1. family and parenting
2. eldercare

Copyright 1997 by
The Cemntological Society of America
The Cerontologist
Vol.37, No.2, 218-232
This critical review of 29 studies published through 1996 on the gain experienced among
informal caregivers of older adults, identifies 13 conceptual (i.e., definitions and theoretical
frameworks) and methodological (i.e., sampling, design, measurement, analysis) observations.
Key limitations of prior research are highlighted and recommendations necessary for
the advancement of research in this area of inquiry are made. Drawing upon relevant
theoretical frameworks and the observations noted in this review, a conceptual framework is
proposed to bring some consistency to the ways in which future research
on positive aspects of caregiving proceeds.
Key Words: Family caregiver, Elderly, Well-being, Satisfaction, Benefits
Gain in the Caregiving Experience:
Where Are We? What Next?1
Betty J. Kramer, PhD2
1
The author gratefully acknowledges the comments of Aaron M. Brower,
Jan S. Greenberg, Nadine F. Marks, Marsha M. Seltzer, and the anonymous
reviewers on earlier drafts. This is article no. 95-19 from the Madison
Veterans Administration, Geriatric Research, Education and Clinical Center
(GRECO.
Assistant Professor at the University of Wisconsin-Madison. Address all
correspondence to Betty J. Kramer, PhD, University of Wisconsin-Madison,
School of Social Work, 1350 University Avenue, Madison, Wl 53706.
218
have been reported in the social-psychological literature (Ryff, 1989a; 1989b).
The focus on detrimental caregiving consequences is somewhat consistent with the long trend
in social science research to focus on general measures of psychological dysfunction (e.g., depression,
lack of health, anxiety). Ryff and Keyes (1995, p. 719)
noted that "prior endeavors have grappled minimally
with the core underlying question: What does it
mean to be well psychologically?" Drawing upon
literatures from developmental psychology, clinical
psychology, and mental health, Ryff (1989a; 1989b)
developed six distinct dimensions of more positive
contours of well-being that include personal growth,
purpose in life, autonomy, environmental mastery,
positive relations with others, and self-acceptance.
Recent structural analysis, using a nationally representative sample, provided support for this 6-factor
model, and extensive research has demonstrated
that these well-being dimensions possess distinguishing age trajectories (Ryff & Keyes, 1995), gender
profiles (Ryff, 1989b; Ryff, Lee, & Na, 1993; Ryff, Lee,
Essex, & Schmutte, 1994), and cultural profiles (Ryff
etal.,1993).
This discussion of more positive psychological
functioning is raised because the field needs a
wholesale rethinking about caregiving experiences
and outcomes to include positive aspects of caregiving and positive indicators of well-being. Clearly,
there is more to mental health than the absence of
pathology, and people experience both positive and
negative emotions. Lack of attention to the positive
dimension of caregiving seriously skews perceptions
of the caregiving experience and limits our ability to
enhance theory of caregiver adaptation. In recent
years, there have been numerous calls to take a more
holistic view by considering positive aspects of caregiving and the ways in which these differ from burden in their correlates and predictors (Greenberg,
The Gerontologist
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The primary thrust of caregiving research over the
past two decades has centered on the negative and
detrimental aspects of the caregiving process. Investigations have been driven by the desire to understand variations in caregiver adaptation so that interventions and policies may be designed to enhance
well-being. While early investigations focused primarily on the study of caregiver burden as a means to
this end, George and Cwyther (1986) compelled the
field to use indicators of well-being, citing their advantage of tapping multiple dimensions and of being
conceptually distinct to caregiving, thus allowing for
noncaregiver comparisons. Since that time, the caregiving literature has seen an expansion in the use of
multidimensional outcome indicators such as depression (Haley, Levine, Brown, Berry, & Hughes,
1987; Pruchno & Resch, 1989), affect (Franks &
Stephens, 1992; Lawton, Moss, Kleban, Glicksman, &
Rovine, 1991), health (Franks & Stephens, 1992; Killeen, 1990, Young & Kahana, 1989), life satisfaction
(Guerriero-Austrom, & Hendrie, 1992; Wallhagen,
1992; Wright, Lund, Caserta, & Pratt, 1991), and social life (Stull, Kosloski, & Ketcher, 1994). This line of
inquiry has enhanced understanding of the challenges facing family caregivers to older adults with
cognitive and physical impairments and has led to a
proliferation of intervention studies designed to reduce caregiver stress (Toseland & Rossiter, 1989). A
striking omission in this research is of attention to
positive psychological functioning and the rich array
of theoretically grounded well-being indicators that
practical, methodological, and theoretical relevance.
The term "gain" will be used to refer to the more
positive appraisals of the caregiving experience.
While strain (or burden) has been defined as "the
extent to which the caregiving role is judged to
infringe upon an individual's life space and be oppressive" (Montgomery, 1989, p. 204), gain may be
defined very broadly as the extent to which the
caregiving role is appraised to enhance an individuals' life space and be enriching. Gain may include
any positive affective or practical return that is experienced as a direct result of becoming a caregiver. As
such, a distinction must be made between gain that is
a specific referent to the caregiving role, and psychological well-being that may be influenced by, but is
potentially independent of, the caregiving experience. The purpose of this article is to critically review
the literature that examines gain associated with
caregiving. With particular attention given to conceptual and methodological issues, the intent of this
review is to examine how gain has been studied, to
identify what has been learned in the process, and to
put forth recommendations necessary for the advancement of research in this area of inquiry.
Literature Review
A computerized literature search was completed
that extended back to 1974 using the following data
bases: Social Science Citation Sociological Abstracts,
Social Work Abstracts, Dissertation Abstracts, Cumulative Index to Nursing and Allied Health Literature
(CINAHL), Medline, and Psych Lit. As discussed
above, gain was defined broadly to include any positive affective or practical return that resulted from
caregiving. Key terms used to identify gain included
variations of the following: benefits, rewards, satisfactions, gratifications, gains, pleasures, enjoyment,
uplifts, and positive aspects. Given the relative lack of
attention to this area of inquiry, all efforts were made
to first identify any and all manuscripts that included
the topic of caregiver gain. A total of 47 studies were
identified. The following criteria were then developed to select research articles for this review:
1. Study participants were providing assistance in
one or more activities of daily living (ADLs) or
instrumental activities of daily living (lADLs);
2. Care receivers were community-dwelling older
adults with cognitive, emotional, or physical impairments;
3. Sufficient detail was provided so as to allow for
replicability of the study;
4. Data were generated beyond descriptions or anecdotal reports of gain; and
5. Attempts were made to analyze the relationship
between gain and other variables within the caregiving context.
Using these criteria, 29 studies were analyzed and
are presented in alphabetical order in Table 1. As
shown in this Table, the vast majority of studies have
been published since 1988, reflecting a very recent
and persistent surge of interest in the study of caregiving gain during the past decade.
Because both theory and research on positive aspects of caregiving are still in their developmental
stages, a review of the literature permits description
of the trends in this investigative area that have
Vol. 37, No. 2,1997
219
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Seltzer, & Greenley, 1993, Kramer, 1993a; 1993b;
Miller, 1989; Motenko, 1989; Stephens, Franks, &
Townsend, 1994). Indeed, the benefits of providing
care for persons with a variety of illnesses such as
AIDS (Ferrari, McCown, & Pantano, 1993; Wardlaw,
1994), schizophrenia (Bulger, Wandersman, & Goldman, 1993), traumatic brain injury (Allen, Linn, Gutierrez, & Wilier, 1994), developmental disabilities
and mental illness (Greenberg et al., 1993) are beginning to surface in the literature.
Why is it important to investigate positive aspects
of caregiving? First, it is an aspect of care provision
that is reported by many caregivers and one that
caregivers seem to want to talk about. Recognition of
positive experiences in caregiving initially surfaced
from anecdotal and qualitative reports of caregiver's
who indicated that giving care increased their feelings of pride in their ability to meet challenges,
improved their sense of self-worth, led to greater
closeness in relationships, and provided an enhanced sense of meaning, warmth, and pleasure
(Archbold, 1983, Motenko, 1988; Reese, Walz, &
Hageboeck, 1983). In a recent qualitative study, 90%
of the 94 caregivers interviewed reported that they
valued positive aspects in caregiving (Farran, KeaneHagerty, Salloway, Kupferer, & Wilken, 1991). Second, understanding positive aspects of caregiving
may help clinicians and practitioners to work more
effectively with the family caregiver. This may be
accomplished by improving both assessment and
intervention methods once predictors of positive
outcomes are identified via research. Research may
provide clues as to how to enhance or increase
positive aspects of care provision or may identify
caregivers who are less likely to need intervention.
By recognizing the ways in which individuals feel
enriched by caregiving, professionals may more appropriately validate feelings and experiences. Clinicians have voiced concern that a preoccupation with
burdens and problems "empowers the problem and
disempowers the person" (Graber & Nice, 1991, p.
3). Attention to positive aspects is consistent with a
strengths perspective that recognizes the capacity
for continued growth in each individual (Weick,
Rapp, Sullivan, & Kisthardt, 1989). Third, positive
aspects of caregiving may be important determinants
of the quality of care provided to older adults, which
has to date received minimal attention (Orbell &
Gillies, 1993a). Finally, an important potential contribution of this line of inquiry is to provide information
to enhance theories of caregiver adaptation and psychological well-being. It is somewhat surprising that
theoretical perspectives have neglected to take positive experiences into consideration (see Biegel,
Sales, & Schulz, 1991, for a review) given that the
positive dimension of caregiving has the potential to
improve understanding of the variability found
among caregivers in other enduring outcomes (Lawton, Rajagopal, Brody, & Kleban, 1992).
ore
©
n
©
M = 77;
dementia
49-92; M = 72;
dementia
Cohen, Gold,
Shulman, &
Zucchero (1994)
Farran,
Keane-Hagerty,
Salloway,
Kupferer, &
Wilken (1991)
Elderly; not
specified
Brody, Litvin,
Hoffman, &
Kleban (1992)
M = 77;
dementia
M = 77; stroke
dementia and
cardiovascular,
muscular,
skeletal, and
gastrointestinal
disorders
Braithwaite
(19%)
Cohen, Gold,
Shulman,
Wortley,
McDonald, and
Wargon (1993)
M = 81; not
specified
Albert (1992)
Author(s)
Care
Receiver
Age&
Diagnosis
N = 94; 66% spouses, 27% adult
children, and 7% other; 81%
Caucasian; middle and
upper-middle socioeconomic
status; ages 30-78, M = 61;
recruited from community
agencies, the Alzheimer's
Association, media
announcements, and the Rush
Alzheimer's Disease Center
Caregivers asked to report aspects
of caregiving they enjoyed; coded
into 6 categories, then treated as
single item, continuous variable
from no enjoyment to multiple
categories of enjoyment
How caregivers
grow and find
meaning through
the caregiving
experience
Open ended questions that
elicited information on positive
aspects of caregiving included:
what are the most pleasant aspects
of caregiving?, what keeps you
going or gives you hope?, what are
the good things in your life?;
verbatim and summary comments
were recorded
Enjoyable aspects Number of enjoyable aspects
of being a
reported; see Cohen et al. (1993)
caregiver
N = 1%, 59% spouses, 27% adult
Enjoyment of
children; M age = 64; 76% women caregiving
N = 196 caregivers recruited from
medical and community social
agencies; 57% spouses, 26% adult
children; 17% other relatives;
M age = 64; 76% women
Four items identified via factor
analytic techniques (i.e., being
appreciated, being care receiver's
confidant, knowing there would
be things missed if caregiving
ended, and having asked for and
received help in the past); alpha
not specified
Caregiving Satisfaction Scale (see
Lawton et al., 1989); used 7 items
rather than 5; alpha = .86
Measurement
Approach
Caregiver
Caregiving Satisfaction Scale (see
satisfaction in the Lawton et al., 1989); alpha = .92
caregiving role
Positive aspects
are appraisals
seen as mutually
rewarding which
reflect intimacy
and love
N = 144 Australian caregivers
recruited from adult day cares and
community home health care
agencies; 75% female; 86%
co-residing with care receiver;
M age = 58; 43% spouses; 51%
adult child; 6% other
N = 492 daughters; 69%
co-resided with their parent; 84%
Caucasian; care receivers were
spouseless; recruited from public
media, work place or religious
organizations, and word of mouth
"Caregiver
satisfaction taps
the pleasures
and rewards of
caregiving" (p.
702)
Definiton
of
Gain
N = 214 persons caring for parent
or in-law; drawn from the
Philadelphia Geriatric Center's
caregiver registry; 92% female;
56% co-residing
Sample
Characteristics
Table 1 . Summary of Studies on Caregiver Gain
Appraisal dimensions identified have parallels in
work of Lawton et al. (1989; 1991); greater intimacy
and love correlated with less negative affect, more
positive affect, more affect balance, and fewer minor
psychiatric symptoms
Although differences across marital status categories
of daughters were found for caregiver and parent
characteristics, and multiple indices of caregiver
well-being, no difference in caregiver satisfaction
across marital status categories were reported
Number of enjoyable aspects associated with
decision to place relative in a nursing home, but not
related to actual placement in nursing home
55% listed at least one enjoyable aspect of carenumber of enjoyable aspects correlated with lower
burden, better health, better prior relationship
quality, more satisfaction with social support, higher
incomes, and fewer negative reactions to care
receiver problems; those caring for females
reported more enjoyable aspects of care
90% of respondents reported "Valuing Positive
Aspects" of caregiving; in another subcategory
called "Searching for Provisional Meaning,"
caregivers reported that they were growing and
finding meaning through the experience of
caregiving; valuing positive aspects was not
correlated with any of the quantitative measures;
search for provisional meaning was associated with
higher levels of social support
Utilized Lawton
and colleagues
(1989; 1991)
conceptualization
of subjective
variables as
appraisals
Not specified
Not specified
Not specified
Existentialism
and a model in
which stages,
responses, and
phases of
suffering are
proposed to
assist caregivers
to find meaning
and grow
(continued on next page)
Satisfaction correlated with thinking of obligation in
communal terms (i.e., feeling a part of one's parent;
own care to parent; return of warmth, spoiling
parent, perform care because parent needs me)
Reported Findings
Not specified
Theoretical/
Conceptual
Framework
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K3
p
u>
M = 71; major
depressive
disorder;
excluding
dementia
55-94; M = 73;
Alzheimer's
disease
57-91; M = 71;
stroke
57-88; M = 7b;
Alzheimer's
disease
57-88; M = 76;
Alzheimer's
disease
Hinrichsen,
Hernandez, &
Pollack (1992)
Kinney &
Stephens (1989)
Kinney,
Stephens,
Franks, & Norris
(1995)
Kramer (1993a)
Kramer (1993b)
Author(s)
Care
Receiver
Age&
Diagnosis
N = 72 wives; co-residing with
husbands, age range = 57-82,
M = 70; primarily Caucasian;
living in Western Washington;
recruited from community
agencies, support group, word of
mouth, and media announcements
N = 72 wives; co-residing with
husbands, age range = 57-82,
M = 70; primarily Caucasian;
living in Western Washington;
recruited from community
agencies, support group, word of
mouth, and media announcements
N = 78 caregivers recruited
through patient medical records at
2 hospitals; 76% female; 94%
Caucasian; Mage = 60 (range
27-81; 74% spouses, 22%
daughters or daughters-in-law, 4%
other family
N - 60; 81% female; spouses,
daughters and other included;
M age = 57
N = 150; 23% wives, 30%
husbands, 30% daughters, 17%
were sons; recruited from hospital
Sample
Characteristics
The Caregiving Satisfaction Scale
(Strawbridge, 1991); 15-item scale
designed to capture long-term
satisfactions and rewards;
responses coded on a 4-point scale
from 1 = strongly disagree to 4 =
strongly agree; alpha = .90
Caregiving Hassles and Uplifts
Scale (Kinney & Stephens, 1987;
see Kinney & Stephens, 1989);
reliability coefficients ranged from
.74 to .94
Caregiving Hassles and Uplifts
Scale (Kinney & Stephens, 1987);
110 events appraised on a 4-point
scale as a hassle or uplift; total
uplift and 4 subscale scores were
computed; alpha coefficients
ranged from .71 to .90
Caregivers asked what they found
most difficult and rewarding about
caregiving; no more than five
responses were recorded for each
of the two questions and
responses were content-analyzed
Measurement
Approach
Caregiver
The Caregiving Satisfaction Scale
satisfaction in the (Strawbridge, 1991; see Kramer,
caregiving role;
1993a)
form of positive
outcome
Caregiver
satisfaction in the
caregiving role;
form of positive
outcome
Uplifts are daily
events that evoke
feelings of joy,
gladness or
satisfaction
"Uplifts are
events that make
you feel good;
they can make
you joyful, glad
or satisfied"
(p. 408)
Rewards
experienced in
caregiving role
Definiton
of
Gain
Table 1 . Summary of Studies on Caregiver Gain (Continued)
Caregivers reported more uplifts than hassles; care
recipient characteristics were stronger predictors of
hassles and uplifts than caregivers characteristics;
hassles demonstrated strongest associations with
well-being (i.e., depression, activity restriction and
negative relations); when uplifts outweighed
hassles, caregivers reported lower levels of distress
Caregiving satisfaction correlated with activities of
daily living (ADL), caregiver age, quality of the prior
relationship, and satisfaction with social
involvement; in multivariate models, differential
predictors found for negative versus positive
outcomes; predictors of depression included
symptoms, caregiving duration, marital history, and
perceived stress regarding IADL; predictors of
satisfaction were ADL and quality of prior
relationship
After controlling for stressors and caregiver
resources, emotion-focused coping predicted
depression; whereas caregiver age, social resources,
problem-focused and relationship-focused coping
predicted satisfaction
Referred to
transactional
theories of stress
Resiliency Model
of Family Stress,
Adjustment, and
Adaptation
Theoretical
framework
drawn from
personenvironment
stress and coping
theories
(continued on next page)
Caregiver and receiver characteristics not associated
with uplifts; types of uplifts were associated with
various types of symptoms; women reported more
uplifts than men; younger caregivers who spent
more time in caregiving activities reported more
behavior uplifts; uplifts not correlated to well-being
Stress Model
Reported Findings
51% reported rewards; 103 rewards identified to
include enhancement in the relationship; rewards
with self (e.g., personal growth), and relationship
with others; rewards not correlated with patient
illness characteristics, caregiver depression, burden,
or psychiatric symptoms; rewards with relationship
negatively correlated with relationship strain
Not specified
Theoretical/
Conceptual
Framework
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3"
rv
K5
Elderly; dementia N = 50 wives identified through
Alzheimer's Disease support
groups, a Memory Disorders
Center in Massachusetts and
public service announcements;
ages 58-87 (M = 70)
Motenko (1989)
Not specified
Stress Theory
and Two-Factor
Theory of
Happiness
Stress Model
Theoretical/
Conceptual
Framework
Not specified
One item based on magnitude
scaling techniques: "How many
points would you give to show
how good it makes you feel to help
(your parent?) The better it makes
you feel, the bigger the number."
(p. 280)
Caregiving Satisfaction Scale (see
Lawton et al., 1989); alpha = .67
for both samples
Caregiving Satisfaction Scale (see
Lawton et al., 1989). Alpha = .71
Five items identified via factor
analytic techniques (i.e., enjoying
the care receiver, feeling pleasure,
feeling closer, being appreciated,
and increased self-esteem); items
scored on 5-point frequency scale;
alpha = .67 for respite sample and
.76 for nursing home applicant
sample; retest reliability = .76
Measurement
Approach
Rewards and
Four separate questions; one
Not specified
gratification from 4-point scale item regarding
caregiving
frequency of warmth, comfort, and
pleasure, and three dichotomous
indicators regarding satisfactions
about changes in relationships,
gratification in marital relationship,
and enjoyment experienced in
husband's presence in the home
N = 575; sons and daughters
Satisfaction in
drawn from the 1982 National Long the caregiving
Term Care Survey; 83% Caucasian; role
M age = 52; 79% had help from
others; 79% daughters
Elderly, M age =
81; chronic
functional
limitations
Miller (1989)
M = 78 (African
Lawton,
American); M =
Rajagopal,
Brody, & Kleban 76 (Caucasian);
dementia
(1992)
N = 285 spouses; Mage = 69;
71% female; 85% Caucasian; N •
244 adult children; Mage = 51;
88% female; 72% Caucasian;
drawn from support groups,
agencies, and public media
M = 76;
Alzheimer's
disease
Lawton, Moss,
Kleban,
Glicksman, &
Rovine (1991)
Caregiving
satisfaction
viewed as one
major dimension
of caregiving
appraisal;
"benefits
accruing to the
caregiver
through his or
her own efforts"
(p.P64)
Definiton
of
Gain
Satisfactions are
"subjectively
perceived gains
from desirable
aspects of, or
positive affective
returns from
caregiving"
(p. P182)
N = 472 Caucasian and N = 157
"Caregiving
African American caregivers drawn satisfaction is the
from a respite-care evaluation
result of
study; approximately 80% female; caregiving
primarily spouses and adult
experiences that
children but in-laws, siblings,
give life a
friends, and other relatives
positive flavor"
included
(p. S157)
N = 632 for respite sample; drawn
from support groups, agencies,
and media; M age = 60; N = 239
for nursing home applicant sample
drawn from nursing home
applications or at-risk state
screening program; Mage = 57
Respite sample M
= 76; dementia;
Nursing home
applicant sample
M = 83; any type
of impairment
Sample
Characteristics
Lawton, Kleban,
Moss, Rovine, &
Glicksman
(1989)
Author(s)
Care
Receiver
Age&
Diagnosis
Table 1. Summary of Studies on Caregiver Gain (Continued)
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ierontolo
(continued on next page)
African American caregivers expressed greater
caregiving satisfaction, and less burden, depression,
and perceived intrusion; greater effort associated
with more satisfaction and burden for both samples;
the "parallel channel" hypothesis was supported in
findings that demonstrated positive affect was
differentially affected by satisfactions, while
depression was more strongly affected by burden
for both caregiver groups
Satisfaction positively correlated with stress, more
time and effort in caregiving, more problems and
costs and negatively correlated with income and
education; multivariate analysis revealed alternative
sets of explanatory variables for satisfaction and
stress; adult children who exerted most effort in
caregiving reported both high stress and high
satisfaction
Wives who perceived the same degree of marital
closeness had greater gratification than those who
had not; wives who provided care to reciprocate
past attention and to nurture their husbands were
more gratified than wives who gave care out of
obligation; gratification correlated with higher
general well-being
Caregiving satisfaction associated with help given,
caregiver burden, positive affect and depression; in
multivariate models, satisfaction was not related to
stressors, but was a significant determinant of
positive affect for spouses; for adult children, high
levels of caregiving effort resulted in both greater
burden and greater satisfaction
Exploratory and confirmatory factor analysis used to
investigate dimensions of caregiving appraisal which
consisted of subjective burden, satisfaction, impact,
mastery, and traditional caregiving ideology;
bivariate correlations revealed that satisfactions were
associated with quality of the relationship, burden,
affect, and relationship to care receiver
Reported Findings
p
Z
58-95, M = 78;
not specified
58-95, M = 78;
not specified
58-95, M = 78;
not specified
> 53; M age =
81; dementia
> 53; Mage =
81; dementia
Not specified;
dementia
Orbell & Gillies
(1993a)
Orbell & Gillies
(1993b)
Orbell,
Hopkins, &
Gillies (1993)
Picot (1995a)
Picot (1995b)
Pruchno,
Michaels, &
Potashnik (1990)
Author(s)
Care
Receiver
Age&
Diagnosis
Satisfaction is
"extent to which
carers derived a
sense of
enhanced
self-worth"
(p. 279)
Satisfaction
viewed as a
positive
dimension of
caregiving impact
appraisals
Satisfaction
defined as
appraisals of
"self-worth gains
from caring"
(p. 101)
Definiton
of
Gain
N = 83 female African American
Rewards are the
caregivers; M age = 59; 60%
positive
daughters; 4% daughters-in-law;
perceptions of
13% wives, 6% sisters, 17% other;
caregiving
63% unemployed; 55% of
household incomes were under
$10,000; drawn from agencies and
public media
N = 83 female African American
Rewards are the
caregivers; M age = 59; 60%
positive
daughters; 4% daughters-in-law;
perceptions of
13% wives, 6% sisters, 17% other;
caregiving
63% unemployed; 55% of
household incomes were under
$10,000; drawn from agencies and
public media
N = 220 spouses recruited from
The positive
community agencies, hospitals,
component of
support groups, and public media; caregiving;
ages 45-94; M = 70; 68% female
perceptions of
caregiving as
uplifts
N = 108 adults identified from a
General Practitioner's registry; 63%
female, 25% co-residing with care
receiver; 59% adult children; 7%
were spouses; 34% distant relative,
friend, or neighbor; M age = 50
(range 18-76)
N = 108 adults identified from a
General Practitioner's registry; 63%
female, 25% co-residing with care
receiver; 59% adult children; 7%
were spouses; 34% distant relative,
friend, or neighbor; M age = 50
(range 18-76)
N = 108 adults identified from a
General Practitioner's registry; 63%
female, 25% co-residing with care
receiver; 59% adult children; 7%
were spouses; 34% distant relative,
friend, or neighbor; M age = 50
(range 18-76)
Sample
Characteristics
Reported Findings
Satisfaction scores lowest and strain scores highest
when demand (behavior problems and difficulty
with tasks) was high and discretion (perceived
reliance) was low
Scale consisting of eight items
assessed frequency of perceptions
(using 3-point scale) regarding
companionship, affection,
enjoyment, appreciation,
cheerfulness of care receiver,
closeness of relationship, and
extent to which they prevent
further deterioration in care
receiver
Picot Caregiver Rewards Scale (see
Picot, 1995a); alpha coefficient =
.86
Caregivers who placed their spouses reported fewer
uplifts than those continuing care; after controlling
for demographic, stressor, and resource variables,
uplifts were marginally significant predictors of
desire to and actual institutionalization
Conceptual
framework for
predicting desire
and actual
institutionalization
drawn from
literatures on
family stress and
placement risk
factors
(continued on next page)
In multivariate models controlling for care recipient
characteristics, perceived rewards significantly
predicted palliative coping (i.e., reframing);
perceived costs significantly predicted emotive
coping
Stress and coping
theory, and
choice and social
exchange theory
Factor analysis identified dimensions of appraisal
which consisted of care work strain, care work
satisfaction, relationship dissatisfaction, and care
lifestyle satisfaction; to examine validity of scales
bi-variate correlations were computed revealing that
satisfactions were positively associated with lifestyle
satisfaction, willingness to care, and inversely
associated with relationship dissatisfaction, behavior
problems and care work demands
Picot Caregiver Rewards Scale;
Choice and social Younger and more educated caregivers perceived
24-item Likert-type scale consisting exchange theory significantly fewer rewards than older less educated
of a variety of rewards; caregivers
caregivers; there was no relationship between
asked to rate the extent to which
duration of caregiving and rewards
each are experienced; ratings are
summed with a possible range of
0 - % ; alpha coefficient = .86
DemandDiscretion
Theory of Job
Strain and
Satisfaction
Theories of Work Satisfaction positively associated with perceived
caring self-competence and negatively associated
Motivation
with the number and frequency of behavior
problems and care receiver's age; satisfaction the
strongest predictor of the caregiver's preference not
to be involved in caregiving
Theoretical/
Conceptual
Framework
Not specified
Care work satisfaction measured
using a factor-analytically derived
6-item scale; each item scored on a
7-point scale (strongly agree to
strongly disagree); alpha = .92
Care Work Satisfaction Scale (see
Orbell, Hopkins, & Gillies, 1993)
Care Work Satisfaction Scale (see
Orbell, Hopkins, & Gillies, 1993)
Measurement
Approach
Table 1. Summary of Studies on Caregiver Gain (Continued)
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o
era
O_
3
O
n
o
n
KJ
KJ
Elderly; frail or
impaired
Elderly; not
specified
Wallsten &
Snyder (1990)
60-90; cognitive
dysfunction and
physical
disabilities
> 64; median
age = 84; not
specified but
excluded
cognitive
impairment
Walker, Shin, &
Bird (1990)
Worcester &
Quayhagen
(1983)
M = 84; not
specified; no
cognitive
impairment
Walker, Martin,
& Jones (1992)
Talkington-Boyer 44-94; M = 74;
& Snyder (1994) Alzheimer's
disease
Stephens,
60-91; M = 76;
Franks, &
not specified
Townsend (1994)
Sheehan &
Nuttall (1988)
Author(s)
Care
Receiver
Age&
Diagnosis
Defi niton
of
Gain
Satisfaction
includes the
appraisal of
benefits gained
through
caregiving effort
Benefits; rewards
from caring or
from the
relationship
between the
mother and
daughter
5-item scale assessing feeling
appreciated, providing opportunity
to repay elder, increased
confidence, sense of enjoyment
rather than duty, and enjoying the
elder's personality; alpha not
specified
Role Stress and Rewards
Questionnaire; caregiver role
rewards consisted of 12 items (e.g.,
•affection, appreciation, improved
relationship, improved care
recipient health) rated on a 4-point
scale from did not happen (0) to
very rewarding (4); alpha = .87
Caregiving Satisfaction Scale (see
Lawton et al., 1989); alpha for
current sample not specified
Measurement
Approach
Caregivers asked how often they
experienced seven benefits (e.g.,
learning, helping, saving money,
improving the relationship, ana
sense of meaning); mothers asked
how often they experienced
feeling loved and a sense that
one's daughter cares
N = 133 adult daughters residing
Satisfaction with Single 7-point item satisfaction
in Western Oregon; median age = the caregiving
scale ana a 10-item semantic
53; 99% Caucasian
role
differential measure (e.g.,
enjoyable, miserable; full, empty)
(Campbell, Converse, & Rogers,
1976); each rated on 7-point scale
(1 = positive to 10 = negative);
mean score computed; reliability
alpha not specified
N = 21 caregivers; 17 females; 18 Uplifts;
Routines, Uplifts, Challenges, and
spouses; 3 adult children; all
experiences that Hassles List (RUCHL); 112 events
co-residing with care receiver; 81% make one feel
appraised as routine, uplift,
Caucasian; Mage = 68; N = 20
good; sources of challenge, or hassle; events also
noncaregivers; 15 females; 80%
satisfaction,
appraised as having a positive or
Caucasian; Mage = 68
peace,
negative impact on 5-point scale;
happiness, or joy reliability alphas not specified;
some items not caregiving-specific
N = 19 co-resident caregivers; (M Satisfaction in
Single item, global rating using a
age = 50) compared to 29 nursing the caregiving
5-point scale
home caregivers recruited from
role
home health care agencies; lower
middle class; relationship type not
specified
N = 110 caregivers recruited from
support groups and an Alzheimer's
Association; 76% female; Mage =
60 (range 28-81); 67% co-resided
with care receiver; 25% caring for
persons in a nursing home
N = 141 adult daughters residing
in Western Oregon; median age =
52; 99% Caucasian
N = 98; recruited from community
agencies and personal contacts;
ages 21-83 (M = 53); 94%
Caucasian; 84% primary
caregivers; mostly adult children,
but also spouses and "other"
Satisfaction;
positive
emotions;
positive
perceptions of
the caregiving
experience
Rewards in
N = 95; 75 daughters and 20
caregiving role;
daughters-in-law recruited from
public notices and hospital medical also evaluated
rewards specific
records of elderly patients; 42%
co-residing with the care receiver; to being wife and
94% were Caucasian; M age = 44
mother; positive
(range 28-59)
experiences
Sample
Characteristics
More satisfaction correlated with higher marital
satisfaction, older age of patient, greater ADL
impairment, lower caregiver depression, greater
problem-solving coping response, greater
satisfaction with informal supports, and less
subjective burden
Factor analytic techniques employed; none of the
positive items loaded tor daughters; therefore
eliminated from further analysis; two benefit items
loaded for mothers to form a factor called "Feeling
Loved"; predictors of feeling more loved included
worse health and less amount of care needed
Not specified
Daughters who reported positive or no change in
their relationships with their mothers were more
likely to report satisfaction than daughters reporting
a negative change in the relationship; satisfaction
was higher among caregivers who were providing
assistance in a greater number of areas and among
those who were caring for older mothers
Ratings of positive impact higher than for negative
impact for caregivers and noncaregivers; negative
impact ratings predicted psychological symptoms;
positive ratings did not; caregivers endorsed more
hassles than noncaregivers but no difference in
uplifts, routines, or challenges
Satisfaction higher among older and co-resident
caregivers; lower when care receivers were
younger; more satisfaction among those caring for
females; psychological problems of care receiver
had strongest negative influence on satisfaction
Social Exchange
Theory
Stress Model
Not specified
Social Exchange
Theory
After controlling for stressors in the roles of
caregiver, mother, and wife, caregiver role rewards
significantly predicted positive affect, but not
physical health, negative affect, or role overload. An
accumulation of role rewards was related to better
well-being, whereas an accumulation of stress across
roles was related to poorer well-being
Role Quality
Perspective and
the Expansion
Hypothesis
Reported Findings
Satisfaction not associated with strain; inversely
associated with depression and negative affect but
this relationship disappeared in multivariate analysis;
much stronger associations observed between strain
and negative emotions and outcomes of depression,
anxiety and somatization
Theoretical/
Conceptual
Framework
Not specified
Table 1. Summary of Studies on Caregiver Gain (Continued)
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Conceptual issues that were considered in this
review included the use and definition of constructs,
the theoretical orientations utilized, and the study
findings that have potential implications for theory.
The most common term used to describe gain in
caregiving was "satisfactions," which was reported
in 15 of the 29 studies. Other terms included uplifts
(n = 4), rewards (n = 4), gratifications (n = 1),
growth and meaning (n = 1), enjoyment (n = 2),
positive aspects (n = 1), and benefits (n = 1). Based
on this review of studies, the following observations
are noted regarding conceptual issues:
Observation #7: Demonstration of Greater Conceptual Clarity Among Theoretically Based Studies.
— As shown in Table 1, nearly half of the studies
reviewed were atheoretical (i.e., no theoretical
base). The most prominent theoretical perspectives
consisted of variations of a stress and adaptation
model or theory (n = 9). Other frameworks included
social exchange theory (n = 4), theories of work
motivation and job satisfaction (n = 2), role theory
(n = 1), and existentialism (n = 1). Few of the
authors provided explanations for the meaning and
definitions for the terms used. Most of the definitions provided in Table 1 were gleaned from the
descriptions of measures provided in the methods
sections of the articles reviewed. Specific meanings
and definitions were provided in only 11 of the studies, most of which were theoretically based.
Observation #2: Conceptualization of Gain as
"Appraisal." — Across the majority of theoretical
orientations specified in this review, gains were either explicitly or implicitly conceptualized, defined,
or measured as appraisals of the caregiving role. The
term appraisal is drawn from the transactional model
of stress and coping proposed by Lazarus and
Folkman (1984), and it refers to the individual's evaluation of the extent to which caregiving is harmful,
beneficial, or irrelevant to well-being. Lawton and
colleagues were the first to introduce "satisfaction"
as one of the major dimensions of caregiving appraisal that was identified via factor analytic techniques (Lawton, Kleban, Moss, Rovine, & Glicksman,
1989). A similar approach was taken in subsequent
studies focusing on the multidimensional nature of
caregiver appraisals (Braithwaite, 1996; Orbell,
Hopkins, & Gillies, 1993). Gain as appraisal is referred to in social exchange theory whereby caregivers "actively appraise their situations and assess
their current and potential for future positive outcomes. . . " (Walker, Shin, & Bird, 1990, p. 147). Exceptions to this construction of gain as appraisal
include the qualitative study by Farran et al. (1991),
which focused on explorations of caregiver growth
and meaning and the study by Stephens et al. (1994),
which focused on the types and amount of rewards
incurred.
Observation #3: Distinction Between Appraisal of
Gain as Event Versus Role-Specific. — Two general
Vol. 37, No. 2,1997
Observation #4; Limitations in Establishing Consistent Empirical Linkages. — Numerous studies have
focused on understanding the correlates and predictors of strain and gain as appraised outcomes of
caregiving (Albert, 1992; Hinrichsen, Hernandez, &
Pollack, 1992; Kramer, 1993a, 1993b; Miller, 1989;
Orbell & Gillies, 1993b; Picot, 1995a; TalkingtonBoyer & Snyder, 1994; Walker et al., 1990; Worcester
& Quayhagen, 1983). Unfortunately, conclusions
that can be drawn from many of these studies are
limited by the methodological problems detailed below, which likely contribute to the contradictory
findings reported to date concerning relationships
between gain and care receiver characteristics and
caregiver characteristics, resources, and burden. For
example, all of these studies were cross-sectional
and only three reported findings that included essential covariates (i.e., stressors and caregiver characteristics; Kramer, 1993a, 1993b; Miller, 1989).
Observation #5: Differential Predictors of Strain
and Gain. —There is limited but suggestive evidence
that the predictors for strain and gain are somewhat
unique, and that attitudinal variables, such as motivations for helping and ideology, may be useful for
understanding gain, but that this may be influenced
by ethnicity. All of the studies that included negative
and positive aspects of care and that controlled for
stressor and demographic variables in their analysis
found some differential predictors for strain and gain
(Kramer, 1993a, 1993b; Lawton et al., 1991, 1992;
Miller, 1989). Three studies documented significant
relationships between attitudinal variables and gain
(Albert, 1992, Lawton et al., 1992, Motenko, 1989).
225
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conceptualizations of gain noted in the literature
include those that are responses to specific caregiving events or tasks, and those that are more general
appraisals of the caregiving role. Event-specific
appraisals are evidenced by the definition and the
measurement approach for "uplifts." Researchers
interested in the "uplifts" construct focus on multidimensional appraisals in which daily tasks or events
are appraised as uplifts, hassles (Kinney & Stephens,
1989; Kinney, Stephens, Franks, & Norris, 1995; Wallsten & Snyder, 1990) routines, and challenges (Wallsten & Snyder, 1990). Kinney and Stephens (1989)
were the first to introduce the concept of "uplifts" of
caregiving events in the literature. Their measurement presents caregivers with 110 daily tasks or
events associated with care recipients' limitations in
ADL, care recipients' cognitive status, care recipients' behavior, and the practical/logistical aspects of
caregiving, and asks them to appraise each one as a
hassle or an uplift. Only one other study took an
event-specific approach, and they too were measuring uplifts (Wallsten & Snyder, 1990). Lawton et al.
(1989) suggested the notion that "the culmination of
daily caregiving uplifts may be thought of as composing" a more enduring state of "caregiving satisfactions" (p. P62). Pruchno, Michaels, & Potashnik
(1990), were the only researchers to use the term
uplifts, and not use events-specific measures.
Conceptual Issues
Given that two out of three of these studies did not
control for other variables, such findings are tentative. In a multivariate model, Lawton et al. (1992)
found a caregiving ideology that included reasons
for providing care (e.g., reciprocity, continuing a
family tradition, mutual concern) to be an important
predictor of gain for Caucasian, but not for African
American caregivers.
Methodological Issues
Methodological problems stemming from sampling, design, measurement, and analysis procedures have a long history in the caregiving literature
(Barer & Johnson, 1990). Based on this review of
studies, the following observations are noted regarding methodological issues:
Observation #7: Reliance on Samples of Convenience. — The majority of the studies reviewed used
samples of convenience. Only one sample was
226
Observation #8: Inattention to Subgroup Differences and the Experience of Males. — The majority of
investigations used heterogeneous samples that
lumped together different caregiver groups, including spouses, adult children, other relatives, neighbors, and friends. The next most frequently studied
group were adult children, primarily focusing on
daughters and/or daughters-in-law (Brody, Litvin,
Hoffman, & Kleban, 1992; Stephens et al., 1994;
Walker et al., 1990, 1992), although Miller (1989)
investigated sons and daughters. There was one report on spouses (Pruchno et al., 1990) and three
reports on wives (Kramer, 1993a, 1993b; Motenko,
1989). Absent were studies of the male caregiver and
careful investigations of differences by gender and
relationship type. Most investigations focused on
gain experienced among caregivers to persons with
dementia (n = 14). It is noteworthy that nine did not
specify the type of care receiver impairment.
Observation #9: Reliance on Quantitative Data
and Cross-Sectional Design. — Only two of the 29
studies utilized qualitative methods to explore positive aspects of caregiving, and none of the studies
reviewed obtained cross-time data on caregiver gain.
Four studies reported on follow-up contact with
caregivers; however, the only measure taken at
follow-up was living arrangements (i.e., community
or nursing home; Braithwaite, 1996; Cohen et al.,
1993, 1994; Pruchno et al., 1990). Thefore, major
questions remain regarding the direction of causality
between gain and other variables studied.
Observation #10: Identification of Multiple Gains
Found Through Qualitative Investigations. — The
open-ended method of data collection used in two of
the studies revealed that caregivers experienced a
wide variety of positive feelings and experiences. For
example, Farran et al. (1991) reported that 90% of
respondents reported "Valuing Positive Aspects" of
the following: family and social relationship, the care
recipient's love for them, the positive relationship
that they experienced with the care recipient, memories of and accomplishments with others, feeling
appreciated by the care recipient and feeling good
about the quality of care that they were providing.
Hinrichsen etal. (1992) noted 103 rewards, including
enhanced relationships with the care receiver (e.g.,
greater liking of the patient, satisfaction in seeing
one's efforts are helping), rewards with oneself (e.g.,
The Gerontologist
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Observation #6: Conceptualization of Gain as an
Intervening Variable. — Although both strain and
gain were often conceptualized as appraised outcomes of providing care, approximately one third of
the studies reviewed focused on the relationship
between caregiver gain and other, more enduring
outcomes, such as desire to institutionalize or actual
institutionalization (Cohen etal., 1993; Cohen, Cold,
Shulman, & Zucchero, 1994; Pruchno et al., 1990),
depression (Kinney et al., 1995; Lawton et al., 1992;
Sheehan & Nuttall, 1988), positive and/or negative
affect (Braithwaite, 1996; Lawton et al., 1991, 1992;
Stephens et al., 1994); and physical health (Stephens
et al., 1994). In general, however, studies did not
utilize statistical methods that would allow for the
evaluation of moderating or mediating effects (Baron
& Kenney, 1986), thereby limiting the conclusions
that may be drawn.
There is limited but suggestive evidence that strain
and gain may be differentially related to negative
versus positive indicators of psychological wellbeing, and that they may vary depending upon certain caregiver characteristics. The work of Lawton
and colleagues (1991,1992), perhaps the most methodologically rigorous work conducted to date, drew
upon the two-factor theory of happiness proposed
by Bradburn (1969), to hypothesize that "one aspect
of mental health, positive affect, would be differentially affected by the uplifting aspects of caregiving
(caregiving satisfaction), while the second aspect of
mental health, depression, would be more strongly
affected by caregiving burden" (p. S163). One study
supported this hypothesis for both Caucasian and
African American caregivers (Lawton et al., 1992) and
another study reported different patterns for
spouses versus adult children (Lawton et al., 1991).
These findings are compatible with other research
that has reported differential correlates of negative
and positive affect (Costa & McCrae, 1980; Diener &
Emmons, 1984, Emmons, 1986) and suggest that
strain and gain are not simply opposites on a unidimensional continuum.
drawn from a national data base (Miller, 1989), and
sample sizes across the 29 studies varied tremendously, ranging from 19 to 632. As convenience samples, most tended to be primarily Caucasian and
middle-class. Picot (1995a, 1995b) was the only researcher to study an exclusively African American
sample, and only one study reported on the differential experience of gain by ethnicity, with African
American caregivers expressing greater caregiver
satisfaction and less burden, depression, and perceived intrusion than Caucasian caregivers (Lawton
etal., 1992).
(Campbell, Converse, & Rodgers, 1976, p. 38). This
scale consisted of 10 semantic differential pairs
which are rated on a 7-point positive to negative
continuum. Caregivers were asked to consider their
responses in terms of how they feel about providing
care. While some of the items clearly suggest caregiver gain (e.g., "rewarding," "enjoyable," "brings
out the best in me"), others are conceptually less
clearly related (e.g., "friendly-lonely" seems to evaluate aspects of social support;, "free-tied down"
may reflect amount of responsibility).
feeling that one grew as a person), and enhanced or
satisfying relationships with others (e.g., family and
health care providers). Given that appraisal of gain is
a complex evaluative process, it is unlikely that the
single-item, dichotomous, and frequency indicators
of gain, reported in five of the studies, adequately
tap the construct (Cohen et al., 1993, 1994; Miller,
1989; Motenko, 1989; Worcester & Quayhagen,
1983).
One exception to this measurement approach was
described by Walker and colleagues (1990), who
used a satisfaction scale that was originally developed as a measure of "perceived quality of life"
Vol.37, No. 2,1997
Observation #12. Inattention to Potential Confounding of Measures. — Examination of item content of the measures used reflects considerable conceptual overlap and potential confounding with
other constructs. For example, gain items reflecting
improved relationships with the care receiver and
other family members create problems when researchers attempt to document the relationship between gain and the quality of the relationship, which,
not surprisingly, has been strong and positive
(Hinrichsen et al., 1992; Kramer, 1993a; Lawton et al.,
1989; Motenko, 1989; Walker et al., 1990). Orbell et
al. (1993) circumvented this problem by using factor
analysis to separate out the factor related to relationship quality. Conceptual and item overlap may obfuscate the meaning of observed correlations between measures of gain and strain when burden
measures both tap interpersonal relationships (e.g.,
see Montgomery, Gonyea, & Hooyman, 1985; Novak
& Guest, 1989; Zarit & Zarit, 1987). Similarly, some
dimensions of psychological well-being (e.g., personal growth and purpose in life) are reflected in a
number of the gain measures.
Observation #13: Limitations in the Analytic Methods Utilized. —There was a tendency for researchers
to rely on bivariate correlations for documenting
associations between gain and other variables. Most
did not control for the fact that caregivers were at
different phases of the caregiving career, or that they
were likely to be managing different stressors. As
mentioned previously, studies largely neglected to
control for the following: differences in the caregiver's relationship to the care receiver, gender, ethnicity, and other distinguishing background and contextual variables that may influence the appraisal of
caregiver gain or strain.
Discussion
An Agenda for Future Research
In order for the field to advance, future research
efforts must work toward addressing the limitations
and knowledge gaps of prior investigations outlined
in this review. Two central criticisms are noted. A first
problem stems from lack of conceptual clarity that is
notably evidenced by the absence of a theoretical
base in nearly half of the studies, or the failure to
elaborate broader theoretical contexts for investigating gain. This neglect of theory has resulted in two
227
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Observation #11: Initiation of Tool Development.
— There is, on a limited basis, the beginning of the
development of tools to measure the caregiver gain
construct. Three studies reported on factor analytic
methods used to identify appraisal of gain as distinct
from other appraisals of caregiving (Braithwaite,
1996; Lawton et al., 1989; Orbell et al., 1993); however, information provided about the psychometric
properties for these measures is somewhat limited.
For example, Braithwaite (1996) did not report reliability coefficients for her appraisal dimensions, testretest reliability is lacking from all studies, and inconsistent findings and limited elucidation of potential
relationships of gain with other outcome measures
have made it difficult to establish construct validity.
The most frequently reported and perhaps the most
methodologically rigorous measure is the 5-item
caregiving satisfaction measure that was developed
by Lawton and colleagues (1989). The reliability alphas reported across studies that have used this
measure vary widely according to the samples that
are investigated (e.g., lowest alpha = .67 for respite
care sample, Lawton etal., 1989; and highest alpha =
.92 for daughter caregiver sample, Brody et al., 1992).
Aside from the two qualitative reports, the singleitem, dichotomous, or frequency ratings, and the
events-specific uplifts measures, most of the measures reviewed were multi-item scales in which caregivers were asked to rate each item according to their
occurrence or frequency. Across these measures
there is considerable item overlap regardless of the
terms that were used to identify gain. For example,
measures that consisted of similar items across studies included the following: improved relationship
with the care receiver or other family members (Albert, 1992; Brody et al., 1992; Farran et al., 1991;
Hinrichsen et al., 1992; Kramer, 1993a, 1993b; Lawton et al., 1989, 1991, 1992; Motenko, 1989; Picot,
1995a; Pruchno et al., 1990; Stephens et al., 1994);
increased self-esteem (Kramer, 1993a, 1993b; Lawton
et al., 1989; Orbell et al., 1993; Picot, 1995a); feeling
appreciated (Braithwaite, 1996; Lawton et al., 1989;
Picot, 1995a; Pruchno etal., 1990; Sheehan&Nuttall,
1988; Stephens et al., 1994); enhanced sense of
meaning or purpose (Kramer, 1993a, 1993b; Walker
et al., 1992); feelings of pleasure (Lawton et al., 1989;
Orbell et al., 1993; Picot, 1995a); and prevention of
further care receiver deterioration (Kramer, 1993a,
1993b; Pruchno et al., 1990; Stephens et al., 1994).
228
out the relationships among various caregiver
groups. Studies that have investigated the role of
gender or kin relationship have reported important
differences across other domains investigated
(Horowitz, 1985; Jutras & Veilleux, 1991; Kramer &
Kipnis, 1995; Miller & Caffasso, 1992; Young & Kahana, 1989). Gain may be appraised very differently
by adult children, husbands, wives, and friends. Similarly, nearly half of the samples consisted of care
receivers with a variety of diagnoses, never distinguishing between the experiences of these caregivers, and only three reported on the gain experienced by non-Caucasian caregivers (Lawton et al.,
1992; Picot, 1995a, 1995b). Future investigations
should attempt to disentangle the effects of gender,
race, relationship, and type of illness to help bring
clarity to our understanding of caregiving benefits.
Basic questions that have yet to be answered include: Who is most likely to experience gain in
caregiving? How do gender, age, race, and kinship
relationship affect the likelihood and extent of gain?
Other methodological and conceptual issues that
warrant further attention include the extent to which
gain is subject to socially desirable responses and the
function of caregiver gain in relation to general wellbeing. Future studies that control for social desirability and that investigate the moderating or mediating
properties of gain are urged. Greater clarity is
needed with regard to the conceptual distinction
between gain and well-being, and the processes
through which the effects of caregiving are moderated by caregiver gain. It would be useful to have
prospective data that allows for comparison of the
magnitude of relationships with indices of positive
psychological well-being, and more reliable evaluation of the direction of causality.
Caregiver Adaptation: A Model of Synthesis
As indicated above, much work has yet to be done
in developing a sound theoretical framework for
understanding caregiver gain. As an emerging and
relatively new field of interest, it seems natural for
researchers to explore the topic from multiple theoretical and conceptual perspectives. Ultimately,
however, the study of caregiver gain would be enhanced if researchers could come to some consistency in the ways in which gain is conceptualized and
studied within the broader context of caregiver adaptation. Without such a framework, it is difficult to
establish the construct validity of the measures used;
there is the problem of confounding of measures,
and the challenge of interpreting inconsistent findings. Much research has been guided by theoretical
and conceptual models that were developed to understand how caregivers adapt to stress or that do
not fully articulate the key variables that should be
important in understanding this realm of the caregiving process. It is likely that stress theories have dominated this area of inquiry because they are the most
comprehensive, taking into consideration the context, stressors, resources, and outcomes. Other theories such as social exchange, role theory, existenThe Gerontologist
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related problems: namely, absent or unclear definitions and the subsequent hindered efforts to develop empirically distinct measures. Having elusive
definitions is problematic because "lack of precision
in use of terms leads to and promotes theoretical
confusion; hinders operationalization of the constructs; promotes gaps between theoretical and operational levels; and ultimately impedes development of knowledge" related to caregiver adaptation
(Hurley-Wilson, 1993, p. 134).
While there are some beginning attempts to evaluate the psychometric properties of existing measures, it is not clear that these measures capture the
full repertoire of gain experienced by caregivers.
Several important questions remain unanswered in
the context of measurement and operational definition of the gain construct. Given the conceptual
overlap in existing measures and definitions, should
we conclude that rewards, satisfactions, gratifications, and benefits are synonymous? Is gain unidimensional or multidimensional? Is there merit in
considering objective gain in addition to subjective
gain, as has been the case in the study of burden?
Objective burden has been examined as the prevalence count of potentially disruptive experiences (Vitaliano, Young, & Russo, 1991), and as disruptions
that are observable or verifiable (Platt, 1985). Are
there gains that caregivers experience that might also
be counted, observed, or verified? Walker, Martin,
and Jones (1992) suggested that gain may be both
emotional and knowledge-based. Knowledge and
skills are two types of gain that are potentially observable, but would doing so enhance understanding of
caregiver well-being? Given that this is a relatively
new area of inquiry, qualitative approaches, such as
those utilized by Farran et al. (1991) and Hinrichsen
et al. (1992) would offer a useful approach for developing comprehensive measures and exploring these
issues. Clearly, the development of psychometrically
sound measures of gain would constitute a considerable contribution to the field.
A second problem concerns the methodological
limitations inherent in the studies reviewed that permits restricted comparisons between studies, constrains generalizability, hampers study validity, and
contributes to limited cumulative knowledge. The
most notable limitations included insufficient attention to the validity and reliability of measures, use of
limited analytic methods, failure to control for extraneous variables, reliance on cross-sectional data,
failure to disaggregate diverse caregiver subsamples,
reliance on convenience samples, and the wide variability in the foci, methods, and measurement used
across studies. These methodological problems
likely contribute to the many contradictory findings
reported in the literature regarding the relationship
between gain and care receiver characteristics, caregiver characteristics, and caregiver's resources and
burden. They also restrict understanding of a number of potentially important variables that should be
addressed in future research. For example, as noted
previously, the majority of samples were heterogeneous and were often not large enough to separate
Background and Context. — Care receiver and
caregiver characteristics and the context of the caregiving situation potentially play a central role in understanding all other aspects of the caregiver's experience (Kramer & Kipnis, 1995). These contextual
variables are conceptualized to determine the types
of caregiving activities the individual is engaged in,
the types of resources that are available to manage
these responsibilities, the appraisal of gain and
strain, and ultimately, well-being. In stress-based
theories that have been applied to caregiving, care
receiver characteristics (i.e., illness severity, type of
illness, cognitive status, functional status, and problematic behavior) are often conceptualized as the
stressors the caregiver is called upon to manage and
are central to investigations of caregiver adaptation
(Biegel et al., 1991; Kramer & Vitaliano, 1994). Social
exchange and role theory have also recognized the
importance of contextual variables.
The most influential social exchange theory, equity
theory, hypothesizes that individuals will provide
care with the expectation of receiving some form of
material, social, or psychological benefit in return,
without which negative affective reactions would be
expected (Buunk & Hoorens, 1992). The extent to
which a beneficial return is expected is largely determined by the type of relationship (Mills & Clark,
1982). The nature and duration of the illness (sudden
or insidious), prognosis (recuperative, stable, degenerative, or terminal), and the symptoms are also
likely to influence the degree of expected reciprocity. This further suggests that it is essential to refrain
from aggregating diverse groups of caregivers and
care receivers and treating them as a homogenous
group, and to look carefully at gender and kin relationship differences. In addition, role theory suggests the importance of considering other essential
roles (e.g., parenting, employment) that have the
potential to impact caregiver well-being either positively or negatively (Thomas & Biddle, 1966). For
example, role theory suggests that the "successful
enactment of roles and identities is expected to bring
social esteem and intrinsic gratification from the experience of instantiated social competence" (Marks,
1995, p. 10). Alternatively, there is also the potential
for role conflicts to occur when caregivers attempt to
juggle multiple roles.
Individual differences in attitudinal variables (i.e.,
motives, values, goals) help to explain how a situa-
INTERVENING PROCESSES
BACKGROUND AND CONTEXT
WELL-BEING OUTCOMES
CARE RECEIVER CHARACTERISTICS/
POTENTIAL STRESSORS
CAREGIVER ATTITUDINAL
VARIABLES AND EFFORT
POSITIVE INDICATORS
APPRAISAL OF
ROLE STRAIN
NEGATIVE INDICATORS
RESOURCES
CAREGIVER CHARACTERISTICS/
OTHER LIFE RESPONSIBILITIES
Figure 1. A conceptual model of caregiver adaptation.
Vol. 37, No. 2,1997
APPRAISAL OF
ROLE GAIN
229
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tialism, and theories of work motivation offer additional insights regarding potentially important considerations. These theories need not be considered
incompatible with stress models; they simply tend to
more narrowly highlight areas of foci (e.g., rewards/
costs ratio, number/types of roles, search for meaning). For example, elsewhere in this symposium (pp.
250-256), Farran identifies similarities and points of
divergence for stress and existential paradigms, and
proposes that a combination of these two approaches could enhance understanding of the caregiving process.
While no single theory currently provides an adequate basis for understanding caregiver gain, a useful model can be generated through the integration
of several different theoretical perspectives. As a first
step, the conceptual framework shown in Figure 1 is
proposed, integrating theoretical perspectives that
seem to be relevant to the study of caregiver adaptation, and taking into consideration the theoretical
observations elucidated in this review. According to
this model, the adaptation process is made up of
three primary domains: background and context;
intervening processes; and well-being outcomes.
only with strain and depression (Kramer, 1993a,
1993b; Lawton et al., 1991). Similarly, positive and
negative outcomes were associated with differing
types of coping strategies among two caregiving
samples (i.e., African Americans, Picot, 1995b; and
Caucasian wives, Kramer, 1993a). Further work is
needed to replicate and document these differential
relationships.
As noted previously, there has been some initial
progress, based on the two-factor theory of happiness (Bradburn, 1969), in documenting intervening
mechanisms that appraisals of strain and gain have in
understanding negative versus positive indicators of
psychological well-being (Lawton et al., 1991,1992).
Drawing upon role theory, it is suggested that future
investigations should go beyond appraisals of the
caregiving role to include appraisals of other significant roles. Recent research has documented the utility of examining caregiver adaptation in the context
of other roles and resources. For example, using
panel data on 293 women, Moen, Robinson, and
Dempster-McClain (1995) found that the effects of
caregiving on well-being were moderated by multiple role involvements and other nonfamily roles.
Stephens et al. (1994) found that an accumulation of
role stress across roles was related to poorer wellbeing, whereas an accumulation of role rewards was
related to better well-being. Interestingly, investigations regarding roles and well-being have been
based on perspectives of role-enhancement or role
strain (Moen et al., 1995), paralleling the interest in
positive versus negative impacts.
Outcomes. — In the model shown in Figure 1,
well-being outcomes include both positive and negative indicators. Consistent with the caregiving literature in general, well-being indicators reported in the
gain studies reviewed excluded positive dimensions
Intervening Processes. — It is widely acknowl- of well-being or utilized extremely narrow and limited definitions of positive well-being (e.g., positive
edged that resources play a central role in underaffect). The understanding of caregiver adaptation
standing caregiver outcomes. They can be generally
defined as either internal, when they are characteris- would be greatly advanced through a program of
research that carefully investigates the correlates and
tics within the individuals (e.g., coping, personal
predictors of theoretically grounded indicators of
control, self-efficacy, health, knowledge, hardiness)
"positive" psychological well-being. Those that
or external, when they are factors or assets outside
seem particularly relevant to the study of caregiver
the individual (e.g., social support, tangible regain include environmental mastery (i.e., a sense of
sources; Lazarus & Folkman, 1984). Resources are
competence in managing one's environment), perhypothesized to be important in explaining the tresonal growth (i.e., a sense of development and of
mendous variation in strain found among caregivers
realizing one's potential), purpose in life (i.e., sense
(Pearlin, Mullan, Semple, & Skaff, 1990). Some of the
studies reviewed have begun to document a relation- of meaning to life), and self-acceptance (i.e., a sense
ship between resources and gain (Farran et al., 1991 ; of positive attitude toward the self; Ryff, 1989a,
1989b). As noted previously, because some of these
Kramer, 1993a, 1993b; Orbell & Gillies, 1993a); howdimensions are currently represented as single items
ever, the nature of this relationship is not consisin measures of caregiver gain, it is imperative that
tently reported. As shown in Figure 1, resources are
future studies that include both constructs ensure
posited to directly influence role appraisal, and they
that the problem of item overlap is addressed.
indirectly or directly influence well-being. However,
Positive indicators of well-being seem particularly
there is some evidence to suggest that specific types
relevant to gerontologists, given evidence of reof resources may have unique relationships with
ported declines in purpose in life and personal
various indicators. For example, social support was
growth across the life span (Ryff, 1989b, 1991) and
correlated with both positive and negative indices
reported differences between women and men
(Kramer, 1993a, 1993b), but health was associated
230
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tion can be appraised as stressful by one person and
beneficial by another (Folkman & Lazarus, 1988).
One of the observations noted in this review is that
attitudinal variables (i.e., motivations for helping,
caregiving ideology) were found to be associated
with caregiver gain (Albert, 1992; Lawton et al., 1992;
Motenko, 1989). Biegel et al. (1991) suggested that
motivations for helping may be a combination of
altruistic or egoistic factors, depending upon the
nature of the care receiver's illness and emotional
status, and that they are inextricably linked to the
amount of effort exerted in caregiving. Motivations
for providing care may also be central to the daily and
more global life goals of the caregiver. Recent shifts
in personality psychology that focus on social cognition suggest that one's goals or strivings directly
influence behavior (Brower & Nurius, 1993;
Emmons, 1986). Personal strivings represent what
individuals are aiming to accomplish through their
behavior (Emmons, 1986). Given the demands of the
caregiving situation and its centrality to the lives of
most caregivers, it is not unlikely that the personal
strivings of many caregivers would involve aspects of
caregiving. One does not have to look far to find a
caregiver who is striving to help an impaired spouse
feel useful, to keep the household running
smoothly, and to maintain a loving relationship. If
caregiving tasks are central to one's goals, then the
caregiver is likely to exert effort and draw upon their
resources to meet these goals. The extent to which
resources help or hinder this effort will likely influence both positive and negative indicators of appraisal and well-being. Caregivers whose goals are
directed outside of the caregiving realm, but who
nevertheless maintain their caregiving role, are likely
to negatively appraise their experience as it detracts
from their ability to achieve their desired goals.
Conclusion
In summary, although there is evidence of the
growing interest in the construct of caregiver gain,
lack of conceptual clarity, methodological problems,
and the wide variability in the foci of the studies
contributes to limited cumulative knowledge. As
studies proceed in this fertile research area, attention to the operational definition of the construct,
development of psychometrically sound measures
that consider the full repertoire of gain, and increasing methodological rigor in the execution of research designs and analysis of data could lead to
notable advances in the field. As a beginning step for
bringing some consistency to the ways in which
future research proceeds, a conceptual framework is
proposed that considers resources and the appraisal
of gain and strain as intervening processes in understanding both negative and positive indicators of
well-being within the broader context of caregiver
adaptation. Programs of research must continue to
explore, replicate, extend, and further develop this
model, with particular emphasis on elucidating positive dimensions of caregiving and addressing broad
gaps in knowledge (e.g., the roles of gender, ethnicity, kin relationship, and type of illness). The methodological, conceptual, and theoretical efforts advocated here are necessary if we hope to improve
assessment methods and better design and target
interventions for caregivers of older adults who need
assistance.
Vol. 37, No. 2,1997
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