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This is to certify that the

thesis entitled

GENDER AND SERVICE USE ATTITUDES
AMONG SPOUSAL CAREGIVERS
OF PERSONS WITH DEMENTIA

presented by
JULIANN BALCOM

has been accepted towards fulfillment
of the requirements for

W degree in W

C g5“; 2 Aha/QM.
Major professor I

Date 7/11/97
I I ’ f

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GENDER AND SERVICE USE ATTITUDES
AMONG SPOUSAL CAREGIVERS
or PERSONS WITH DEMENTIA
By

Juliann Balcom

A THESIS

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

MASTER OF SCIENCE

College of Nursing

1997

ABSTRACT
GENDER AND SERVICE USE ATTITUDES
AMONG SPOUSAL CAREGIVERS OF PERSONS WITH DEMENTIA
By

Juliann Balcom

The purpose of this study was to determine if there were difl‘erences in attitudes
towards utilization of community services between elderly male and female spousal
caregivers. A secondary analysis was done on data obtained from spousal caregiver
respondents interviewed during Wave H of the longitudinal study “The Impact of
Alzheimer’s Disease on Family Caregivers” (Clare Collins, PhD, Principal Investigator,
Grant #ZROl-MH 417666-02). The only socio-demographic difi‘erence noted between the
two groups of caregivers was related to caregiver age. Statistical analysis revealed
significant differences between husband and wife caregivers in attitudes toward caregiver
independence from the service system and confidence in the service system. Implications

of the findings for practice and further research are presented.

To Donald and Chad Michael

iii

ACKNOWLEDGMENTS

I would like to thank my thesis chair, Clare Collins for her guidance and support
throughout this academic endeavor. In addition, I would like to acknowledge the other
members of my thesis committee, Sharon King and Louise Selanders, in appreciation of
their time and efl‘ort in reviewing the drafts of this thesis.

Special thanks to my family for their patience and ongoing support and to Kristin
Forrester, Carol Wank and Janet Woods, MSNS, for mentoring and encouraging my

graduate school career.

iv

TABLE OF CONTENTS

LIST OF TABLES ................................. vii
LIST OF FIGURES ............................... viii
INTRODUCTION

Background ................................ l

Caregiver/Recipient Relationship .................... . 3
REVIEW OF LITERATURE

Attitudes toward Community Service Utilization among

Dementia Caregivers ........ 4
Gender Influences on Attitudes toward Caregiving ............ 8
Relationship Between Gender and Attitudes toward
Community Service Use ...... 11

Purpose of Study/Research Question ................... 12

Conceptual Framework .......................... 12

Study Relevance ............................. 14
METHODS

Research Design ............................. 16

Sample Procedures ............................ 17

Data Collection Procedures/Protection of Human Studies. . ...... 19

Operational Definition of Variables .................... 19

Instrumentation .............................. 20
RESULTS

Socio-demographic Characteristics .................... 22

Scale Properties of the Male and Female Spousal Samples ......... 24

Comparison of Mean Differences on Attitude Scales ............ 28

Analysis of Covariance ........................... 31

DISCUSSION

Methodological Limitiations ........................ 33
Instrument Limitations ........................... 33
Interpretation of Findings ......................... 34
Implications for Advanced Nursing Practice and Primary Care ....... 38
Recommendation for Future Research ................... 41
APPENDICES
Appendix A: Community Service Attitude Inventory Items ........ 43
Appendix B: UCRIHS Approval ..................... 45
LIST OF REFERENCES ............................. 46

Table 1:

Table 2:

Table 3:

Table 4:

Table 5:

Table 6:

LIST OF TABLES

Demographic Variables for the Male and Female Spousal Samples. . . .

Scale Characteristics for Samples: Caregiver Relationship and
Spousal Gender. . .

Interscale Correlations of Male Spousal Caregiver Sample .......
Interscale Correlations of Female Spousal Caregiver Sample ......
Analysis of Variance: Subscale Scores by Spousal Gender ........

Analysis of Covariance: Subscale Scores for Gender
with Age as a Covariate. . .

vii

23

26

28

28

3O

32

LIST OF FIGURES

Figure 1: Effects of External Variables on Behavior ................ 13

Figure 2: Adaptation of Reasoned Action Model ................. 14

viii

Introduction

Bac und

According to the US. Senate Special Committee on Aging 1987-88, it is projected
that by the year 2020, when approximately half of the 80 million "baby-boomers" reach the
age of 65 years, 20% of the population will fall into this category. The full significance of
the growth in the older population requires that morbidity must be considered. The
prolongation of survival by increasingly effective medical technology results in a growing
number of people living into old age with on-going health problems, most of which are not
life-threatening, but chronic diseases resulting in cognitive and functional impairment
(Eliopoulos, 1993). As the population over the age of sixty-five increases rapidly, so do
the demands placed on the health care delivery system, especially on those health care
providers who will need to broaden their understanding of the needs and concerns of this
diverse population.

AS America’s older population continues to grow, the number of people with
Alzheimer’s Disease and other dementias, will continue to rise. Dementia is a chronic
disease characterized by a decline in intellectual functioning severe enough to interfere
with a person’s normal daily activities and social relationships (National Institute on
Aging, 1995). Although there is no agreement on the exact percentage of people with

dementia, studies project that after the age of 65, the percentage of affected people

2

approximately doubles with every decade of life (Evans et al., 1990). Although dementia
may be the result of multi-infarct dementia, Huntington’s Disease or Parkinson’s Disease
with dementia, Alzheimer’s Disease (AD) is the most common cause of dementia among
older people, affecting 60% of that population (Ofiice of Technology Assessment, 1987).
The marked, progressive and irreversible decline in mental firnctioning, the personality
changes and the impairment in judgment creates, over time, the need for continuous care
by others. This creates an increasing incidence of caregiving needs and concerns
experienced by the elderly and dealt with by their families.

In view of the grth and vulnerability of this population, development of
interventional strategies in direct support of family caregivers is becoming an important
clinical and policy priority. Physical, emotional and financial burdens, both experienced
and perceived, of caring for a family member with dementia are well documented in
caregiving literature. Support for caregivers may come from both informal and formal
sources. Informal support includes assistance fi'om the individual ’s family and friends
while formal support consists of health care providers and social/community
agencies/ services. Whether older persons will actually utilize available community
services is a firnction of many motivating and restraining factors in their lives. Frequently
identified influences on service use include: access, availability and knowledge of services,
demographic characteristics, strength of informal networks and objective and self-defined

need; but an understanding of caregiver attitudes on community service use is required

(McCaslin, 1988).

Cam’ «er/Recipient Relationship

The consensus in the literature is that the primary caregiver for impaired elders will
generally be a spouse, followed by adult children (Bass & Noelker, 1987; Wilhoite &
Buschmann, 1991; Zarit, Todd & Zarit, 1986). In a study of nonspousal caregivers,
Stoller (1990), found that helping patterns among caregivers reflected the cultural division
of labor based on gender. Research based on gender differences among caregiving
spouses suggest that the demands of the caregiver role are experienced differently by men
and women (Pruchno & Resch, 1989) and that while husbands and wives participate
extensively in caregiving, they differ in the type of care provided and amount of help they
receive with caregiving tasks (Enright, 1991).

Gender influences on attitudes toward caregiving may reflect stereotypical
male/female role expectations of husbands and wives. There is no evidence that husbands
are less likely to take on the caregiving role for their wives, but fl more likely to become
secondary caregivers, leaving more of the hands-on care to other formal and informal
helpers. There is evidence in the research that husbands are more likely to become
primary or secondary caregivers than sons (Stone et al, 1987); thus, gender differences
among caregivers should not be treated as if they were uniform across all types of
caregivers; the caregiver ’S relationship to the care recipient is an important role
characteristic that can modify gender difl'erences (Dwyer & Seccombe, 1991).

Stoller and Cutler (1992) state, “Spouses are the first line of defense in cOping
with. disease and disability” (p. 313). Spouses provide the most consistent, dependable

care and tolerate greater disability for longer periods of time with fewer mediating

4

resources and at greater personal cost than any other caregivers (Horowitz, 1985;
Motenko, 1988; Stoller, 1992; Stone, Cafl‘erata & Sangl, 1987). Research has purported
that spouse caregivers are at great risk for the negative consequences of caregiving:
health problems and role overload. During the time of caregiving, these elder spouses
sometimes become enmeshed in the dependency demands of their care recipient, resulting
in little time for pursuing other interests or meeting their own needs. Elderly caregivers
may have their own physical problems that diminish their ability to respond to the
increasing demands of caregiving as their spouse’s disability increases and they feel a
greater obligation to provide care (Barnes, Given & Given, I992; Lindgren, 1993).

One of the many dimensions that could be problematic for meeting the needs of the
spousal dyad is a lack of utilization of the community services, both informal and formal,
available to support the caregiving skills of the person expected to provide care. While
various motivations and barriers contribute to the pattern of service use, the concept of
attitudes toward the utilization of services available has not been adequately studied.
Therefore, the focus of this study is to describe the attitudinal difl‘erences of caregivers of

spouses with dementia toward community service use based on gender.

Review of Literature
Attitudestow m n’ rviceU" ' n'
Community support services are the means by which the formal system can
improve care recipient’s functioning and enhance caregiver effectiveness. They are not

intended to replace the caregivers or the care recipient’s natural support network or areas

5

of independent functioning, but to provide services that cannot be performed by the older
adult or his/her informal support system (Maslow, 1990).

Though perceived by providers as important elements in assisting the maintenance
of the elderly in the community by promoting the highest level of functioning, enhancing
the quality of life for both the care recipient and the caregiver; empirical evidence indicates
a pattern of service use where many services were used often by a few caregivers of
dementia, while the majority used few services infi'equently or not at all (Lawton, Brody &
Saperstein, 1989, Stommel, Given & Given, 1990). While this pattern is found in
caregiving of the physically impaired (Gwyther, 1988; Stone, Cafl‘erata & Sangl, 1987), it
was reported in the studies by Stommel, Given & Given (1990) and Bass, Looman &
Ehrlich (1992) that caregivers of family members with dementia used only halfas many
community services as those caring for the physically impaired. Studies have shown that
increased physical disability in the recipient and care-related health changes (need factors)
in the caregiver predict the use of formal services and that when services are used by
caregivers it is often very late in the caregiving process, when the needs for assistance
exceed the resources of the informal network (Noelker & Bass, 1989; Stoller & Cutler,
1993 and Winslow & O'Brien, 1992).

A study by Lawton, Brody and Saperstein (1989) on the use of respite services for
caregivers of Alzheimer’s patients found that the impact of the intervention was minimal
due to the reluctance of caregivers to seek assistance. The data supported the tendency of
many AD patients and their caregivers to become socially isolated and not use the social

supports and services that are available. The reluctance of caregivers to seek assistance

6

from community resources can result from various barriers to usage, but attitudes toward
caregiving, having a family member with cognitive impairment and the utilization of
services are factors that influence the decision.

The influence of caregiver attitudes on the decision to use community services has
been cited in anecdotal reports of demonstration projects (Gwyther, 1988, Lawton, Brody,
and Saperstein, 1989; Montgomery & Borgatta, 1989) and studies of the elderly (Harel,
Noelker and Blake, 1985), where categories of caregiver attitudes reflected: a) attitudes
regarding the acceptability of using the formal service system and b) attitudes about the
quality of services. Commonly cited attitudes among caregivers with dementia included:
1) the belief, based on ethnic or cultural role expectations, that caregivers should/need to
provide all the care required by an impaired relative without the assistance of informal or
formal systems; 2) that it is preferable to use assistance fi'om family and friends rather than
relying on formal providers, and 3) preferring to be independent of the service system
(Collins, King, Given & Given, 1994). Other concerns, based on beliefs/experiences with
formal services involve relinquishing control of family concerns to strangers and concern
that the quality of the care for the cognitively impaired family member would be
appropriate and adequate to meet their special needs (Bass, McCarthy, Eckert & Bichler,
1994', Gwyther, 1988, 1990).

In a retrospective study on utilization of support services by family caregivers to
Alzheimer’s patients, negative service attitudes were assessed. The first measure,
inadequacy of services, reflected respondents agreement that services were not used

because someone in the family felt the quality of service was not good (i.e., service

7

providers do not provide good care, cannot be trusted and do not give care as well as the
care given by family members). The second measure, denial of the illness, reflected the
respondents perceptions that someone in the family avoided the use of services because
they did not accept the Alzheimer’s disease (i.e. didn’t want to admit there was a problem,
afraid to find out what was wrong and didn’t want person’s outside the family knowing
about the illness). In the sample of respondents in the Information and Referral Group

(I & R), that is directed toward families dealing with earlier stages of the disease, users
were more likely to report negative attitudes than the Educational or Support Groups
(Bass et al., 1994).

A qualitative study by King, Collins & Liken (1995) identified four themes
reflecting attitudes based on beliefs, values and social norms. Family/caregiver sense of
obligation was modeled by role behaviors observed within the family unit reflecting how
problems were handled and the acceptability of assistance fiom outside the boundaries of
the family. Family/caregiver as owner of the difliculties expressed the belief, especially by
spouses, that problems were kept within the family unit and not allowed to become
problems for others. In addition, beliefs of the care recipient might out-weigh the beliefs
of the caregiver in determining who should provide care. Control of and trust in the
quality of care being provided were values expressed by families/caregivers as protectors
of vulnerable mews. The sense of need to be able to reciprocate for assistance received
appeared to define the extent to which assistance was most acceptable from formal or
informal sources. In the attitudinal theme of family/careg‘ver as self-reliant uni_t§, the

value of independence, not feeling as sense of personal obligation, of taking advantage of

8

others or becoming dependent on outside assistance was expressed. Reciprocity was
indicated as a motivation for caregiving within the family unit as a means of “paying back”
the recipient for past caring.

Consideration of attitudes constitutes the first step toward an understanding of
why people behave they way they do. The consensus among researchers is that attitudes
are determined by the beliefs individuals hold about themselves and their environment and
the value placed upon them. Norms are also a function of beliefs. Sociologically defined
as: “shared rules, guidelines or beliefs that prescribe the behavior appropriate in a given
situation or under particular circumstances” (Robertson, 1987, p.62). Norms provide
guidelines for individual behavior and reliable expectations for the behavior of others. The
function of norms is so culturally important that there is always strong social pressure to
conform. In the course of a person’s life his experiences lead to the formation of many
different beliefs about various objects, actions and events. They may be the result of direct
observation, acquired indirectly by accepting information from outside sources or they are
self-generated through the inference process (Ajzen & Fishbein, 1980; Robertson, 1987).
For purposes of this study, attitudes towards community services will be conceptually
defined as those beliefs, values and social norms held by caregivers that influence the
decision to utilize formal services.

er In on Attitud tow C in

Given, Stommel, Collins, King & Given (1990) state that characteristics of

caregivers shown to predict responses to caregiving include age, sex, marital status,

physical and mental health status, employment and other role obligations. Including

9

primary caregiver's characteristics into the study of the factors that influence service use
expands the potential for understanding use. Gender differences are believed to influence
the amount and type of care provided, access to social resources that may alleviate
caregiver strain, and appraisal of the caregiving experience (Miller, 1987, 1990; Miller &
Cafasso, 1992; Pruchno & Resch, 1989).

Gender difl‘erences in attitudes and behavior are the result of pervasive gender role
values, beliefs and subjective norms found in our society. These attributes become the
stereotypes for masculine and feminine characteristics that tend to be internalized by the
person. F rom these stereotypes emerge assumptions, expectancies and attitudes about
gender roles and their enactment (David & Bannon, 1976, O’Neil, 1982). Based on and
influenced by economic and social conditions along with technological and medical
advances, cohorts/ generations may enact gender roles difl‘erently.

The current population of elderly spousal caregivers was born in what Sheehy
(1995) describes asthe “World War II Generation (1914-1929)” (p.27), a period when
gender roles were strictly differentiated. Research in the literature proposes that
dimensions associated with masculinity: exercising power and control over others, being
(and being recognized as) a person of strong will, a leader who will get things done; and
strength, toughness and stamina to undertake long, grueling work and endure severe
bodily stress, (David & Brannon, 1976; O'Neil, 1982; Solomon, 1982) formed the basis of
the male gender role for this generation. Thus men saw life in terms of “missions”,
approached problems through organization, top-down hierarchies and authority. Shaped

by this socialization pattern, men became convinced “they must remain forever strong,

10

virile, the providers for and protectors of their families and without doubts, needs or fears
that require expressing feelings” (Sheehy, 1995).

Women were socialized to be kind and caring, obedient and dependent on men or
powerful others, responsible, unselfish and to assume the nurturing role for the family.
Self-identity was/is connected to domestic and family matters and women seemed to place
greater importance on external or interpersonal sources of esteem rather than objective
accomplishments. Because of this societal expectation about the appropriate role of
women, women tend to feel obligated, and men expect them, to provide care to the
recipient (Brody, 1989', Noelker and Bass, 1989).

Some studies have suggested that older women become more instrumental and
assertive as they age; focused, more interested in tasks and accomplishments than
nurturing: whereas older men become more expressive and Show greater interest in
nurturing and being nurtured (Gutrnan, 1994; Sheehy, 1994; Zarit et al., 1986). This does
not negate or enhance their roles as caregivers as men and women come to this role from
opposing directions. In a study by Miller (1987) the dominant pattern of caregiving
appeared to be congruent with previous role behaviors. Female caregiving was viewed as
an extension of the nurturing component of their earlier roles as homemaker and care
provider. For men, being in charge of another person was an extension of his role as
authority figure in the home and at work. While nurturing may be a new experience for
some men, taking charge of a situation is not; Miller (1987) found male’s assumption of
authority, sense of control over a situation and ability to manage/delegate care routines to

be an efl’ective enactment of a caregiving role.

ll

Husbands and wives cannot easily evade their responsibility for caregiving,
confionted by a set of social expectations and obligations concerning support for each
other ’5 instrumental and emotional needs, but they may discharge their caregiving
responsibilities in ways that reflect gender specific patterns of caring. In this study, it is
hypothesized that male and female caregivers will difl‘er in their attitudes towards the use
of community services.

Relationship Between Gender and Attitudes toward Community Service Use

Little research has been done to examine the attitudinal differences that may exist
within the population of caregivers and the relationship of these attitudes to the inclination
to use services.

Some studies found that husband caregivers are likely to receive greater social
support and marshal more resources, including additional informal help and formal
services, than wife caregivers (Allen, 1994; Stone, Cafl‘erata & Sangl, 1987; Zarit, Todd &
Zarit, 1986); while others determined that husbands used only occasional formal and
informal assistance (Miller, 1990; Motenko, 1988) and that women were more likely to
have informal and formal help assisting them (Chappell, 1989). Research has shown that
the caregiver's sex is a factor difl‘erentiating which types of service combinations are used:
women used formal services to supplement their caregiving, whereas men used formal
services to provide care different fi'om what they were providing (Bass, Looman &

Ehrlich, 1992).

12

Despite the discrepancies and inconsistencies in usage patterns between husbands
and wives, there is no research literature on why this is so; just speculation that gender and
kinship influence the interaction with formal and informal support systems.

Pu S IR h uesti n

While utilization of community services is acknowledged to be influenced by a
multitude of factors, it is not within the scope of this study to investigate all of these
variables. The focus of this study and specific research question is " Are there differences
in attitudes towards utilization of community services between elderiy male and female
spousal caregivers?"
ngggpgal Framewogk

The beliefs, values and social norms which make up the attitudes toward family
responsibility and community service use are variable and can influence the caregiver ’s
decision to seek assistance with caregiving. The concept of gender/kinship influence on
caregiving is closely reflective of the relationship between gender/kinship and attitudes
toward community service use.

As a means of understanding and predicting behavior, Azjen & Fishbein (1980)
developed the Theory of Reasoned Action. Based on the assummions that people are
rational, make systematic use of information available to them and consider the
implications when making decisions about initiating an action/behavior, a person ’s
intention/or volitional choice is the immediate determinant of the that behavior. In order
to understand that choice or intention to perform the behavior, the determinants, or the

components that influence the decision, must be identified.

I3

Personality characteristics, demographic variables (i.e. sex, age, race,
socioeconomic status, religion and education) and social values/perceptions about objects
or institutions (i.e. marriage, parenting, social roles) are considered external variables
which may form or influence beliefs. These personal beliefs concerning the performance
of the behavior involve outcome evaluations and motivations to perform or not perform
the behaviors. Attitudes toward the behavior, a judgment that performing the behavior is
either ”good or bad” involving a perception of social judgment, are based on these beliefs.

According to the theory of reasoned action, intention to perform a behavior is a function

 

  
 
 
   
  

 

 

 

 

 

of attitudes.
External Variables
Demographics - Attitudes A Intention A
toward to Perform
Social Values Behavior Behavior
Personality Traits

 

Figure l-Efi’ects of external variables on behavior (Ajzen & Fishbein, 1980)

This theory emphasizes attitudes toward behaviors rather than toward objects or
institutions and can be adapted to help focus the discussion on the influence of
gender/kinship on attitudes toward community service utilization. The intention of the

author is not to examine these relationships in terms of actual service use.

.4}

14

The adapted model of Azjen & F ishbein’s Theory of Reasoned Action reflects the

components of the decision-making process.

 

 

Attitudes toward
Gender Utilizing

Community Services

 

 

 

 

Figure 2-Adaptation of Reasoned Action Model

An individual’s perception of husband/wife gender role expectations are the external
variables that influence attitudes toward seeking and utilizing community services. For
example, a husband who perceives himself as “strong, tough, able to do it alone”, one who
values his independence, coupled with the perception that society expects a husband to
take care of his wife may believe he is totally capable and responsible for providing care
and therefore be unwilling or emotionally unable to seek, ask or utilize informal support or
community services. In contrast, he may believe that caregiving is primarily a female
endeavor and seek assistance from female informal or formal caregivers. Gender/kinship
expectations influences beliefs and values; beliefs and values are the determinants of
attitudes and subjective norms; and attitudinal differences do result in differences in the
intention to utilize community services.
Study Relevance

Whether older persons will actually utilize available community services is a
fimction of many motivating and restraining factors in their lives. As mentioned in the

research literature, caregiver's sociodemographic characteristics and attitudes would be

15

predisposing factors toward utilizing community services (Ajzen and F ishbein, 1980, Bass
and Noelker, 1987; Given et al., 1990).

Situations in which a husband finds himself to be sole caregiver are likely to
become more common in the fixture, given declining family size, decentralization of the
family and increasing proportions of women entering the labor force (Kaye & Applegate,
1990). The issue of utilization of community services to assist in meeting client needs can
be pertinent to elderly male spouse caregivers who were socialized in a era of division of
labor along gender role lines and live in a society where caregiving is predominantly a
female endeavor. Much of the data generated fiom caregiving research supports gender-
role socialization theory, as most of the current cohort of elderly people exhibit traditional
attitudes regarding gender roles in the attitudes toward caregiving, division of labor,
caregiver burden and actual receipt of community services (Fitting & Rabins, Lucas, &
Eastham, 1986; Harris, 1993; Motenko, 1988; Stoller and Cutler; 1992; Stone, Cafi‘erata
and Sangl, 1987), but this data does not address caregivers' attitudes toward community
services.

The dominant subjects of caregiver research have been women. Community
services are planned and developed based on the perceived needs of the clients, thus if
interventions are initiated based on current caregiving samples then most of the
interventions may be more effective for women than men. Little empirical research has
been done to examine the attitudinal and normative difl‘erences that may exist within the

population of caregivers in relation to the attitudes forming the inclination to use

16

community services and little information is available on the adequacy and appropriateness
of informal and formal support services required by the elderly male spouse.

For these reasons, the study of caregiver attitudes towards utilizing services is
important to determine if current services are both appropriate and acceptable to both
male and female caregivers; to design programs and ofl‘er various types of assistance that
address the needs and concerns of both male and female caregivers; to identify attitudes
that serve as barriers to utilization of services; as well as to develop strategies to promote
their usage. Understanding these attitudes can promote effective collaboration between
healthcare providers, service providers and the caregivers/care recipients who can benefit
from the services offered.

Advanced Practice Nurses in primary care practice are in the position of providing
efficient, cost efl‘ective health care at the individual and community level. Information
regarding attitudes toward utilizing services will guide the provider’s counseling and
advocacy efforts in support of the caregiver/recipient dyad and assist in the referral to the
most appropriate and acceptable community service available. Information concerning
clients’ attitudes toward community services is invaluable in deveIOping policies and
programs, at the local, state and federal levels, for delivering community-based services

that are acceptable to caregivers providing care to their spouses with dementia.

Methods
Reseaggh My} :
A secondary analysis was conducted on data collected as part of a four year, three

wave, longitudinal study (1988-1992) of family caregivers of relatives with dementia who

l7

reside in the community (ROI-MH 417666-02, ”The Impact of Alzheimer's Disease on
Family Caregivers,” Principal Investigator-Clare Collins, RN, PhD.) Funded by the
National Institute of Mental Health, one aim of the study was to describe community
service use patterns of family caregivers of relatives with Alzheimer’s Disease and other
dementia; including the need for and barriers to use of services. Data for the analysis of
gender differences in attitudes towards community service utilization was extracted from
this section of the original study.
Present Study

As the data for this study is based on a secondary analysis, the research on the
relationship between gender and attitudes toward utilization of community services was
developed using a non-experimental, descriptive design. The design is non-experimental
in that the independent variable, gender, is a human characteristic not subject to
manipulation and the subject under study is not amenable to the other experimental
requirements, control and randomization. It is a descriptive study in that
the research is more concerned with describing how one variable, gender (independent), is
related to another, attitudes toward community services (dependent), than in determining a
cause-and-efi‘ect relationship.
S le edu
Origy_r' al Study

The target population for the original study was family caregivers of relatives with
dementia who reside in the community. A convenience sample of family caregivers
(n=180) was located through mailings distributed by local chapters of the Alzheimer's
Association, the Michigan Association of Adult Day Care Centers and health agencies in
southwest Michigan. A cover letter explaining the study and return postcards were sent
to Adult Day Care Centers, home health care agencies, and geriatric clinics. Clinicians
were asked to distribute information to the families in their agencies. Families interested in

participating in the study were asked to return the postcard indicating their name, address
17

18

and the best time to contact them. A direct mailing was done by the Michigan chapter of
the Alzheimer's Association to individuals on their mailing list using the same card back
system. In addition, recruitment was enhanced by the use of local radio and television
spots and posted information about the study in local libraries and church bulletins.
Potential participants were then screened by data collectors to determine if they met the
eligibility criteria of the study.

The criteria for entry into the original study by caregiver/patient dyads included the
following: 1) the patient was at least 55 years old; 2) the patient was dependent in at least
one instrumental activity of daily living (IADL) and one activity of daily living (ADL); 3)
the patient had received a diagnosis of Alzheimer's disease or other progressive dementia:
4) the caregiver was self-identified as the family member providing the most care to the
relative with dementia; and 5) the patient with dementia was residing in the community at
the time of data collection. Participants were involved in the second wave of the original
study and all had completed the self-administered booklet.

Present Study

The gender samples (those meeting criteria) was drawn fiom the original
convenience sample and was small and fairly homogeneous. Inclusion in this study of
attitudes toward community service use included all of the original criteria, plus the
restriction that the caregiver is the care recipient's spouse and that the caregiver is 55 years
or older. By narrowing the inclusion criteria, control of extraneous variables was
attempted, though it limits the population to which the study can be generalized.
Requiring the patient to be living in the community and dependent in ADLs and IADLs
supports the reason for caregiving and the possible need to consider community resources.
Restriction to caregivers of clients with Alzheimer's disease or dementia and designation
as the primary caregivers attempts to control for the variable of whose attitudes are being
reflected, as the caregiver in this instance usually makes the decisions. By restricting

participation to a specific age group, a cohort influence may be introduced in attempting

19

to control for possible additional extraneous variables that could be introduced by
younger caregivers, such as employment, presence of young children and history.
Designating the relationship to the care recipient as spouse, generally controls for
variables of residence and attitudes based on marital vows.

Data Collection Procedures:

Ori ' Stud

Participants were informed that they would be participating in a longitudinal study
that would involve several encounters both by telephone and mail. They were told that
participation in the study was entirely voluntary and that they could withdraw at any point.
Confidentiality was explained to the participant and informed consent was signed.

The subjects enrolled at the second data collection point of the study participated
in an extensive telephone interview conducted by a trained research stafl‘ member.
Interview training procedures are described in Collins, Given, Given and King (1988). In
addition, each study participant completed the self-administered booklet containing the
Community Service Attitude Inventory (CSAI) which was mailed to them (Appendix A).
Present Study

The use of a secondary data precludes control over data collection procedures.
This researcher does not know the content of the interview format or what instructions
were given to the participants, in relationship to how they were to respond to the
statements on the CSAI, that could have influenced their responses. No mention of
respondent's literacy abilities was mentioned.

Prior to any data analysis, the University Committee on Research Involving Human
Subjects at Michigan State University approved the use of the identified sample for this
study (Appendix B).

Caution] Definition of Variables:
In this study attitudes towards community services are operationalized as scores on

the five sub-scales of the Community Service Attitudes Inventory (Collins, Stommel, King

20

& Given, 1991). Caregivers were asked to respond to 25 items that measured five
dimensions of attitudes toward community services derived from the research literature
and independent data accumulation. The five sub-scales of the CSAI measure: 1) concern
for the opinion of others (6 items); 2) confidence in the service system (8 items); 3)
caregiver preference for informal care (4 items); 4) belief in caregiver independence (4
items); and 5) acceptance of governmental services (3 items). Answers to the individual
items were recorded on a four-point Likert scale for scoring: l=strongly disagree,
2=disagree, 3=agree and 4=strongly agree.

Gender is operationalized as the sex (male or female) of the caregiver as indicated
in the original study data.

W
The instrument utilized to measure the concept of attitudes toward utilization of

community services was the CSAI, developed by Collins et al. (1991). It is a mmmated
rating scale composed of five subscales. Internal consistency of the subscales, the best
method of assessing the sampling of items which is a source of measurement error, was
evaluated by use of Cronbach's alpha and ranged fi'om 0.74 to 0.84. Specifically:
1)concern for the opinion of others (.84); 2) confidence in the service system (.78); 3)
caregiver preference for informal care (.78); 4) belief in caregiver independence (.74); and
S) acceptance of governmental services (.74). Reliability coeflicients usually range
between 0.0 and 1.00. In general, the higher the coefficient the more stable the measure
and, in practice, reliability coefficients greater than .70 are considered satisfactory for
group-level comparisons, thus the scales have an acceptable levels of internal consistency.

(Polit and Hungler, 1995).

21

Validity is the degree to which an instrument measures what it is supposed to be
measuring. The CSAI appears to have face validity in that the questions and categories of
the subscales appear to be related to the attitudes in question. This is only pertinent in that
the other types of validity, content, criterion-related and construct, have been
demonstrated. Content validity, concerned with the sampling adequacy of the content
area, was enhanced by the use of focus groups and intensive interviews with individual
caregivers to determine prevalent themes/attitudes and use of a panel of experts to analyze
the items for representativeness of the construct. Construct validity of the instrument was
tested by predicting a relationship between scores on the CSAI scales and two measures of
present and past service use of three specific community services (visiting nurses, home-
health aides, and adult day care). Predictions were based on: 1) the frequency of current
service use (within the 3 months prior to the interview), and 2) the number of these
services (0-3) ever used for the care of the individual with dementia. Construct validity of
the subscales was identified through use of principle component factor analysis followed
by a varimax rotation performed on the selected items (Collins, 1991). All items that met
the statistical criteria were firrther examined for theoretical fit with the subscales. The
formation of the five scales resulted fi'om these procedures. Interscale correlations were
low, ranging fi'om .11 to .38, suggesting that the scales reflect distinctive attitudes
(Collins, 1991; Polit and Hungler, 1995).

The final version of the CSAI is an easily administered, brief (25 item), self-
administered instrument using a four-point Likert scale that ranged fiom strongly agree (1)

to strongly disagree (4). Instructions for completing the instrument were given at the

22

beginning and included the caveat that the services considered should include visiting
nurses, home health aides or companions, adult day care or family support groups; not
hospitals, nursing homes, adult foster care or doctor visits. Examples of statements within
the subscales include: People outside my family would think less of me if I used services; I
would rather use community services that ask for help from family; and I believe in the

idea that families should care for their own and not ask for outside help (Collins, 1991).

Results

The findings described in this section are compiled fi'om the self-reported CSAI
questionnaires of 39 male and 80 female spousal caregiver subjects eligible for this study.
Tables showing sociodemographic and scale characteristics of the samples and tables
giving the results of the data analysis are included.
Sociflemgggphic Characteristics

This sample of caregivers, drawn from the original study of 182 subjects, were
predominantly white (96%), female (67%) and had at least a high school education (82%).
The majority of caregivers were unemployed (77%) and caring for a spouse with a
diagnosis of Alzheimer’s Disease (81%). The average household income was $25,858 and
the average caregiver age was 68.5 years. The average years of caregiving was more than
five years (Mean=5.5, SD=4.37). Table 1 presents the sociodemographic characteristics
of the combined caregiver sample, the male (n=3 9) and female (n=80) group samples and
results of significance testing (p<.05). Chi Square tests of significance between the male

and female samples revealed no significant difference in the composition of the two groups

23

on the variables of race, education, employment and caregiver recipient diagnosis. T-Tests

for the differences in mean caregiver age, income and duration of caregiving between the

male and female sammes revealed a significant difl’erence in the composition of the groups

in regard to age, p=.00. Male spousal caregivers were, on average, four years older than

female caregivers.

Table l - Demographic Variables for the Male and Female Spousal Samples

 

 

 

 

 

 

 

 

 

 

Caregiver Combined Male Female Sign. Test for
Characteristics Group Caregivers Caregivers Difference
(n=ll9) (t-teet or Chi-square)
p<.05
Gender 119 (100%) 39 (33%) 80 (67°@
Caregiver Age (yrs)
Mean 68.50 70.94 67.32 p=.00
SD 7.187 7.38 6.83
Race
White 114 (96%) 38 (97%) 76 (95%) p=.74
Non-white 5 (4%) 1 ( 3%) 4( 5%)
Education
Less than HS 22 (18%) 7 (18%) 15 (19%) p=.46
High School 78 (66%) 23 (59%) 55 (69%)
College/Higher 19 (16%) 9(23%) 10 (12%)
Employment
Employed 27 (23%) 11 (28%) 16 (20%) p=.31
Not Employed 92 (7 7%) 28 (72%) 64 (80%)
Household Income
Mean 25,858 29,529 24,125 p=.08
SD 14,971 17,837 13,194
Patient Diagnosis
Alzheimer’s Ds. 96 (81%) 32 (82%) 64 (80%) p=.30
Other 23 (19%) 7 (18%) 16 (ZW/i
Duration of
Caregivins (yrs)
Mean 5.45 5.40 5.48 p=.92
SD 4.37 3.46 4.77

 

 

 

 

 

 

24

Scale MIN—1'2. of the Mgle and Femalg Smusal SEEM
Subscale characteristics are presented in Table 2. Cronbach’ Alpha was utilized to

determine the internal consistency of the Community Service Attitude Inventory subscales.
Polit & Hungler (1995) describe alpha coefficients of 60-70 as adequate levels of
reliability when making group—level comparisons. The coefficient alphas of the subscales
for the original sample ranged from 74. to .84.

In the present study of the male and female spousal caregivers, the alpha
coefficients for the combined spousal sample was comparable to those of the subscales for
the original sample with a range from .71 to .79. Alpha coeficients for the male sample
ranged from .52 to .84; while the alpha coefi'rcients for the female sample ranged fi'om .68
to .79, a much more homogeneous grouping and again, comparable to the combined
sample and original sample ranges. The coeficient alpha for the subscale Concern for the
Opinion of Others was the highest for the female sample and one of the lowest for the
male sample (.82, .71). The coefficient alphas on the subscales Preference for Informal
Care and Belief in Caregiver Independence were the highest for the male sample (.84,
.82), while being the lowest for the female sample (.70, .68). This indicates that these
subscales have a high internal consistency reliability in measuring these attitudes and
beliefs for this male sample, while the low alpha coefficient (.52) indicates that the
subscale Acceptance of Government Services may not be a reliable measure. Though the
combined-sample group scale properties were fairly consistent with the original sample,
the exception of the subscale Concern for the Opinion of Others (.79 vs .84) the scale

properties for the male and female spousal samples exhibited a wider variability. This may

25

indicate that sample size, as well as gender may influence the coefficient alpha. The
original sample included caregivers who had relationships to the care recipient, other than
spousal; it may be that that factor also causes fluctuations in scale properties. These
fluctuations raise questions about the reliability of using the subscales on other population

samples.

26

Table 2 - Scale Characteristicsfor Samples: Caregiver Relationship and Spousal Gender

 

 

 

 

 

 

 

CSAI Subscales Scale Scale Cronbach’s Interitem
Mean“ SD Range Alpha Correlation
Concern for the Opinion
Total Original Sample 1.71 .41 10-40 .84 .47
Combined Sample
Spouses (n=113) 1.72 .36 10-27 .79 .39
Male 1.78 .33 10-27 .71 .30
Female 1.69 .37 l .0-2.7 .82 .43
Confidence in Service
Total Original Sample 2.77 .37 1.6-4.0 .78 .32
Combined Sample
Spouses (n=109) 2.76 .36 1.6-4.0 .78 .31
Male 2.64 .38 1.6-3.6 .75 .30
Female 2.82 .34 2.0-4.0 .78 .30
Informal Care
Total Original Sample 2.31 .50 10-38 .78 .47
Combined Sample
Spouses (n=111) 2.30 .49 1.0-3.8 .76 .44
Male 2.39 .52 1.3-3 .8 .84 .58
Female 2.24 .46 10-33 .70 .37
Caregiver Independence
Total Original Sample 2.25 .48 10-35 .74 .43
Combined Sample
Spouses (n=110) 2.26 .49 10-33 .75 .44
Male 2.45 .48 1.3-3.3 .82 .54
Female 2.19 .47 10-33 .68 .36
Government Services
Total Original Sample 2.96 .59 1.3-4.0 .74 .49
Combined Sample
Spouses (n=111) 2.97 .56 1.7-4.0 .71 .45
Male 2.85 .46 1.7-3.7 .52 .27
Female 3.03 .61 l .740 .75 .52

 

 

 

 

 

 

* Likert Scale: 1=strongly disagree 2=disagree 3=agree 4=strongly agree
(higher mean scores indicate increased belief in dimension of attitude)

 

27

Interscale correlations for both samples were computed to test the degree of
relationship between the individual subscales (Tables 3 & 4). Directional changes in the
correlations are noted between the two samples with absolute difference ranges from .06
to .64. For example, in the male caregiver sample Concern for the Opinion of Others and
Acceptance of Governmental Services are positively correlated (.27), while in the female
caregiver sample they are negatively correlated (-.37). Differences in subscale correlations
between the male and female spousal caregivers appear to reflect variations based on
gender. The male sample showed a more negative correlation between Belief in Caregiver
Independence and Confidence in the Service System than did the female sample, while the
female spousal sample reflected a strong negative correlation between Acceptance of
Government Services and Belief in Caregiver Independence. These findings suggest that
the attitude structure between the two groups may be different.

Ranges for the male caregiver sample were fiom -.62 to .35. For the female
caregiver sample, correlations ranged from -.52 to .48. Despite the directional
differences, moderate correlations in the male samfle subscales Belief in Caregiver
Independence and Confidence in Service System (-.62) and the female sample subscales,
Belief in Caregiver Independence and Acceptance of Governmental Services

(-.52) and Belief in Caregiver Independence and Preference for Informal Care (.48), the
over-all low interscale correlations suggest that the subscales do represent distinct
attitudes and supports the use of the separate subscale scores to reflect individual attitudes
rather than the use of the total C SAI score. Low interscale correlations were found with

the original sample (Collins, 1991).

28

Table 3 - Interscale Correlations of Male Spousal Caregiver Sample

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subscale: Concern Confidence Informal Independence Gov’t

- in Services Care Services
Concern for the -.39 -.00 .35 .27
Opinion
Confidence in; Services -.08 -.62 .08
Informal Care .16 -.14
Independence -. 12
Government Services
Thhle 4 - Interscale Correlations of Female Spousal Caregiver Sample
Subscalel Concern Confidence Informal Independence Gov’t

in Services Care Services

Concern for Opinion -.33 .23 .30 -.37
Confidence in Services -.36 -.35 .22
Informal Care .48 -.28
Independence -.52
Government Services #

 

 

 

 

 

 

Qmm’ n 2! Meg Dfl‘ erencg on Attitude §um
Two-tailed t-tests were utilized to test the significance of the differences between

the male and female spousal caregiver samples on the five attitude subscales of the CSAI

(see Table 2 for Means and SD. by subgroup) and were verified by an Analysis of

Variance (Table 5). Statistically significant (p<.05) differences between the male and

 

 

female sample groups were found in attitudes related to Confidence in the Service System
@011) and Belief in Caregiver Independence (p=.008). Significantly more male spousal
caregivers held the belief of caregiver independence than female caregivers (mean=2.45 vs
2.19); they also had significantly less confidence in the service system (mean=2.64 vs

2.82). Though not statistically significant, the subscale means of the male spousal

29

caregivers suggested more agreement with the attitudes, Concern for the Opinion of
Others (mean=l .7 8 vs. 1.69) and Preference for Informal Care (mean=2.39 vs 2.24) and
less belief in Accepting Government Services (mean=2.85 vs 3.03) than the female

caregiver sample.

Table 5 -Analysis of Variance: Subscale Scores by Spousal Gender

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source of Variance Sum of Mean F-

Squares df Squares F- probability
ratio

Concern for

Opinion of Others

Between Groups .1752 1 .1752 1.3500 .25

Within Groups 14.4038 111 .1298

Total 14.5790 112

Confidence in the

Service System

Between Groups .8207 1 .8207 6.6565 .01

VVrthin Groups 13.1921 107 .1233

Total 14.0128 108

Preference for

Informal Care

Between Groups .5206 1 .5206 2.2806 .13

\Vrthin Groups 24.8792 109 .2282

Total 25.3998 110

Belief in Caregiver

Independence

Between Groups 1.7019 1 1.7019 7.6073 .01

VVrthin Groups 24.1611 108 .2237

Total 25.8629 109

Acceptance of

Government Services

Between Groups .7787 1 .7787 2.4531 .12

\Vrthin Groups 34.6002 109 .3174

Total 35.3789 110

 

 

3 1
Ana_lysis of Covariance

ANCOVA was computed next to test for the significance of differences in group
means after first adjusting the scores on the dependent variables to control for the effects
of age. Age was chosen as the covariate because of a significant difi‘erence was noted in
the age composition of the male and female spousal samples with male caregivers being
older that female caregivers. In addition, chronological age groupings have been shown to
produce a cohort effect, theoretically influencing beliefs and attitudes. Further supporting
the data from the t-tests and Anova, review of the subscale Confidence in the Service
System shows that after controlling for the effects of age, the group/ gender efl‘ect (main
effect) remains significant at the .028 level; the subscale Belief in Caregiver Independence
data indicates that the group/ gender effect is significant at the .005 level.

The focus of this study and specific research question was " Are there differences
in attitudes towards utilization of community services between elderly male and female
spousal caregivers?" Gender differences in attitudes towards utilizing community services
was demonstrated among husband and wife caregivers with regard to a belief in caregiver
independence and attitude of confidence in the service system. No gender difl‘erences with
regard to a concern for the opinion of others, a preference for informal care or of

accepting governmental service were demonstrated.

32

Table 6 - Analysis of Covariance: Subscale Scores for Gender with Age as a Covariate

 

Source of Variance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sum of (If Mean F-ratio F-
Squares Squares probabilig
Concern for
Opinion of Others
Covariate-Age .223 1 .223 1 .695 . 196
Main Effect-Group .319 l .319 p 2.419 .123
Explained .444 2 .222 1.686 . 190
Residual 13.574 7 103 .132
Total 14.018 105 .134
Confidence in
Service System
Covariate-Age .012 l .012 .100 .752
Main Efl‘ect-Group .608 1 .608 4.977 .028
Explained .612 2 .306 2.507 .086
Residual 12.572 103 .122
Total 13.184 105 .126
Preference for
Informal Care -
Covariate-Age .822 1 .822 3.822 .053
- Main Effect-Group .667 1 .667 3.104 .081
Explained 1.217 2 .609 2.831 .064
Residual 22. 149 103 .215
Total 23.366 105 .223
Belief in Caregiver
Independence
Covariate-Age .009 1 .009 .040 .843
Main Efi‘ect-Group 1.857 1 1.857 8.093 .005
Explained 1.904 2 .952 4.149 .018
Residual 23.635 103 .229
Total 25.539 105 .243
Acceptance of
Government Services
Covariate-Age 15080 1 1 .080 3.43 5 .067
Main Effect-Group .214 1 .214 .679 .412
Explained 1.590 2 .795 2.530 .085
Residual 32.378 103 .314
Total 33.969 105 .324

 

 

33

Discussion

Methodolgn’cal Limitations

Generalization of these research findings to the clinical setting should be exercised
with caution. The use of spousal gender samples, drawn fi'om the convenience sample of
the original study, resulted in a small, non-randomized selection of participants which
limits the usefulness of study results. The original sample consisted of a group of
individuals who had been caregivers for a length of time, were motivated to respond to a
request to participate in the study and/or who were already receiving services and were
referred to the study. With this bias, they do not represent the entire p0pulation of
caregivers. The homogeneity among the sample subjects limits generalizability of findings
to only those with similar characteristics and who meet similar inclusion criteria.
Restricting the caregiver/recipient dyad to 55 years or older may be producing a cohort
efi‘ect, where the results are not applicable to younger dyads. Probability or random
sampling would have been the preferred method to use in this study because it would have
increased the variability with the population of caregivers, a larger sample would have
allowed for broader use of and interpretation of study findings, and while gender may
influence some attitudes towards utilization of community services in this study, a larger,
more heterogeneous population may demonstrate difl‘erent findings.
Instrument Limitag'ons

The CSAI represents an initial attempt to measure one aspect of the complex issue
of understanding the use of community services by caregivers of individuals. Initial

analysis of the psychometric properties of the scales revealed adequate reliability and

34

content validity of the instrument, however further testing is needed. As of this date, the
CSAI has been used with a minimal number of caregiver samples. Further testing in
clinical settings with more heterogeneous samples of caregivers, including: individuals in
different geographical regions, at different stages of caregiving, of different ethnic and
cultural backgrounds, of different age cohorts, of various relationships to the care
recipient and caregivers of clients with different mental and physical disabilities, would
increase the reliability and validity of the instrument and would increase the
generalizability of the results obtained. As there have been no previously developed scales
to measure attitudes that caregivers may have regarding use of community services,
equivalence studies for reliability could not be performed, this also points out that though
the instrument is standardized, there are no norms by which to compare the sample
measurements. The variability in subscale characteristics between sample groups may
limit interpretation of study findings.
Interpretation of Finding

Both the combined sample mean and the mean scores of the male & female
spouses do not support the attitudes identified in the ancedotal and qualitative literature on
attitudes toward caregiving among dementia caregivers in general (King, Collins and
Liken, 1995, Bass et al, 1994, Collins, King, Given & Given, 1994). Spousal caregivers
held less of a belief in the opinion of others as to who should be providing care; less of a
belief in caregiver independence from the service system; agreed with the attitude of
confidence in community services; agreed with the attitude of accepting governmental

services; and did not agree with the attitude of preferring to utilize assistance from

35

informal caregivers rather than formal services when there was need. While the data for
this sample does not reflect the dementia caregiving attitudes previously mentioned; it
does support the findings of other studies of elder spousal caregivers in which both male
and female caregivers relinquish some measure of independence, privacy and pride as
these concerns become of secondary importance to providing care for an increasingly
dependent spouse (Stoller & Cutler, 1992; Stommel, Given & Given, 1990). The attitudes
held by this sample may reflect those of elderly caregivers later in the caregiving process
(mean=5.45 yrs), when the needs for assistance exceed their capabilities. The indication
of a lack of preference for informal care may reflect the elder spouses’ desire not to
become a “burden” to their children or friends without the ability to “repay” them
(reciprocity). Thus the expression of confidence in the service system and the
acceptability of governmental services and the use of services might minimizes the
psychological consequences of needing and receiving care, of retaining some measure of
control because the dyad is “paying for” or “entitled to” the assistence (Stoller & Cutler,
1992)

Findings from this study indicate there may be gender differences in attitudes
towards utilizing community services. Although statistically significant differences were
demonstrated among husband and wife caregivers only with regard to a belief in caregiver
independence from the service system and the attitude of confidence in the service system,
mean differences on the subscales with regard to a concern for the opinion of others, a
preference for informal care and of accepting governmental services also suggest a gender

influence on attitudes for this spousal sample, controlling for relationship differences.

36

Differences were found and could be related to gender-based belief/attitudes within
the context of the marital relationship. Findings would appear to support the work of
those researchers who found the a spouse’s role as caregiver was based on gender
attitudes and role enactment beliefs, especially for the male spouse. Miller (1987) found
that when an elderly spouse cared for a cognitively impaired mate, the dominant pattern
appeared to be congruent with previous role behavior.

Male spouses in this study were more likely to support the belief in caregiver
independence. This may reflect the traditional attitude/belief held by men that they are the
providers and protectors of their families; responsibile for and in control of the situations
in which they may find themselves. Gender socialization provided the expectation that
males be self-reliant, competent and to keep their weaknesses hidden (Robertson, 1987, p.
324); upholding the male spouses’ need for independence and reluctance to ask for
assistance. Caring for an impaired spouse may reflect study findings that men become
more family oriented and nurturant as they age and the demands of the caregiving role are
in harmony with the needs of men (Gutman, 1994; Sheehy, 1994; Miller 1987). Assuming
authority and management over dependent wives would be an extension of the husband’s
role as authority figure in the family and reinforces a sense of control in the home through
attritubes such as organization of resources, problem-solving and authoritative decision-
makingrerniniscent of the workplace. This explanation can be supported by the data that
shows male spouses exhibit less confidence in the service system than do female spouses
(means=2.64 & 2.82). The male spouse may feel a lack of trust and a loss of

control/autonomy/authority over the care of his spouse when dealing with community

37

service personnel; he may have the expectation they will not honor his decisions or follow
his directions.

In looking at the statistically significant data from the female spouse perspective,
less of a belief in caregiver independence than men may reflect study findings that indicate
after the post-parental years a change in the acceptance of total obligation/responsibility
for the care of another occurs on the part of women as they become more active/assertive
in roles outside of family/home (Gutrnan, 1994; Sheehy, 1994). Exhibiting more
confidence in the service system than men possibly reflects an increased acceptance of the
need for assistance to supplement their care in providing for a spouse’s needs in order to
provide for their own. Therefore, the significant differences between the male and females
subjects in this study may be pertinent to understanding the attitudes toward utilization of
community services.

Variations of these findings, reflective of the variations in the subscale
characteristics, might also be found in other caregiver-care recipient dyads based on
gender/relationship (i.e. children vs spouse or daughters vs sons). For example, a spouse
may have a different set of attitudes/beliefs than adult children; a wife’s belief in the
caregiving role may difi‘er from a daughter’s attitude, a son’s attitude may vary from a
husband’s. Therefore, the influence of gender may be confounded by the caregiver-care
recipient relationship as it reflects various attitude/beliefs and role expectations held by the
caregiver.

The Theory of Reasoned Action was developed by Azjen & Fishbein (1980) as a

means of understanding and predicting behavior. The premise states that external

38

variables (i.e. personality characteristics, demographic variables and social
values/perceptions) influence beliefs/attitudes which may result in the intention to perform
a behavior. In this sample of caregivers, the demographic characteristic of gender, in the
context of a spousal relationship, appeared to influence the strength of the beliefs/attitudes
toward utilizing community services. The decision to utilize services is influenced by a
variety of variables, (i.e. cost, availability, need, knowledge of services, social and cultural
expectations); the model is useful in that it allows for the wide range of caregiver/care
recipient characteristics that would influence and confound beliefs/attitudes when used in
the study of other p0pulations. The model illustrates the interactions/possible interactions
between the external variables and their relationship to beliefs and attitudes; it does not
demonstrate the degree of influence between the concepts. Though presented in a linear
fashion, the model would further explain the relationship between attitudes, the intention
to perform the behavior and the actual performance of the behavior if a “feed-back” loop
between behavior and attitude toward the behavior was included. An experience with
performing the behavior, resulting in either a positive or negative result, can influence
attitudes toward performing the behavior a second time.
Implications for Advanced Nursing Practice and Prima_r1 Care

Evaluating research findings for applicability in clinical practice by the APN
requires a comparative evaluation of the appropriateness of its applicability to her/his
practice. According to Stetler and Marram (197 8), this involves determination of
substantiating evidence of the study results; the fit of setting and client population; the

feasibility of implementing the findings in terms of resources and legal/ethical issues and

39

evaluation of the basis for practice in terms of the theory behind and effectiveness of
current intervention strategies and proposed changes. Based on these determinations,
decision-making occurs. The APN may choose not to apply the study findings to practice;
or to apply the findings in a direct manner, as evidence for change, as a catalyst for the
evaluation of current practice or as a model for action. The APN may choose to apply the
findings in a cognitive manner, utilizing the findings of the study to enhance understanding
of various situations, to analyze the dynamics of practice and/or add the information to
her/his theoretical approach to nursing. Due to the limitations of the present study, the
APN may choose to apply the findings in a cognitive manner, adding to a theoretical basis
of nursing practice and increasing a knowledge base concerned with gender, caregiving,
dementia and attitudes toward the utilization of community services.

In view of the growth and vulnerability of the elderly population in regard to
dementia, the Advanced Practice Nurse (APN) will need to identify and define her/his role
within the health care delivery system in dealing with the issues presented by the elders
and their family/support group. The APN, fimctioning in the roles of advocate,
clinician,counselor/collaborator, case manager, educator and consultant, can be effective in
influencing the provision of care to a demented patient and in supporting the health and
well-being of the caregiver on an individual basis, as well as in developing and supporting
eflicient, cost efl’ective services at the community level .

Recognition and understanding of any gender differences in attitudes toward
caregiving and utilization of community services may assist the APN in developing

strategies to promote the most appropriate and acceptable care for both male and female

40

spousal caregivers. This study indicated that there were gender difl’erences in attitudes
concerning confidence in the service system and caregiver independence fi'orn that service
system: suggesting that male spousal caregivers might be less likely to utilize community
services and had less confidence in the services than female caregivers. This type of
information can be utiliwd to identify barriers to service utilization and guide the APN’s
counseling and advocacy efforts in referring to available services. Recognition that men
may be less receptive to utilia'ng community services, especially those that meet the needs
of the female caregiver, is. emotionally-based support groups vs. task-skill classes, would
permit change to occur, encourage development of new/acceptable services promoting
both caregiver/care recipient well-being and support the caregiving process/relationship.
Utilizing the C SAI with individual clients entering into or involved in a caregiving
situation would enable a APN and the caregiver an insight into attitudes/beliefs that can
influence their decisions and behaviors and ultimately affect the effectiveness of the
caregiving and the health and well-being of the dyad. A caregiver who resists asking for
assistance or utilizing service to the detriment of his/her own health, as well as the well-
being of the care recipient, may strongly believe in being or maintaining independence
from the system; feel a personal responsiblity for the care; have little confidence in or had
bad experiences with the service system; or feel pressured by perceived family and/or
societal expectations to be responsible for the care. Reducing the twenty-five questions
into a shorter, more open-ended assessment too] would provide more individualized
responses. For instance, one could ask: Are you planning on caring for your spouse by

yourself (Independence)? Ifyou need assistance who would you ask to provide it

41

(Informal or Formal Services)? How do you feel about using the community services
available in terms of competence, trust and safety (Confidence)? Understanding of these
attitudes, along with knowledge of the other factors that may be affecting caregiving
decisions, allows the APN information with which to develop strategies for intervention
and support that would be appropriate and acceptable to the client within hiscaregiving
fiamework. Based on the information gathered, the APN can reconsider any past gender
bias in regard to attitudes toward caregiving based on stereotypical gender characteristics
that could influence the provision of services and educate others in this area to promote a
more realistic and acceptable plan of assistance.
Recommendations for thugg Research

The limitations of methodology found in this study and the original study fi'om
which it was taken, reflect the problems which plague the majority of caregiving research:
those related to utilizing small, homogeneous, non-randomized samples. Participants in
this study were spouses, over the age of 55 years, middle-class and predominantly white;
other relationship dyads and younger cohorts were excluded from the study for control
purposes and other racial and ethnic populations were not adequately represented.
Further research, with larger samples, for gender difi‘erences in attitudes toward utilization
of community services among all these groups may provide useful information. The
average length of caregiving duration in this study was approx. 5 years and some of the
respondents in the sample were already utilizing community services. A longitudinal study
of caregivers attitudes toward utilizing services following a population from the beginning

of the experience, (before services were needed), through to the end, (the death or

42

institutionalization of the care recipient), may provide a better understanding of attitude
difl‘erences based on gender, other variables and changes over time.

Research into the effect of gender differences on various issues in caregiving is
vast and covers a wide assortment of variable combinations, caregiver distress, burden,
type and number or tasks performed, utilization of services. Most examine how the
components of caregiving vary by gender but pay little attention to the structural or
cultural context influencing the difl’erences. The meaning or significance of gender may
change in different cultures or at different points in the caregiving experience. Further
research needs to examine the role that gender socialization /role expectations play in
assigning meaning to the caregiving experience and how the persistence of these
expectations continue to influence the behaviors and decision-making of caregivers, older
persons, practitioners and policy makers. Research is needed to examine possible
differential effects on men and women of policies directed towards development of health

care services, home health care and caregiver support services.

APPENDIX A

43

Appendix A

Community Service Attitude Inventory

CSAI Subscales
Concern for the opinion of others
People outside my family would think less of me if I used services.
My family would think less of me if I used services for my relative's care.
My family prevents me from using services for my relative.
Families should not use community services to care for a relative with
Alzheimer's disease.
I do not want others to know my relative has Alzheimer's disease.

My family supports my use of community services.

Confidence in the service system
People fi'om community services can take care of my relative as well as 1 can.
I am fearfirl of having people from community services take care of my relative.
I trust people from community services to take care of my relative.
People from community services would follow my directions in caring for my
relative.
It is hard to trust someone from community services to take care of my relative.
People from community services might be better at caring for my relative.
I worry about my safety when someone else is takinfg care of him/her.

Community services might have better ideas about caring for my relative.

Preference for informal care
I would rather use community services than ask for help from my family.
I would rather use community services than ask for help fi'om fiiends.
I would rather ask my farme for help than use community services.

I would rather ask my fiiends for help than use community services.

Belief in caregiver independence
I am proud of being able to care for my relative with little help from community
services.
I believe in the idea that families should care for their own and not ask for outside
help.
I think I should care for my relative without help from community services.

I feel good about using community services to help care for my relative.

Acceptance of government services
It is not the government's responsibility to help me find ways to care for my
relative.
I would use more services if the government would provide more assistance.
I believe the government should support more community sevices to help

families care for persons at home.

APPENDIX B

 

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RESEARCH
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45

 

Appendix B
MICHIGAN STATE
LI hi I \I E I! S I 'r Y
W: 25. use
ro: Clare Collins
A-129 Life Sciences
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RIVISIOI IIOUIITID: KIA
CIIEGOIY: l-I
APPROVAL DASI: 11/22/96

The Universit Con-uttee on Research Involving uueen Subjects'IUCRI351
review of thi: project is complete. I an pleased to advise that the

rights

pggtected
refore.

above.

PIOILIII/
m:

and welfare of the huean subjects appear to be adequately
and cathode to obtain infer-ed consent are appropriate.

the 0:113! approved this project and any reVisions listed

UCRIHS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators p to

continue a project be one year must use the green renewal
fore (enclosed with t original e rovel letter or when a
project is renewed) to seek te certification. There is a

maximum of four such expedite renewals possible. Investigators
wishingoto continue a proaect beyond that time need to submit it

again r coeplete revaew.

0:318: must review any changes in procedures involving hunan
subjects. rior to initiation of t e change. If this is done at
the_tine o renewal. please use the green renewel form. To
revise an approved protocol at an other time during the year.
send your written request to the, 185 Chair. requesting reVised
approval and referencing the project's IR) 0 and title. Include
in your request a description of the change and any revised

ins runents. consent for-s or advertise-once that are applicable.

Should_either of the following arise during the course of the
work. lbfllltlg‘tOtI oust noti UCRIhs promptly: (1) roblems
(unexpected side effects. coup eints. etc.1_involVing unen
subjects or-(2) changes in the research enVironment or new
information indicating greater risk to the hu-en sub ects than
enisted when the protocol was previously reviewed and approved.

If we can he of any future h.1§i please do not hesitate to contact us

at (517)355-2180 or FIX (517l4

Sincerely.

71.

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Ikneuaune-I
Ill-heels '
(m1 David E . Wright h. D .
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