรรมสำหรับผู ้สูง
่
อำยุ (งำนอดิเรก, กำรพักผ่อน, อำหำร, และ
อืนๆ ทีผู ้สูงอำยุควรทำ):
่
่
11. จัดกำรกับปั ญหำพฤติกรรมของผู ้สูงอำยุ
ี
ั
(อำรมณ์เสย, หงุดหงิด, สบสน, หลงลืม,
ฯลฯ):
12. จัดหำและจัดกำรบุคคลเพือดูแลผู ้สูง
่
อำยุเมือท่ำนจะไม่อยูบ ้ำน:
่
่
ื่
่
13. กิจกรรมกำรติดต่อสอสำร (ชวยเรือง
่
ิ่
โทรศัพท์, เขียนหรืออ่ำน, อธิบำยสงต่ำงๆ,
ิงทีผู ้สูงอำยุพด, ฯลฯ):
่ ่
พยำยำมเข ้ำใจส
ู
14. ประสำนงำน, จัดกำร, และบริหำรเกียว
่
ิ่
กับบริกำรและสงสนับสนุนต่ำงๆ (นัดแพทย์,
จัดยำนพำหนะ, อำนวยควำมสะดวกในกำร
ิ่
ิ่
จัดสงของและอุปกรณ์ตำงๆ, และจัดหำ สง
่
สนับสนุนภำยนอก):
15. หำข ้อมูลและพูดคุยกับแพทย์, พยำบำล
และบุคลำกรสุขภำพอืนๆ เกียวกับ สภำพ
่
่
ของผู ้สูงอำยุและแผนกำรรักษำ:

156

ี ิ
ด ัชนีคณภาพชวต (Quality of Life Index)
ุ
ชุดทีหนึง แบบประเมินระด ับความพึงพอใจ
่ ่
จำกหัวข ้อแต่ละหัวข ้อต่อไปนี้ โปรดพิจำรณำเลือกคำตอบทีบงชถงระดับควำมพึงพอใจ ของท่ำนใน
่ ่ ี้ ึ
ี ิ
ชวต ด ้ำนต่ำงๆ คำตอบแต่ละข ้อไม่มควำมหมำยว่ำถูกหรือผิดอย่ำงแท ้จริง หำกคำตอบทีมไม่ตรงกับ
ี
่ ี
ึ
ควำมรู ้สกของท่ำนทีเดียว กรุณำเลือกคำตอบทีใกล ้เคียง กับระดับควำมพึงพอใจของท่ำนมำกทีสด
่
่ ุ
และโปรดตอบข ้อคำถำมทุกข ้อ
Table A7

ึ
ไม่พงพอใจอย่ำงมำก

พึงพอใจเล็กน ้อย

พึงพอใจปำนกลำง

พึงพอใจอย่ำงมำก

1. สุขภำพของท่ำน
2. กำรดูแลทำงด ้ำนสุขภำพทีทำนได ้รับอยู่
่ ่
3. ควำมรุนแรงของอำกำรเจ็บปวดทีทำนมีอยู่
่ ่
4. พละกำลังในกำรประกอบกิจวัตรประจำวัน
ิ่
5. ควำมสำมำรถในกำรทำสงต่ำง ๆ ได ้ด ้วยตนเอง
ี้
ี ิ
6. ควำมสำมำรถควบคุมและชนำชวตของ ตนเอง
ีวตยืนยำว
7. โอกำสทีจะมีช ิ
่
ิ
8. สุขภำพของสมำชกในครอบครัวของท่ำน
9. ลูกหลำนของท่ำน
10. ควำมสุขในครอบครัวของท่ำน
ั
11. กำรมีเพศสมพันธ์
ั
12. ควำมสมพันธ์กับคูครอง / บุคคลทีม ี ควำมหมำยต่อ
่
่
ท่ำน
13. เพือน ๆ ของท่ำน
่
่
14. ควำมชวยเหลือ ควำมเห็นอกเห็นใจ หรือ กำลังใจที่
ท่ำนได ้รับจำกครอบครัว

ึ
ไม่พงพอใจเล็กน ้อย

ิ่
้
ท่านมีความพึงพอใจในสงต่อไปนีเพียงใด

ึ
ไม่พงพอใจปำนกลำง

Ferrans and Powers Quality of Life Index, Part 1 (Thai)

1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6
6
6
6

1
1

2
2

3
3

4
4

5
5

6
6

"Copyright 1984 & 1998 Carol Estwing Ferrans and Marjorie J. Powers"
แปลเป็ นภำษำไทย โดย อัจฉรำ สุคนธสรรพ์

157

ึ
ไม่พงพอใจอย่ำงมำก

พึงพอใจเล็กน ้อย

พึงพอใจปำนกลำง

พึงพอใจอย่ำงมำก

่
15. ควำมชวยเหลือ ควำมเห็นอกเห็นใจ หรือ กำลังใจที่
ท่ำนได ้รับจำกผู ้อืน
่
16. ควำมสำมำรถทีจะทำหน ้ำทีตอครอบครัว
่
่ ่
17. ควำมมีประโยชน์ หรือมีคณค่ำต่อผู ้อืน
ุ
่
ี ิ
18. ระดับควำมเครียด หรือควำมกังวล ในชวตของท่ำน
19. เพือนบ ้ำนของท่ำน
่
20. บ ้ำนของท่ำนหรือทีอยูอำศัย
่ ่
21. งำนของท่ำน (หำกทำงำน)
22. กำรไม่มงำนทำ (หำกไม่ได ้ทำงำน ออกจำกงำน
ี
หรือทุพลภำพ)
ึ
23. กำรศกษำของท่ำน
24. ควำมสำมำรถพึงตนเองด ้ำนกำรเงิน
่
25. งำนอดิเรก หรือกิจกรรมยำมว่ำงของท่ำน
26. โอกำสทีจะมีควำมสุขในวัยชรำ เกษียณ อำยุ
่
27. ควำมสงบทำงใจของท่ำน
ื่
28. ควำมเชอของท่ำนเกียวกับพระเจ ้ำ และ ศำสนำ
่
ี ิ
29. ควำมสำเร็จตำมเป้ ำหมำยในชวต
30. ควำมสุขโดยทั่วไปของท่ำน
ี ิ
31. ชวตโดยทั่วไปของท่ำน
32. รูปร่ำงหน ้ำตำ สภำพร่ำงกำยของท่ำน ตำมทีปรำกฎ
่
33. ตัวของท่ำนเองโดยทั่วไป

ึ
ไม่พงพอใจเล็กน ้อย

ิ่
้
ท่านมีความพึงพอใจในสงต่อไปนีเพียงใด

ึ
ไม่พงพอใจปำนกลำง

Table A7 (cont’d)

1

2

3

4

5

6

1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

4
4
4
4
4
4
4

5
5
5
5
5
5
5

6
6
6
6
6
6
6

1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6
6
6

"Copyright 1984 & 1998 Carol Estwing Ferrans and Marjorie J. Powers"
แปลเป็ นภำษำไทย โดย อัจฉรำ สุคนธสรรพ์
ี ิ
ด ัชนีคณภาพชวต (Quality of Life Index)
ุ

158

ชุดทีสอง แบบประเมินระด ับความสาค ัญ
่
จำกหัวข ้อแต่ละหัวข ้อต่อไปนี้ โปรดพิจำรณำเลือกคำตอบทีบงชถงระดับควำมสำคัญ ทีทำนให ้กับ
่ ่ ี้ ึ
่ ่
ี ิ
ชวตในด ้ำนต่ำง ๆ คำตอบแต่ละข ้อไม่มควำมหมำยว่ำถูกหรือผิดอย่ำงแท ้จริง หำกคำตอบทีมไม่ตรง
ี
่ ี
ึ
กับควำมรู ้สกของท่ำนทีเดียว กรุณำเลือกคำตอบทีใกล ้เคียงกับ ระดับควำมพึงพอใจของท่ำนมำก
่
ทีสด และโปรดตอบข ้อคำถำมทุกข ้อ
่ ุ
Table A8

ไม่สำคัญต่อท่ำนเลย

สำคัญต่อท่ำนเล็กน ้อย

สำคัญต่อท่ำนปำนกลำง

สำคัญต่อท่ำนอย่ำงมำก

1. สุขภำพของท่ำน
2. กำรดูแลทำงด ้ำนสุขภำพทีทำนได ้รับอยู่
่ ่
3. ควำมรุนแรงของอำกำรเจ็บปวดทีทำนมีอยู่
่ ่
4. พละกำลังในกำรประกอบกิจวัตรประจำวัน
ิ่
5. ควำมสำมำรถในกำรทำสงต่ำง ๆ ได ้ด ้วย ตนเอง
ี้
ี ิ
6. ควำมสำมำรถควบคุมและชนำชวตของ ตนเอง
ี ิ
7. โอกำสทีจะมีชวตยืนยำว
่
ิ
8. สุขภำพของสมำชกในครอบครัวของท่ำน
9. ลูกหลำนของท่ำน
10. ควำมสุขในครอบครัวของท่ำน
ั
11. กำรมีเพศสมพันธ์
ั
12. ควำมสมพันธ์กับคูครอง / บุคคลทีมควำมหมำย
่
่ ี
ต่อท่ำน
13. เพือน ๆ ของท่ำน
่
่
14. ควำมชวยเหลือ ควำมเห็นอกเห็นใจ หรือ กำลังใจ
ทีทำนได ้รับจำกครอบครัว
่ ่

ไม่สำคัญต่อท่ำนเล็กน ้อย

ิ่
้
ท่านให้ความสาค ัญต่อสงต่อไปนีเพียงใด

ไม่สำคัญต่อท่ำนปำนกลำง

Ferrans and Powers Quality of Life Index, Part 2 (Thai)

1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6
6
6
6

1
1

2
2

3
3

4
4

5
5

6
6

"Copyright 1984 & 1998 Carol Estwing Ferrans and Marjorie J. Powers"
แปลเป็ นภำษำไทย โดย อัจฉรำ สุคนธสรรพ์

159

ไม่สำคัญต่อท่ำนเลย

สำคัญต่อท่ำนเล็กน ้อย

สำคัญต่อท่ำนปำนกลำง

สำคัญอย่ำงมำก

่
15. ควำมชวยเหลือ ควำมเห็นอกเห็นใจ หรือ กำลังใจ
ทีทำนได ้รับจำกผู ้อืน
่ ่
่
16. ควำมสำมำรถทีจะทำหน ้ำทีตอครอบครัว
่
่ ่
17. ควำมมีประโยชน์ หรือมีคณค่ำต่อผู ้อืน
ุ
่
ี ิ
18. ระดับควำมเครียด หรือควำมกังวล ในชวตของ
ท่ำน
19. เพือนบ ้ำนของท่ำน
่
20. บ ้ำนของท่ำนหรือทีอยูอำศัย
่ ่
21. งำนของท่ำน (หำกทำงำน)
22. กำรไม่มงำนทำ (หำกไม่ได ้ทำงำน ออก จำกงำน
ี
หรือทุพลภำพ)
ึ
23. กำรศกษำของท่ำน
24. ควำมสำมำรถพึงตนเองด ้ำนกำรเงิน
่
25. งำนอดิเรก หรือกิจกรรมยำมว่ำงของท่ำน
26. โอกำสทีจะมีควำมสุขในวัยชรำ เกษียณ อำยุ
่
27. ควำมสงบทำงใจของท่ำน
ื่
28. ควำมเชอของท่ำนเกียวกับพระเจ ้ำ และ ศำสนำ
่
ี ิ
29. ควำมสำเร็จตำมเป้ ำหมำยในชวต
30. ควำมสุขโดยทั่วไปของท่ำน
ี ิ
31. ชวตโดยทั่วไปของท่ำน
32. รูปร่ำงหน ้ำตำ สภำพร่ำงกำยของท่ำน ตำมที่
ปรำกฎ
33. ตัวของท่ำนเองโดยทั่วไป

ไม่สำคัญต่อท่ำนเล็กน ้อย

ิ่
้
ท่านให้ความสาค ัญต่อสงต่อไปนีเพียงใด

ไม่สำคัญต่อท่ำนปำนกลำง

Table A8 (cont’d)

1

2

3

4

5

6

1
1
1

2
2
2

3
3
3

4
4
4

5
5
5

6
6
6

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

6
6
6
6

1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6
6

1

2

3

4

5

6

"Copyright 1984 & 1998 Carol Estwing Ferrans and Marjorie J. Powers"
แปลเป็ นภำษำไทย โดย อัจฉรำ สุคนธสรรพ์
้ ่
บ ัดนีทานได้ทาแบบสอบถามเสร็จสมบูรณ์แล้ว
ขอขอบพระคุณในความร่วมมือเปนอย่างสูง
็

160

APPENDIX B

Study Instrument (English Version)

161

Caregiver Socio-Demographic Questionnaire
Please complete the following personal information by writing in the blank and making a check
mark in front of the most appropriated items.
1. Caregiver age_______years (write the number of age in years)
2. Caregiver sex (check one) ___Male
___Female
3.Religion (check one)
___Buddhist
___Christian
___Islam
___Others (specify)___________
We have listed religious activities below. Read each one carefully. If you have been participated
those activities, let us know how OFTEN you participate in those activities by checking one to
rate for each activity.
Table B1
Caregiver Religious Activities Questions

Religious activities

Once
a day

Once a Once a
week month

Less than
once a
month

Not at
all

Praying (check one)
Meditating (check one)
Going to the temple (check one)
Offering food and things for
monks (check one)
Donation (check one)
Others (specify)

4. Relationship to the ECR (check one)
___Spouse
___Daughter/ Son
___Granddaughter/ grandson
___Sister/ Brother
___Daughter-in-law
___Other relatives (specify)
5. Household income/ monthly (Baht) (check one)
___Lower 2000
___2001-5000
___5001-10000
___10000 and over
6. Co-morbid conditions (check all that apply)
___No
___High blood pressure
___Diabetes Mellitus
___Heart disease
___Chronic bronchitis
___Low back pain
___Arthritis
162

___Others (specify)_______________________
7. Length of caregiving______months (write the number of length in months)
8. ECR age_______years (write the number of age in years)
9. Diagnosis______________________ (write the diagnosed disease)
10. Sex (check one) ___Male
___Female
SF-12® Questionnaire
This survey asks for your views about your health. This information will help keep track of
how you feel and how well you are able to do your usual activities. For each of the following
questions, please mark on the line in front of the appropriate answer.
1. In general, would you say your health is:
_____ Excellent (1)
_____ Very Good (2)
_____ Good (3)
_____ Fair (4)
_____ Poor (5)
The following two questions are about activities you might do during a typical day. Does YOUR
HEALTH NOW LIMIT YOU in these activities? If so, how much?
2. MODERATE ACTIVITIES, such as moving a table, pushing a vacuum cleaner, bowling, or
playing golf:
_____ Yes, Limited A Lot (1)
_____ Yes, Limited A Little (2)
_____ No, Not Limited At All (3)
3. Climbing SEVERAL flights of stairs:
_____ Yes, Limited A Lot (1)
_____ Yes, Limited A Little (2)
_____ No, Not Limited At All (3)
During the PAST 4 WEEKS have you had any of the following problems with your work or
other regular activities AS A RESULT OF YOUR PHYSICAL HEALTH?
4. ACCOMPLISHED LESS than you would like:
_____ All of the Time (1)
_____ Most of the Time (2)
_____ Some of the Time (3)
_____ A Little of the Time (4)
_____ None of the Time (5)
5. Were limited in the KIND of work or other activities:
_____ All of the Time (1)
_____ Most of the Time (2)
_____ Some of the Time (3)
_____ A Little of the Time (4)
_____ None of the Time (5)
During the PAST 4 WEEKS, were you limited in the kind of work you do or other regular
activities AS A RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or
anxious)?

163

6. ACCOMPLISHED LESS than you would like:
_____ All of the Time (1)
_____ Most of the Time (2)
_____ Some of the Time (3)
_____ A Little of the Time (4)
_____ None of the Time (5)
7. Didn’t do work or other activities as CAREFULLY as usual:
_____ All of the Time (1)
_____ Most of the Time (2)
_____ Some of the Time (3)
_____ A Little of the Time (4)
_____ None of the Time (5)
8. During the PAST 4 WEEKS, how much did PAIN interfere with your normal work (including
both work outside the home and housework)?
_____ Not At All (1)
_____ A Little Bit (2)
_____ Moderately (3)
_____ Quite a Bit (4)
_____ Extremely (5)
The next three questions are about how you feel and how things have been DURING THE PAST
4 WEEKS. For each question, please give the one answer that comes closest to the way you have
been feeling. How much of the time during the PAST 4 WEEKS –
9. Have you felt calm and peaceful?
_____ All of the Time (1)
_____ Most of the Time (2)
_____ Some of the Time (3)
_____ A Little of the Time (4)
_____ None of the Time (5)
10. Did you have a lot of energy?
_____ All of the Time (1)
_____ Most of the Time (2)
_____ Some of the Time (3)
_____ A Little of the Time (4)
_____ None of the Time (5)
11. Have you felt downhearted and blue?
_____ All of the Time (1)
_____ Most of the Time (2)
_____ Some of the Time (3)
_____ A Little of the Time (4)
_____ None of the Time (5)
12. During the PAST 4 WEEKS, how much of the time has your PHYSICAL HEALTH OR
EMOTIONAL PROBLEMS interfered with your social activities (like visiting with friends,
relatives, etc.)?
_____ All of the Time (1)
_____ Most of the Time (2)
_____ Some of the Time (3)
164

_____ A Little of the Time (4)
_____ None of the Time (5)
______________________________________________________________________
SF-12® Health Survey © 1994, 2002 by Medical Outcomes Trust and Quality Metric
Incorporated. All Rights Reserved
SF-12® is a registered trademark of Medical Outcomes Trust

165

Personal Resource Questionnaire Part II (PRQ85-II)
Below are some statements with which some people agree and others disagree. Please READ
EACH STATEMENT AND CIRCLE the response most appreciate for you. There is no right or
wrong answer.
Table B2

STRONGLY DISAGREE
166

SOMEWHAT DISAGREE

NEUTRAL

SOMEWHAT AGREE

AGREE

STRONGLY AGREE

a.There is someone I feel close to who makes me feel
secure
b.I belong to a group in which I feel important
c.People let me know that I do well at my work (job,
homemaking)
d.I can’t count on my relatives and friends to help me
with my problem
e.I have enough contact with the person who makes me
feel special
f.I spend time with others who have the same interest
that I do
g.There is little opportunity in my life to be giving and
caring to another person
h.Others let me know that they enjoy working with me
(job, committees, projects)
i.There are people who are available if I needed help
over an extended period of time
j.There is no one to talk to about how I am feeling
k.Among my group of friends we do favors for each
other
l.I have the opportunity to encourage others to develop
their interests and skills

DISAGREE

Personal Resource Questionnaire Part II (PRQ85-II)

1

2

3

4

5

6

7

1
1

2
2

3
3

4
4

5
5

6
6

7
7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1
1

2
2

3
3

4
4

5
5

6
6

7
7

1

2

3

4

5

6

7

STRONGLY DISAGREE
167

SOMEWHAT DISAGREE

NEUTRAL

SOMEWHAT AGREE

AGREE

STRONGLY AGREE

m.My family lets me know that I am important for
keeping the family running
n.I have relatives or friends that will help me out even
if I can’t pay them back
o.When I am upset there is someone I can be with who
lets me be myself
p.I feel no one has the same problems as I
q.I enjoy doing little “extra” things that make another
person’s life more pleasant
r.I know that others appreciate me as a person
s.There is someone who loves and cares about me
t.I have people to share social events and fun activities
with
u.I am responsible for helping provide for another
person’s needs
v.If I need advice there is someone who would assist
me to work out a plan for dealing with the situation
w.I have a sense of being needed by another person
x.People think that I’m not as good a friend as I should
be
y.If I got sick, there is someone to give me advice about
caring for myself

DISAGREE

Table B2 (cont’d)

1

2

3

4

5

6

7

1
1

2
2

3
3

4
4

5
5

6
6

7
7

1
1

2
2

3
3

4
4

5
5

6
6

7
7

1
1
1

2
2
2

3
3
3

4
4
4

5
5
5

6
6
6

7
7
7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1
1

2
2

3
3

4
4

5
5

6
6

7
7

1

2

3

4

5

6

7

Rewards of Caregiving
We know that some people find aspects of their caregiving situation rewarding and others do not.
These questions are about things that you may or may not find rewarding because of caring for
your family member. Please READ EACH STATEMENT AND CIRCLE the response most
appreciate for you. There are no right or wrong answers.
Table B3
Rewards of Caregiving
Not
at all

To what extent…
1. does caring for him or her help you understand
your own aging?
2. does caring for him or her help you feel like
you are doing something important?
3. does caring for him or her help you understand
the situation of older people in general?
4. is caring for your family member rewarding for
you because it keeps him or her out of a nursing
home?
5. does caring for him or her help you feel good
about yourself?
6. is it rewarding because you feel you make life a
little easier for him or her?
7. does caring for him or her add meaning to your
life?
8. have you learned a lot about health and illness
because of caregiving?
9. does caring for him or her give you a sense of
accomplishment?
10. is just “being there” for him or her rewarding
to you?
11. have you personally grown as a result of being
a caregiver?
12. do you feel glad that you are the one who is
providing care to him or her?
13. do you understand more about the aging
process because of caregiving?
14. is caring for your family member rewarding
because it makes him or her happy?
15. is it rewarding to know that you are helpful to
him or her?

168

A
little

Some

Quite
a bit

0

1

2

3

A
great
deal
4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

THE BARTHEL INDEX
This list of indexes is about the record of what an elder does. For each of the following index,
please write in the number (0, 5, 10, or 15) to score the dependency of the elder you cared for.
Activity
Score
FEEDING
0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent
______
BATHING
0 = dependent
5 = independent (or in shower)
______
GROOMING
0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided)
______
DRESSING
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)
______
BOWELS
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent
______
BLADDER
0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident
10 = continent
______
TOILET USE
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)
______
TRANSFERS (BED TO CHAIR AND BACK)
0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
15 = independent
______
MOBILITY (ON LEVEL SURFACES)
0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards
______
STAIRS
0 = unable
5 = needs help (verbal, physical, carrying aid)
10 = independent
______
TOTAL (0–100):
(for researcher)
______
Provided by the Internet Stroke Center — www.strokecenter.org
169

Memorial Symptoms Assessment Scale
Section 1. We have listed 24 symptoms below. Read each one carefully. If the elder you cared
for has had the symptom during this past month, let us know how OFTEN the elder had it, how
SEVERE it was usually and how much it DISTRESSED or BOTHERED the elder by circling
the appropriate number. If the elder DID NOT HAS the symptom, make an “X” in the box
marked “DID NOT HAVE.”
Table B4

Moderate

Severe

Very Severe

Not at all

A Little Bit

Somewhat

Quite a Bit

Very Much

Difficulty concentrating
Pain
Lack of energy
Cough
Feeling nervous
Dry mouth
Nausea
Feeling drowsy
Numbness/ tingling in
hands/feet
Difficulty sleeping
Feeling bloated
Problems with urination
Vomiting
Shortness of breath
Diarrhea

Slight

Did the elder have any
of the following
symptoms?

Almost Constantly

IF YES
How much did it
DISTRESSED or
BOTHER you?

Frequently

IF YES
How SEVERE
was it usually?

Occasionally

If YES
How OFTEN
did you have
it?

Rarely

During the past month

DID NOT HAVE

Memorial Symptoms Assessment Scale – Section 1

1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4

1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4

0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

4
4
4
4
4
4

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

4
4
4
4
4
4

0
0
0
0
0
0

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

4
4
4
4
4
4

170

Moderate

Severe

Very Severe

Not at all

A Little Bit

Somewhat

Quite a Bit

Very Much

Feeling sad
Sweats
Worrying
Problems with sexual
interest or activities
Itching
Lack of appetite
Dizziness
Difficulty swallowing
Feeling irritable

Slight

Did the elder have any
of the following
symptoms?

Almost Constantly

IF YES
How much did it
DISTRESSED or
BOTHER you?

Frequently

IF YES
How SEVERE
was it usually?

Occasionally

If YES
How OFTEN
did you have
it?

Rarely

During the past month

DID NOT HAVE

Table B4 (cont’d)

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

0
0
0
0

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

171

Section 2. We have listed 8 symptoms below. Read each one carefully. If the elder has had the
symptom during this past month, let us know how SEVERE it was usually and how much it
DISTRESSED or BOTHERED the elder by circling the appropriate number. If the elder DID
NOT HAS the symptom, make an “X” in the marked “DID NOT HAVE.”
Table B5

Mouth sore
1 2 3 4 0 1 2 3
Change in the way food tastes
1 2 3 4 0 1 2 3
Weight loss
1 2 3 4 0 1 2 3
Hair loss
1 2 3 4 0 1 2 3
Constipation
1 2 3 4 0 1 2 3
Swelling of arms or legs
1 2 3 4 0 1 2 3
“I don’t like myself”
1 2 3 4 0 1 2 3
Changes in skin
1 2 3 4 0 1 2 3
If the elder had any other symptoms during the past month, please list below and
indicate how much the symptom has distressed or bothered the elder.
Other:
0 1 2 3
Other:
0 1 2 3

172

Very Much

Quite a Bit

Somewhat

A Little Bit

Not at all

IF YES
How much did it
DISTRESSED or
BOTHER you?
Very Severe

Severe

Moderate

Did you have any of the following
symptoms?

IF YES
How SEVERE
was it usually?

Slight

During the past month

DID NOT HAVE

Memorial Symptoms Assessment Scale – Section 2

4
4
4
4
4
4
4
4

4
4

Oberst Caregiving Burden Scale
This group of questions is about the tasks and activities that you do to help the elder. For each of
the following activities, please mark HOW MUCH TIME you spend and HOW DIFFICULT
each activity is for you to do
Time 5 = A great amount
Difficulty
5 = Extremely difficult
4 = A large amount
4 = Very difficult
3 = A moderate amount
3 = Moderately difficult
2 = A small amount
2 = Slightly difficult
1 = None
1 = Not difficult
Table B6
Oberst Caregiving Burden Scale

A small amount
A large amount
A moderate amount

A great amount
Not difficult
Slightly difficult
Moderately difficult

Very difficult

Extremely difficult

Difficulty

None

Time

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1
1

2
2

3
3

4
4

5
5

1
1

2
2

3
3

4
4

5
5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Tasks and activities that you do to help the
elder:

1. Medical or nursing treatment (giving
medications, skin care, dressing, etc.):
2. Personal care (bathing, toileting, getting
dressed, feeding, etc.):
3. Assistance with walking, getting in and out of
bed, exercises, etc.:
4. Emotional support, “being there” for the elder:
5. Watching for and reporting the elders’
symptoms, watching how the elder is doing,
monitoring the elder’s progress:
6. Providing transportation or “company”
(driving, riding along with elder, going to
appointments, driving elder around for errands,
etc.):
7. Managing finances, bills, and forms related to
the elder’s illness:
8. Additional household tasks for elder (laundry,
cooking, cleaning, yard work, home repair, etc.):
9. Additional tasks outside the home for the elder
(shopping for food and clothes, going to the
bank, running errands, etc.):

173

Table B6 (cont’d)
A small amount
A large amount
A moderate amount

A great amount
Not difficult
Slightly difficult
Moderately difficult

Very difficult

Extremely difficult

Difficulty

None

Time

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Tasks and activities that you do to help the
elder:

10. Structuring/planning activities for the elder
(recreation, rest, meals, things for the elder to do,
etc.):
11. Managing behavior problems (moodiness,
irritability, confusion, memory loss, etc.):
12. Finding and arranging someone to care for
the elder while you are away:
13. Communication (helping the elder with the
phone, writing or reading, explaining things,
trying to understand what the elder is trying to
say, etc.):
14. Coordinating, arranging, and managing
services and resources for the elder (scheduling
appointments, arranging transportation, locating
equipment and services, and finding outside
help):
15. Seeking information and talking with
doctors, nurses and other professional health care
workers about the elder’s condition and
treatment plans:

174

Ferrans and Powers
Quality of Life Index©Generic Version – III
PART 1. For each of the following, please choose the answer that best describes HOW
SATISFIED you are with that area of your life. Please mark your answer by circling the number.
There are no right or wrong answers.
Table B7

Very Dissatisfied
175

Slightly Satisfied

Moderately Satisfied

Very Satisfied

1. Your health?
2. Your health care?
3. The amount of pain that you have?
4. The amount of energy you have for everyday
activities?
5. Your ability to take care of yourself without help?
6. The amount of control you have over your life?
7. Your chances of living as long as you would like?
8. Your family’s health?
9. Your children?
10. Your family’s happiness?
11. Your sex life?
12. Your spouse, lover, or partner?
13. Your friends?
14. The emotional support you get from your family?
15. The emotional support you get from people other than
your family?
16. Your ability to take care of family responsibilities?

Slightly Dissatisfied

HOW SATISFIED ARE YOU WITH:

Moderately Dissatisfied

Ferrans and Powers Quality of Life Index, Part 1

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

6
6
6
6

1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6
6
6

1

2

3

4

5

6

Very Dissatisfied

Slightly Satisfied

Moderately Satisfied

Very Satisfied

17. How useful you are to others?
18. The amount of worries in your life?
19. Your neighborhood?
20. Your home, apartment, or place where you live?
21. Your job (if employed)?
22. Not having a job (if unemployed, retired, or
disabled)?
23. Your education?
24. How well you can take care of your financial needs?
25. The things you do for fun?
26. Your chances for a happy future?
27. Your peace of mind?
28. Your faith in God?
29. Your achievement of personal goals?
30. Your happiness in general?
31. Your life in general?
32. Your personal appearance?
33. Yourself in general?

Slightly Dissatisfied

HOW SATISFIED ARE YOU WITH:

Moderately Dissatisfied

Table B7 (cont’d)

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

4
4
4
4
4
4

5
5
5
5
5
5

6
6
6
6
6
6

1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6
6
6

© Copyright 1984& 1998 Carol Estwing Ferrans and Marjorie J. Powers

176

PART 2. For each of the following, please choose the answer that best describes HOW
IMPORTANT that area of your life is to you. Please mark your answer by circling the number.
There are no right or wrong answers.
Table B8

Very Unimportant
177

Slightly Important

Moderately Important

Very Important

1. Your health?
2. Your health care?
3. The amount of pain that you have?
4. The amount of energy you have for everyday
activities?
5. Your ability to take care of yourself without help?
6. The amount of control you have over your life?
7. Your chances of living as long as you would like?
8. Your family’s health?
9. Your children?
10. Your family’s happiness?
11. Your sex life?
12. Your spouse, lover, or partner?
13. Your friends?
14. The emotional support you get from your family?
15. The emotional support you get from people other than
your family?
16. Your ability to take care of family responsibilities?
17. How useful you are to others?

Slightly Unimportant

HOW IMPORTANT TO YOU IS:

Moderately Unimportant

Ferrans and Powers Quality of Life Index, Part 2

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

6
6
6
6

1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6
6
6

1
1

2
2

3
3

4
4

5
5

6
6

Very Unimportant

Slightly Important

Moderately Important

Very Important

18. The amount of worries in your life?
19. Your neighborhood?
20. Your home, apartment, or place where you live?
21. Your job (if employed)?
22. Not having a job (if unemployed, retired, or
disabled)?
23. Your education?
24. How well you can take care of your financial needs?
25. The things you do for fun?
26. Your chances for a happy future?
27. Your peace of mind?
28. Your faith in God?
29. Your achievement of personal goals?
30. Your happiness in general?
31. Your life in general?
32. Your personal appearance?
33. Yourself in general?

Slightly Unimportant

HOW IMPORTANT TO YOU IS:

Moderately Unimportant

Table B8 (cont’d)

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

5
5
5
5
5

6
6
6
6
6

1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6
6
6

© Copyright 1984& 1998 Carol Estwing Ferrans and Marjorie J. Powers
NOW YOU ARE FINISHED!
THANK YOU VERY MUCH FOR YOUR PARTICIPATION.

178

APPENDIX C

Study Consent Form (Thai-Translated and English Versions)

179

(PhD in Nursing)
(Michigan State University)

.

(Distinguished Professor Barbara Given, PhD, RN, FAAN)
45-60

พัฒนา

18

____________________________ ____________________

____________________________ ____________________

ได้ รับ
“

”
180

,

:
: Distinguished Professor Barbara Given, PhD, RN, FAAN
(

)

:
B510 West Fee Hall
College of Nursing, Michigan State University
East Lansing, MI 48824-1315
Phone (517) 355-6526
Fax (517) 353-8612
Email: barb.given@hc.msu.edu; cindy.espinosa@hc.msu.edu
:
(Ms. Saowaluk Netchang)
(

)

:
35

5 .

.

.

53000

:
1625 Spartan Village, Apt J
Michigan State University
East Lansing, Michigan 48823-5933, U.S.A
: +1(517) 355-9901

: netchang@msu.edu

181

: 081-532-5427

,

(Michigan State University Human Research Protection Program)
Michigan State University Human Research Protection Program
207 Olds Hall, MSU East Lansing, MI 48824-1034, U.S.A

Informed Consent This consent form was approved by the Biomedical and Health Institutional
Review Board (BIRB) at Michigan State University. Approved 05/06/11 – valid through
05/05/12. This version supersedes all previous versions. IRB# 11-462.

182

Study Title: Health-Related Quality of Life of
Rural Thai Family Caregivers
To: Family Caregiver
This research is a study conducted by Ms. Saowaluk Netchang, a doctoral student in the PhD
Nursing program at Michigan State University, United States, under supervision of
Distinguished Professor Barbara Given, PhD, RN, FAAN. This study aims to examine the key
factors influencing the overall Health-related Quality of Life (HRQOL) of rural Thai family
caregivers of elderly care recipients (ECR) with one or more chronic conditions who possess at
least two activity of daily living (ADL) deficits. The questionnaire should take about 45-60
minutes to complete. There are no foreseeable risks associated with your participation in this
study. Although it may be possible that you would feel mildly uncomfortable answering some of
the questions, you will never be obligated to answer any questions that may make you feel
uncomfortable.
This research is voluntary and you can withdraw or refuse to answer any particular question
without penalty. Your responses will be released only as summaries in which no individual’s
answer can be identified. In addition, only those directly involved in this study will be allowed to
access the research data. Your decision on whether or not to join this study is entirely your own
decision. Your usual medical care provided at the Primary Care Unit (PCU) will not change if
you do, or do not decide to enroll in this study. None of the healthcare professionals at the PCU
will be capable of knowing whether you decided to participate in this study or not. Your
confidentiality will be protected to the maximum extent allowable by law.
You will not specifically benefit from your participation in this study. Your participation in this
study may contribute to the understanding of predictors of caregivers’ HRQOL leading to initiate
appropriate interventions to enhance positive aspect of providing care for elders in rural setting.
To participate, you must be at least 18 years old, caring for chronically-ill ECR who has two or
more ADLs deficits at home without payment, and be fluent and functionally literate in the Thai
language.
The research data will be kept on the campus of Michigan State University in a locked file
cabinet or password protected computer for three years after the close of the research and only
the appointed researchers and the Institutional Review Board (IRB) will have access to the data.
Thank you very much
Your signature below means that you voluntarily agree to participate in this research study.
____________________________ ____________________
Signature
Date
______________________________ ____________________
Person Obtaining Consent
Date
“PROVIDE COPY TO CAREGIVER”

183

If you have any concerns or questions about this study, such as scientific issues, how to do any
part of it, or to report an injury, please contact the researchers.
Investigator contact information:
Name: Distinguished Professor Barbara Given, PhD, RN, FAAN
(Principal Investigator and Major Advisor)
Address in U.S.A:
B510 West Fee Hall
College of Nursing, Michigan State University
East Lansing, MI 48824-1315
Phone (517) 355-6526
Fax (517) 353-8612
Email: barb.given@hc.msu.edu; cindy.espinosa@hc.msu.edu
Name: Saowaluk Netchang, PhD(c), RN
(Secondary Investigator)
Address in Thailand:
35 M. 5 Pasao, Muang
Uttaradit 53000
Phone: (081)-532-5427
Address in U.S.A:
1625 Spartan Village, Apt J
Michigan State University
East Lansing, Michigan 48823-5933, U.S.A
Phone: +1(517) 355-9901
Email: netchang@msu.edu

184

If you have any questions or concerns about your role and rights as a research participant, would
like to obtain information or offer input, or would like to register a complaint about this research
study, you may contact, anonymously if you wish, Michigan State University Human Research
Protection Program at 517-355-2180, FAX 517-432-4503, or email irb@msu.edu, or regular mail
at:
207 Olds Hall, MSU East Lansing, MI 48824-1034, U.S.A
Please keep this sheet for your reference
Informed consent This consent form was approved by the Biomedical and Health Institutional
Review Board (BIRB) at Michigan State University. Approved 05/06/11 – valid through
05/05/12. This version supersedes all previous versions. IRB# 11-462

185

APPENDIX D

IRB Approval Letter

186

Renewal
Application
Approval
April 9, 2012
To: Barbara A. Given
B5l0 W. Fee Hall
MSU
Re:

INB# 71-462 Category: EXPEDITED 2-7
Renewal Approval Date: April 6, 2012
Project Expiration Date: April 5,2A13

Title: Health-Related Quality oflife ofRural Thai Family Caregivers
The Institutional Review Board has completed their review of your project. I am pleased to
advise you that the renewal has been approved.
This letter notes approval for data analysis only (contact with subjects and data collection is
complete). Any further recruitment, data collection or contact with subjects will require IRB
review and approval via a revision before implementation.
The review by the committee has found that your renewal is consistent with the continued
protection of the rights and welfare of human subjects, and meets the requirements of MSU's
Federal Wide Assurance and the Federal Guidelines (45 CFR 46 wrd2l CFR Pa* 50). The
protection of human subjects in research is a partnership between the IRB and the investigators.
We look forward to working with you as we both fulfill our responsibilities.
Renewals: IRB approval is valid until the expiration date listed above. If you are continuing your
project, you must submit an Application for Renewal application at least one month before
expiration. If the project is completed, please submit an Application for Permanent Closure.
Revisions: The IRB must review any changes in the project, prior to initiation of the change.
Please submit an Application for Revision to have your changes reviewed. If changes are made
at the time of renewal, please include an Application for Revision with the renewal application.
Problems: If issues should arise during the conduct of the research, such as unanticipated
problems, adverse events, or any problem that may increase the risk to the human subjects, notify
the IRB office promptly. Forms are available to report these issues.
Please use the IRB number listed above on any forms submitted which relate to this project, or
on any correspondence with the IRB office.
Good luck in your research. If we can be of further assistance, please contact us at 517-355-2180
or via email at irb@msu.edu. Thank you for your cooperation.
187

Sincerely'
Ashir Kumar' M'D'
BIRBChair
c:SaowalukNetchang

188

APPENDIX E

Permission for Models

189

Date: Fri, 6 Apr 2012 11:59
From: Carol Ferrans <cferrans@uic.edu>
To: netchang@msu.edu <netchang@msu.edu>
Subject: RE: Introducing Thai Scholar and requesting for instrument use
Hello Saowaluk,
Thank you for my email. I am happy t grant you permission to use the figure referenced in your
email below, as well as any other figures I have published, for your dissertation. Of course, you
will need to credit the figures appropriately with citations in your dissertation, but I'm sure you
were already planning on that.
Because this is a dissertation, this permission should be sufficient. When you move forward to
publish reports from your dissertation, you would need permission from the journal also, in
addition to my permission.
Thanks and good luck with your work.
Sincerely,
Carol Estwing Ferrans, PhD, RN, FAAN
Professor and Associate Dean for Research
Co-Director, UIC Center of Excellence in Eliminating Health Disparities
Co-Director, Community Engagement and Research Core, UIC Center for Clinical and
Translational Science
University of Illinois at Chicago
College of Nursing
845 S. Damen Avenue (M/C 802)
Chicago, IL 60612
phone 312-996-8445; fax 312-996-497 9
email cferrans@uic.edu
QLI website www. uic.ed u/orgs/q li

From: netchang@msu.edu fmailto:netchang@msu.edu]
Sent: Tuesday, April 03, 2OL2 7 :44 PM
To: Carol Ferrans
Subject RE: Introducing Thai Scholar and requesting for instrument use
Dear Dr.Ferrans,
I'm now done collecting and analyzing data. The QLI has a good reliability coefficient
(alpha=.98).
I have another question to ask about the permission to use your revised Wilson & Cleary {1995)
model in your article "Conceptual model of health-related quality of life," (Journal of Nursing
Scholarship, 2005;37(4):336-42). I have both original model and your revised model in my
dissertation. What should I do to ask for the permission to use that model? Do I have to contact
the journal or ask form the owner? Please give me some suggestions.
190

Thank you very much.
Regards,
Saowaluk Netchang

Quoting Carol Ferrans <cferrans@uic.edu>:
Dear Ms. Netchang,
Thank you for your email. I am happy to grant you permission to use the Quality of Life Index
for your study, and there is no charge for this use. You may download copies of the instrument
from our website for your IRB application, ard all other uses for your study, including copies
within your proposal and final dissertation.
I wish you all success with your work.
Sincerely,
Carol Estwing Ferrans, PhD, RN, FAAN
Professor and Associate Dean for Research
Co-Director, UIC Center for Excellence in Eliminating Health Disparities
Co-Director, Community Engagement and Research Core, Center for
Clinical and Translational Science
University of Illinois at Chicago
College of Nursing (M/C 802), Room 606
845 S. Damen Avenue
Chicago, IL60612
phone 312-996-8445
fax 312-996-4979
email cferrars@uic
Q Ll website www. uic. ed u/orgs/qli< lrttp: //www. uic. ed u/orgs/qli>

From: netchang@msu.edu [netcharg@msu. edu]
Sent: Thursday, February 10, 3:45 PM
To: Carol Ferrans
Subject: Introducing Thai Scholar and requesting for instrument use
Dear Dr .Carol Ferrans,
I am Saowaluk Netchang, Thai scholar, studying PhD in Nursing at Michigan State University,
College of Nursing. According my research interest, health-related quality of life of rural Thai
caregivers taking care of chronically-ill elders, I am looking for the effects of caregivers and
elders key factors on caregivers' health-related quality of life. I am going to use the Thaitranslated version of Quality of Life Index in my study, collecting data in rural Thai caregivers. I
am, now, working on my IRB process and would like to have the copy of the instrument to attach
191

with the IRB application. I would like to ask for the permission of using the QLI; please let me
know what should I process next or if you have any other questions about my future study. I am
looking forward to hear from you very soon.

Regards,
Saowaluk Netchang

192

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