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Aging & Mental Health

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Self-transcendence, spiritual perspective, and sense

of purpose in family caregiving relationships: a
mediated model of depression symptoms in Korean
older adults
a b c
Suk-Sun Kim , R. David Hayward & Pamela G. Reed
a
Division of Nursing Science, College of Health Sciences, Ewha Womans University,
Seoul, Korea
b
Department of Health Behavior and Health Education, School of Public Health, The
University of Michigan, Ann Arbor, MI, USA
c
College of Nursing, The University of Arizona, Tucson, AZ, USA
Published online: 04 Apr 2014.

To cite this article: Suk-Sun Kim, R. David Hayward & Pamela G. Reed (2014) Self-transcendence, spiritual perspective,
and sense of purpose in family caregiving relationships: a mediated model of depression symptoms in Korean older adults,
Aging & Mental Health, 18:7, 905-913, DOI: 10.1080/13607863.2014.899968

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 Aging & Mental Health, 2014
Vol. 18, No. 7, 905–913, http://dx.doi.org/10.1080/13607863.2014.899968

Self-transcendence, spiritual perspective, and sense of purpose in family caregiving

relationships: a mediated model of depression symptoms in Korean older adults
Suk-Sun Kima*, R. David Haywardb and Pamela G. Reedc
a
Division of Nursing Science, College of Health Sciences, Ewha Womans University, Seoul, Korea; bDepartment of Health Behavior and
Health Education, School of Public Health, The University of Michigan, Ann Arbor, MI, USA; cCollege of Nursing, The University of
Arizona, Tucson, AZ, USA
(Received 13 August 2013; accepted 10 February 2014)

Objectives: This study used structural equation modeling to test the mediated model of late-life depression to understand
the mechanisms that account for the direct and indirect effects of spiritual variables and purpose in life on depression
within the context of Korean family caregiving relationships.
Method: A secondary analysis study design used data from a study that tested a theory of family interdependence of 157
Korean elder-family caregiver dyads in Seoul, Korea.
Results: Both caregivers’ and elders’ self-transcendence was positively related to their own sense of purpose in life.
However, only elders’ spiritual perspective was related to purpose in life. Also, elders’ purpose in life was positively
Downloaded by [UQ Library] at 14:43 31 October 2014

associated with caregivers’ purpose in life. Furthermore, there was a strong negative relationship between elders’ purpose
in life and their depressive symptoms, but there was not a significant negative relationship between caregivers’ purpose in
life and elders’ depressive symptoms. Last, elders’ purpose in life mediated the negative effects of elders’ self-
transcendence and spiritual perspective and of caregivers’ self-transcendence and purpose in life on elders’ depression.
Conclusion: The findings suggest that purpose in life for both the caregiver and elder played an important role in elders’
depression. Self-transcendence also was related to decreased depression in elders. It is suggested that more attention be
given to caregiver and elder purpose in life in developing interventions to reduce or avoid elder depression in Korean
elders.
Keywords: spirituality; self-transcendence; depression; Korean elders; family caregiving

Introduction religious congregation (Lim & Putnam, 2010). However,

Older adult depression in Korea has gained increased
attention because of its high prevalence and its relation-
ship to increased health care utilization, suicide attempts,
and mortality (Hamer, Bates, & Mishra, 2011; Kim, Park,
Jang, & Kwon, 2011; Lee et al., 2009; Vinkers, Stek,
Gussekloo, van der Mast, & Westendorp, 2004). Although
numerous studies have reported a beneficial impact of
spirituality on depression in older adults (Koenig, King, &
Carson, 2012; Lee, 2007; Stanley et al., 2011; You et al.,
2009), few studies have examined mechanisms that might
account for the effects of spirituality on elder depression.
Recent research findings suggest that purpose in life may
be a potentially important intermediate factor explaining
the association between spirituality and elder depression
(Nelson et al., 2009).
To understand the role of spirituality and purpose in
life in depression in older adults, it is important to con-
sider the social context of family caregiving relationships.
The family is a significant context for Korean elders’
mental health. When older adults rely on family care-
givers, the caregiving relationship is highly salient and
caregivers’ spirituality is an important predictor to deter-
mine Korean elders’ well-being (Kim, Reed, Hayward,
Kang, & Koenig, 2011; Lee & Holm, 2011). Spirituality
may be most beneficial for mental health when it is part of
a mutually reinforcing social network such as a family or
to our knowledge, no published studies were found that
examined the role of Korean family caregiving relation-
ships with respect to the interplay between spirituality and
purpose in life in elder depression. Therefore, the purpose
of this study was to explore the mechanisms by which
spiritual factors and purpose in life directly and indirectly
influence elders’ depression within Korean elder–care-
giver dyads of the family caregiving relationship.
Theoretical framework
The theory of self-transcendence (Reed, 2014) provided
the theoretical framework for this study. Self-transcen-
dence is defined as the capacity to expand self-boundaries
and to achieve broadened perspectives that help one dis-
cover or make meaning of experience (Reed, 2014).
According to this theory, vulnerability and life challenges
can motivate self-transcendence along with other positive
psychosocial processes such as finding purpose and mean-
ing in life, which may in turn diminish depression and
enhance physical and psychological well-being (Reed,
2014). For example, older adults’ vulnerability to experi-
ences, such as loss of a loved one, chronic illness, and
end-of-life challenges, can activate elders’ self-transcen-
dence towards a renewed meaning and purpose in life to
prevent depression. This is not to negate the fact that

*Corresponding author. Email: suksunkim@ewha.ac.kr

Ó 2014 Taylor & Francis

 906 S.-S. Kim et al.
responses to illness and loss are unique to each person and
for many at least initially, it is a difficult process that can
diminish well-being. Nevertheless, with adequate resour-
ces and time, people display an ability to integrate
difficulties and life changes in a way that helps sustain
well-being. It is this pattern and possibility of human emo-
tional strength that the theory of self-transcendence builds
upon.
We applied Reed’s (2014) theory of self-transcen-
dence to both the caregiver and the elder in the specific
context of Korean family caregiving. Based upon this
theoretical framework, we proposed that a spiritual per-
spective and purpose in life represented an expansion of
self-boundaries, and if they occurred in both the elder and
caregiver, they would play a role in decreased depression
in elders. Research findings presented below support these
proposed relationships.
Spirituality and depression, and purpose in life
Many empirical studies have demonstrated that spiritual-
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type variables (e.g., self-transcendence, spiritual perspec-
tive, and religious participation) are negatively associated
with depression in older adults (Ellermann & Reed, 2001;
Koenig et al., 2012; Lee, 2007; Stanley et al., 2011;
Stinson & Kirk, 2006; You et al., 2009). However, a rela-
tively small number of studies have explicated the mecha-
nism that underlies this relationship between spirituality
and depression. Krause (2007) reported that older adults
who had a strong sense of purpose in life tended to experi-
ence stress-buffering effects of traumatic life events on
depressive symptoms. Nelson et al. (2009) identified pur-
pose in life as an important mediator between spirituality
and depression in cancer patients.
Although older adults are at risk for maintaining high
levels of purpose in life due to increasing losses such as
retirement or losses of spouse, family, and friends
(Pinquart, 2002), spirituality and related experiences may
be a significant resource for meaning and purpose in life
(Acton & Wright, 2000). Self-transcendence may contrib-
ute to the ability of older adults to find and maintain a
sense of meaning in life in the face of these losses. This
sense of meaning may in turn help to reduce psychologi-
cal distress and other symptoms of depression among
older adults at high risk. Also, self-transcendence may
allow both elders and caregivers to perceive their situa-
tions differently; to accept their current life circumstances
and stressors; and to help them move toward more mean-
ingful and fulfilling lives by reviewing their entire lives,
connecting with religious beliefs, caring for others, and
increasing self-awareness, and transforming their own
lives and the lives of others in a positive way (Reed,
2014).
Caregivers’ and elders’ spirituality and purpose in life in
the context of caring relationship
The role of family caregiving relationships in the mental
health of older adults has received relatively little atten-
tion from researchers. However, there is some evidence
that family ties can play an important role in late life
depression. Pinquart (2002) reported that social and fam-
ily integration showed a significant association with
purpose in life in older adults. Frequent, intimate family
relationships can be a major source of health promotion
and prevention of emotional decline in older adults. More-
over, in the tradition of filial piety and familism, Korean
older adults highly value family relationships and want to
live with and receive care from their family (Kim & Lee,
2003). According to Lee and Holm (2011), family rela-
tionships and support were important predictors that
prevented depression in Korean elders.
Consistent with Korean family-centered caregiving
(Kim, Hayward, & Kang, 2013), understanding the recip-
rocal relationship between elders and their family
caregivers is important for understanding the mechanisms
that account for the effects of spirituality and purpose in
life on depression in older adults and for promoting their
mental health. Caregivers’ spirituality and sense of pur-
pose in life may have an impact on elders’ mental health
in a number of ways. First, since meaning and purpose
can have beneficial influences on health and well-being
(Krause, 2007), caregivers who feel more fulfilled in these
respects are likely to be healthier and happier. Caregivers’
well-being is likely to help them better provide for their
elders’ needs (Mittelman, Haley, Clay, & Roth, 2006).
Second, elders who perceive that their family caregivers
share their worldview, in terms of their spirituality and
sense of purpose, may feel that they have been successful
in transmitting their values and culture to the next genera-
tion. This is an especially important concern in highly col-
lectivist cultures like Korea’s where the self is highly
intertwined with and dependent on close others
(Oyserman, Coon, & Kemmelmeier, 2002); thus Korean
elders may likely derive a sense of personal well-being
from their families’ spirituality and sense of purpose.
Given these factors, it is likely that the interplay between
elder’s and caregiver’s spirituality is particularly impor-
tant for promoting a sense of purpose for both members of
the caregiving dyad. In the presence of a positive caregiv-
ing relationship, spirituality in each member is likely to
reinforce spirituality in the other via a reciprocal process.
In this context, purpose in life is derived not only from
one’s own spiritual sense, but also from the sense of hav-
ing a shared experience with the other dyad member, and
from the sense of fulfilling on the one hand a filial obliga-
tion from caregiver to elder, and on the other hand the
obligation of the elder to transmit cultural traditions and
wisdom to the family. Both may benefit from a mutual
sense of enacting these roles.
Mediated model of elder depression
Given the research findings reviewed above along with the
theoretical framework, we developed the mediated model
of elder depression presented in Figure 1 to illustrate how
purpose in life may serve as a mechanism relating spiritu-
ally related factors and depression in Korean elders. This
model is based on the assumption that family caregiving
relationships have a role in the interplay between spiritual
 Aging & Mental Health
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Figure 1. The mediated model of older adult depression.
variables and purpose in life in this study. The theoretical
model depicts several relationships where purpose in life
and spiritual variables positively relate to each other and
negatively relate to caregiver and elder depression. The
following hypotheses were proposed:
Hypotheses
(1) Elders’ and caregivers’ spirituality (i.e., spiritual
perspective and self-transcendence) will have a
significant positive relationship to their own pur-
pose in life.
(2) Caregivers’ purpose in life will be positively
related to elders’ purpose in life.
(3) Caregivers’ and elders’ purpose in life will each
have a direct and inverse relationship with elders’
depression.
(4) Elders’ depression will be indirectly related to
elders’ spirituality, caregivers’ spirituality, and
caregivers’ purpose in life, via the pathway of eld-
ers’ purpose in life.
Method
Design
This secondary data analysis study used data from a previ-
ous cross-sectional, descriptive correlational study that
tested a theory of family interdependence among 157
Korean elder-family caregiver dyads in Seoul, Korea
(Kim et al., 2011). An Institutional Review Board’s
907
Human Subjects Committee approved this study. Prior to
data collection, participants provided informed consent.
Sample
Dyads consisting of both elders and their family care-
givers were the target population. The inclusion criteria
for the elders were: (1) 60 years of age or older; (2)
receiving family caregiving from someone who was living
in the same household; (3) able to read or speak Korean;
and (4) absence of a serious cognitive disorder (to ensure
their ability to communicate clearly with an interviewer
and complete questionnaires). They were asked basic
demographic questions (e.g., name, birth date, age,
address, telephone number, and current date) to assess
their cognitive and communication abilities. The sample
criteria for caregivers were: (1) 20 years of age or older;
(2) regarded themselves as the primary caregivers of eligi-
ble elders; (3) able to read or speak Korean; and (4) co-
resided with the elder. A primary caregiver was a family
member who attended to the needs of an elder and
provided care functionally or economically or at least
daily assistance for elders’ activities of daily living
(ADLs). Family caregivers could be the elder’s spouse,
daughter, son, son-in-law, daughter-in-law, grandchildren,
or other relatives who lived with the elder and provided
care for them.
A convenience sampling method was used to recruit
230 Korean elders from welfare centers, senior commu-
nity centers, and religious institutions (i.e., churches and
temples) in Seoul Korea by using flyers and announce-
ments in community bulletins. Of the 230 recruited, 192
 908 S.-S. Kim et al.
dyads met the inclusion criteria; however, 35 dyads
including 21 elders and 14 caregivers were excluded
because one member of the dyad did not complete the
questionnaire. One hundred fifty-seven Korean
elder–family caregiver dyads (82%) were the final sample
for this analysis. Of the final 157 dyads, 6 (3.8%) were
recruited from a welfare center, 21 (13.4%) from senior
community centers, 60 (38.2%) from churches, 14 (8.9%)
from temples, and 56 (35.7%) were referred by partici-
pants. Data were collected separately from older adults
and family caregivers in their homes.
Measures
Demographic factors used as controls in these analyses
included age (in years), gender (female ¼ 0, male ¼ 1),
and education (assessed on an 8-point scale from ‘no edu-
cation’ to ‘doctoral degree’). All instruments used in the
study have established reliability and validity (see
Table 2). The coefficients met the standard criterion (.80
or above) as recommended by Zeller and Carmines
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(1980). These instruments were translated from English
into Korean using an initial translation and back transla-
tion method.
Self-transcendence scale
Spirituality was measured by the self-transcendence scale
(STS; Reed, 1986) and the spiritual perspective scale
(SPS; Reed, 1987). The STS (Reed, 1986; Korean transla-
tion by Kim, Reed, Kang, & Oh, 2012) consists of 15
items indicating specific behaviors or perspectives involv-
ing the expansion of self-boundaries in several ways:
inwardly through introspective activities, outwardly
through involvement with others, transpersonally through
reaching toward spiritual dimensions, and temporally by
living in the present or holding perspectives of past and
future that enhance the present (Sample item: ‘Accepting
myself as I grow older’, ‘Sharing my wisdom or experi-
ence with others’). Each item is measured on a 4-point
scale from ‘not at all’ to ‘very much.’ Possible scores
range from 15 to 60; higher scores indicate greater self-
transcendence.
Spiritual perspective scale
The SPS (Reed, 1987; Korean translation by Kim et al.,
2012) consists of 10 items to measure the saliency of a
spiritual perspective and practices in a person’s life (Sam-
ple item: ‘In talking with your family or friends, how
often do you mention spiritual matters?’ ‘How often do
you share with others the problems and joys of living
according to your spiritual beliefs?’). Each item is mea-
sured on a 6-point scale from ‘strongly disagree’ to
‘strongly agree.’ Spiritual perspective is defined as a form
of self-transcendence that emphasizes religious as well as
broader spiritual views and practices including prayer,
meditation, forgiveness, and belief in God or a higher pur-
pose, where there is a distinct sense of connectedness to
something greater than the self (Reed, 1991). Possible
scores range from 10 to 60; higher scores indicate a
greater spiritual perspective.
Purpose in life
The purpose-in-life test (PIL; Crumbaugh, 1968; Korean
translation by Kim, 2008) includes 20 items measuring
one’s sense of purpose (Sample item: ‘In life I have: no
goals or aims at all – very clear goals and aims’ ‘My life is:
in my hands and I am in control of it – out of my hands and
controlled by external factors’). The respondent answers
questions based on the stem phrase ‘My personal existence
is’ on a scale from 1 for ‘utterly meaningless and without
purpose’ to 7 for ‘very purposeful and meaningful.’
Possible scores range from 20 to 140; higher scores indicate
a greater sense of purpose and meaning in life.
Depression
The outcome variable of depression was measured by the
Center for Epidemiological Studies-Depression Scale
(CES-D; Radloff, 1977; Korean translation by Choi &
Kim, 1998). The CES-D measures the current level of
depression by 20 items rated by frequency, such as ‘I had
crying spells.’ Total scores range from 0 to 60; higher
scores indicate greater experience of depressive symp-
toms during the previous week. Scores of 16 or above
indicate that an individual is at risk for clinical depression.
Data analysis
The hypotheses derived from the mediation model
described above were tested using path analysis. The ini-
tial model is shown in Figure 1. For clarity of presenta-
tion, the figure does not depict certain relationships that
were calculated as part of the final model results. These
include controlling for demographic variables (gender,
age, education, and marital status) in the equations for
PIL and CES-D, and allowing covariances between all
exogenous variables (STS, SPS, and all demographics for
elders and caregivers). Descriptive statistics and bivariate
correlations for all model variables are presented in
Table 2. Analyses were conducted with AMOS 20.0. Indi-
rect effects were computed automatically using this
method, and significance tests for these indirect effects
were conducted using bootstrapping methods to produce
bias-corrected confidence intervals (Nevitt & Hancock,
2001).
Results
Sample characteristics
Descriptive statistics for elder and caregiver demo-
graphics are presented in Table 1. The final sample for all
analyses was 314 individuals, grouped into 157 elder–
caregiver dyads. Caregivers’ ages ranged from 26 to 77
with a mean of 51.01 (SD ¼ 12.30). Elders’ ages ranged
from 60 to 94 with a mean age of 67.99 (SD ¼ 7.24).
The mean CES-D score of elderly participation was 10.92
 Aging & Mental Health 909

Table 1. Descriptive statistics.

Mean (SD) or N (%) Range Reliability (a)

Elders
Age 67.99 (7.24) 60 94
Gender (male) 86 (54.8%)
Educationa 4.41 (1.96) 1 8
Married 119 (75.8%)
Self-transcendence scale (STS)b 44.74 (6.30) 26 58 .85
Spiritual perspective scale (SPS)b 43.70 (13.87) 10 60 .97
Purpose-in-life test (PIL)b 95.18 (18.77) 44 135 .91
Center for Epidemiological Studies-Depression Scale (CES-D)b 10.92 (9.28) 0 40 .91
Caregivers
Age 51.01 (12.30) 26 77
Gender (male) 29 (18.5%) 0 1
Educationa 5.21 (1.34) 2 8
Married 143 (91.1%) 0 1
Self-transcendence scale (STS)b 45.94 (5.82) 29 59 .85
Spiritual perspective scale (SPS)b 46.10 (12.92) 10 60 .97
Purpose-in-life test (PIL)b 99.13 (16.85) 47 140 .91
Note: STS, self-transcendence scale; SPS, spiritual perspective scale; PIL, purpose-in-life test; CES-D, Center For Epidemiological Studies-Depression
Scale.
a
Education was assessed on an 8-point scale from ‘no education’ to ‘doctoral degree’.
b
Raw additive scores for multiple-item scale.
Downloaded by [UQ Library] at 14:43 31 October 2014

(SD ¼ 9.28), with a score range of 0–40 (possible maxi-
mum score is 60); 22.3% of the participants scored 16 or
more; and 10.2% scored 25 or more. The cut-off point of
16 and 25 was used to screen for probable and definite
depression, respectively, in Korean older adults (Park &
Kim, 2011). Elders answered how many days they had
been in bed at home due to sickness or illness in the past
six months; the mean was 4.37 (range 0–100 days). The
mean days spent in hospitals due to sickness or illness in
the past six months was 5.71 (range 0–150 days). The
number of different medications taken for sickness or ill-
ness in the past six months ranged from 0 to 10 with a
mean of 1.79.
Relationships among study variables
The correlation matrix for the model variables shows that
several study and demographic variables were significantly
associated with elders’ depression at the bivariate level
(Table 2). Among elders, lower depression was found
among men; more highly educated individuals; married
people; and those with higher levels of self-transcendence,
spiritual perspective, and purpose in life. Among family
caregivers, lower depression was found among those who
were older; more highly educated; and who had higher lev-
els of spiritual perspective and purpose in life.
Testing of the hypothesized model
Path analysis was performed to determine the direct and
indirect effects of spiritual perspective, self-transcen-
dence, and purpose in life on elders’ depression in family
caregiving relationships with Korean elders. Results are
presented in Table 3, and illustrated in Figure 2. Model
statistics indicated a good fit with the data, x2(20) ¼
26.15, p ¼ .161, RMSEA ¼ .044, GFI ¼ .978, CFI ¼
.995, AGFI ¼ .870. Comparing these results with an
alternative model eliminating mediation through purpose
in life revealed mixed results (alternative: x2[4] ¼ 1.76,
p ¼ .133, RMSEA ¼ .070, GFI ¼ .993, CFI ¼ .997,
AGFI ¼ .846). The RMSEA and AGFI indexes indicated
that the hypothesized model fit the data better, whereas
the GFI and CFI indicated a better fit for the alternative
model.
Consistent with hypothesis 1, both caregivers’ and
elders’ self-transcendence was positively related to their
own sense of purpose in life (caregivers: b ¼ 21.50, p <
.001; elders: b ¼ 14.48, p < .001), and elders’ spiritual
perspective was related to purpose in life (b ¼ 2.49,
p ¼ .030). However, spiritual perspective was not related
to purpose in life among caregivers (b ¼ 2.00, p ¼ .189).
Consistent with hypothesis 2, elders’ purpose in life was
positively associated with their caregivers’ purpose in life
(b ¼ 0.19, p ¼ .003). Hypothesis 3 was partially
supported; as anticipated, there was a strong negative
relationship between elders’ purpose in life and their
depressive symptoms (b ¼ 0.32, p < .001), but there
was not a significant negative relationship between
caregivers’ purpose in life and elders’ depressive symp-
toms. Hypothesis 4, which predicted that elders’ purpose
in life would mediate the effects of other study variables
on elders’ depression, was also supported. Analysis of
indirect effects, based on bias-corrected bootstrap-based
confidence intervals, indicated that elders’ depression
scores were indirectly related to several key model varia-
bles via the pathway of elders’ purpose in life, including
their own levels of self-transcendence (b ¼ 4.62, p ¼
.007) and spiritual perspective (b ¼ 0.79, p ¼ .027), and
their caregivers’ self-transcendence (b ¼ 1.45, p ¼ 0.34)
and sense of purpose in life (b ¼ 0.06, p ¼ .011). In
other words, elders’ purpose in life mediated the negative
effects of elders’ self-transcendence and spiritual perspec-
tive, and caregivers’ self-transcendence and sense of pur-
pose in life on elders’ depression.
Demographic factors are not illustrated in Figure 1,
but were included in the model. Caregivers’ gender
 910 S.-S. Kim et al.

0.62
Table 3. Model results.
14
Elder CES-D

Caregiver PILa Elder PILa Directa Indirectb

0.87
0.69
13

Elders
Age 0.29 0.05 0.09
(0.11) (0.04) (0.07)
1.11 0.62

0.12
0.14
0.12
Gender (male) 1.95
12

(0.05) (0.06) (0.03)

Education 2.21 0.08 0.70
(0.23) (0.02) (0.15)

0.23
0.24
0.20
0.71 1.55

0.05
Married 4.91
11

(0.11) (0.03) (0.07)

STS 14.48 4.62
(0.34) (0.22)
2.49 0.79
0.24
SPS
0.17
0.08
0.11

0.12
10

(0.24) (0.15)
PIL 0.32
Note: STS, self-transcendence scale; SPS, spiritual perspective scale; PIL, the purpose-in-life test; CES-D, Center for Epidemiological Studies-Depression Scale. (0.63)
Caregivers
0.32

0.28

0.01
0.22

Age 0.08
0.19
0.03
0.12
9

(0.06) (0.01)
Gender 9.22 0.62
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(0.21) (0.03)
Education 0.80 0.05
0.26

0.29
0.23

0.23

(0.06) (0.01)
0.04

0.11
0.14

Married 2.06 0.14

8

(0.04) (0.004)
STS 21.50 1.45
(0.51) (0.06)
0.67

0.26

0.26
0.33
0.41

0.14
0.22

SPS 2.00
0.01

0.14

(0.20) (0.02)
7

PIL 0.19 0.01 0.06

(0.17) (0.02) (0.11)
Notes: STS, self-transcendence scale; SPS, spiritual perspective scale;
0.63
0.38

0.26

0.37
0.32
0.24
0.16

PIL, the purpose-in-life test; CES-D, Center For Epidemiological Stud-

0.04
0.02
6

ies-Depression scale.
a
Scalar and (standardized) regression weights.
b
Bias-corrected bootstrap estimates.

p < .05, p < .01, p < .001.
0.85
0.66
0.36

0.25
0.29
0.30
0.20
0.17
0.06
0.02
5

(b ¼ 9.22, p < .001) was related to caregivers’ purpose in

life, such that male caregivers tended to report higher lev-
els of purpose in life. Other demographic characteristics
0.29
0.24

were unrelated to purpose in life among caregivers.

0.001
0.21
0.10
0.03

0.11
0.14
0.11
0.13
0.06
4

Among the elders’ demographic controls, only level of

education was related to purpose in life (b ¼ 2.21, p ¼
.002). Additionally, the demographic factors of elders’
level of education (b ¼ 0.70, p ¼ .012) and caregivers’
0.54
0.33
0.29
0.49
0.37

0.38

0.29

0.28
0.40
0.26
0.19
0.13

gender (b ¼ 0.62, p ¼ .039) were related to elders’ lev-

3
Table 2. Correlation matrix for model variables.

els of depression.
0.58
0.50

0.27

0.41

0.27
0.25

0.19

0.19

Discussion
0.11
0.04

0.08
0.12

0.14
2

In this study, we tested a mediated model of elder depres-

sion, which examined the direct and indirect effects of
p < .05, p < .01, p < .001.

spirituality and purpose in life on depression within the

0.47
0.53
0.24

0.18

context of Korean family caregiving relationships. Results

0.15
0.08
0.15
0.10

0.13

0.12
0.06
0.10
0.09
0.05
1

comparing our hypothesized mediated model with an

alternative unmediated model were mixed, with the
RMSEA and AGFI indexes indicating that the hypothe-
11. Education
3. Education

sized model fit the data better, and the GFI and CFI indi-
12. Married
10. Gender
Caregivers
4. Married
2. Gender

8. CES-D
Measures

cating a better fit for the alternative model. However, it is

13. STS
14. SPS
15. PIL
5. STS
1. Age

9. Age
6. SPS
Elders

7. PIL

important to note that the GFI and CFI are highly sensitive
to the number of parameters in the model and tend to

 Aging & Mental Health
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Figure 2. Illustration of path results.
Note: Effects estimated but not illustrated in figure include elder demographics (gender, age, education, and marital status) on elder PIL
and elder CES-D; caregiver demographics on caregiver PIL; and covariances between all exogenous variables. p < .05, p < .01,

p < .001.
favor models with fewer degrees of freedom. Because the
number of parameters in the two models differed greatly,
the AGFI and RMSEA were better methods of judging
relative fit in this situation.
Regarding the relationship between spirituality and
purpose in life in individuals, the results of our path analy-
sis demonstrated that higher levels of self-transcendence
and spiritual perspective were positively associated with
higher levels of purpose in life among Korean older
adults. These findings are consistent with a previous study
in which investigators found positive relationships
between self-transcendence and purpose in life among the
oldest old (Nygren et al., 2005). However, among care-
givers, only self-transcendence, not spiritual perspective,
significantly predicted purpose in life. This may be due, in
part, to the age differences between older adults and care-
givers. In this study, the caregivers who were younger
tended to have lower levels of spiritual perspective than
older adults (Moberg, 2005). The lower spiritual perspec-
tive scale scores may have lacked the variability among
the caregivers to generate a significant relationship with
purpose in life.
More importantly, these results supported the exis-
tence of interdependency within elder–caregiver dyads.
As expected, caregivers’ purpose in life was positively
related to elders’ purpose in life. This is congruent with
the results from a prior study conducted among commu-
nity-dwelling older adults’ spousal dyads, which revealed
that greater satisfaction with the meaning and purpose of
life one’s spouse experienced significantly correlated with
the other spouses’ satisfaction with the meaning and
911
purpose of life (Bookwala & Schulz, 1996). One possible
explanation for this result may be the interdependence
between elders and caregivers in a transpersonal caring
relationship. Watson (1988) defined the transpersonal car-
ing relationship as one in which there are mutual influen-
ces between caregiver and care receiver. Caregivers may
develop new meaning from the caregiver role (Kidd,
Zauszniewski, & Morris, 2011). At the same time they
may help their care-receiving partners restore or recon-
struct the sense of meaning eroded by role loss (Pinquart,
2002) by reconciling the past life with present and future,
and viewing their vulnerability and life challenges from a
different perspective.
We found that elders’ purpose in life was directly
related to elders’ depression. However, caregivers’ pur-
pose in life was indirectly related to elders’ depression
through elders’ purpose in life. In other words, elders’
depressed affect was influenced directly by their own pur-
pose in life and indirectly by family caregivers’ purpose
in life once the interdependency of elders’ and caregivers’
sense of purpose in life was taken into account. Again,
these results are consistent with past studies that having a
strong sense of purpose in life reduced depression among
older adults (Krause, 2007; Nygren et al., 2005). More-
over, they contribute new knowledge about the relation-
ship of caregivers’ purpose in life on elders’ depression
through elders’ purpose in life. These findings suggest
that caregivers may help older adults decrease depressive
symptoms by actively taking part in a joint process of
reconstructing a sense of meaning in life for both them-
selves and older adults.
 912 S.-S. Kim et al.
Last, we also found mediating effects of purpose in
life between elder spirituality and elder depression. While
spirituality alone may not impact elder depression,
purpose in life may have a more direct influence on
depression than spirituality. Previous research has
reported that purpose in life and depression were found to
be significantly and inversely related (Krause, 2007).
Furthermore, elders’ purpose in life mediated the effects
of caregivers’ self-transcendence on elders’ depression in
the family caregiving relationship such that elder depres-
sion was reduced. These findings are consistent with those
of a previous study conducted among cancer patients, in
which investigators found that having a purpose in life
significantly increased the beneficial effects of spirituality
on depression (Nelson et al., 2009).
The results contribute new knowledge about the impor-
tance of purpose in life by its mediating role on depression,
through both caregivers’ and elders’ spirituality in the
transpersonal caring relationship. One potential implica-
tion of these findings is to develop interventions designed
to reduce depression and enhance purpose in life by facili-
Downloaded by [UQ Library] at 14:43 31 October 2014
tating self-transcendence. Self-transcendence can promote
a sense of purpose in life for not only elders but also for
their caregivers. Thus, promoting self-transcendence in
both members of caregiving dyads may serve to decrease
the symptoms of depression in older adults receiving care
by enhancing both partners’ sense of purpose.
Interventions to facilitate self-transcendence and
improve meaning in life have been suggested. For exam-
ple, several researchers suggested reminiscence therapy
and life review intervention for depressed older adults
(Pot et al., 2010; Westerhof, Bohlmeijer, van Beljouw, &
Pot, 2010), and a poetry-writing intervention for family
caregivers of elders with dementia (Kidd et al., 2011).
However, the findings here support developing interven-
tions at the elder–caregiver dyad level, family level as
well as at the individual level.
Limitations
Our results should be interpreted with caution due to the
research method we used. First, a convenience sample
was used and thus the study participants may not be repre-
sentative of the Korean older adult population as a whole.
A large proportion of this sample was recruited from
churches and temples, and these religiously involved older
adults may have been more spiritually oriented and less
depressed than the general population. Additionally, the
relationship between caregivers’ gender and elders’
depression is somewhat unexpected, but appears to be
attributed to the exceptionally strong relationship between
male gender and greater sense of purpose in life among
caregivers. However, given the relatively small proportion
of male caregivers in the sample (18.5%), this effect
should be explored further with a larger sample and needs
to be interpreted with caution. Furthermore, the data were
collected cross-sectionally, making it impossible to infer
causality; there may be other plausible explanations for
the relationships observed among the variables examined
in this particular model. For example, it is not possible to
rule out the possibility that the relationship between
dyadic partners’ purpose in life is due to stable personality
traits shared within families, rather than the result of
dynamic interpersonal influences as our model suggests.
Finally, the family-oriented nature of Korean culture may
enhance the extent of dyadic interdependence found in
this study, and thus the model tested in this study may
need further adaptations to be appropriate for use in dif-
ferent cultural contexts.
Conclusion
Understanding the protective mechanisms of spirituality
and purpose in life on later life depression with samples
of Korean elders and caregivers can be helpful for design-
ing culturally appropriate interventions for Korean elders’
depression within the Korean family caregiving relation-
ship. These interventions could help restore both care-
givers’ and elders’ purpose in life within the context of
the family caregiving relationship and help older people
deal more effectively with late-life depression. Our study
represents a first step in mapping the pathways by which
spirituality and purpose in life of both caregivers and eld-
ers may contribute to decreased depression among Korean
elderly within the context of family caregiving.
Acknowledgements
This study is a secondary data analysis using data from doctoral
dissertation research of the first author, Dr Suk-Sun Kim. This
research was supported by the Susie Dissertation Research Fel-
lowship from the Global Korean Nursing Foundation (GKNF).
We gratefully acknowledge editing by Dr Beverly Rosenthal.
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