Informal Caregiving: Differential Experiences by Gender

Author(s): Maryam Navaie-Waliser, Aubrey Spriggs and Penny H. Feldman

Source: Medical Care , Dec., 2002, Vol. 40, No. 12 (Dec., 2002), pp. 1249-1259
Published by: Lippincott Williams & Wilkins

Stable URL: https://www.jstor.org/stable/3767944

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MEDICAL CARE
Volume 40, Number 12, pp 1249-1259
?2002 Lippincott Williams & Wilkins, Inc.

Informal Caregiving
Differential Experiences by Gender

MARYAM NAVAIE-WALISER, DRPH, AUBREY SPRIGGS, MA, AND PENNY H. FELDMAN, PHD

BACKGROUND. With an aging population and were examined between the genders using
descriptive and multivariate analyses.
public policies that limit accessible and afford-
able formal care services, informal caregivers, RESULTS. Compared with men caregivers,
largely women, will continue bearing the over- women caregivers were significantly more
likely to be 65 years of age or older, black,
whelming responsibility for home and long-
term care services provision. married, better educated, unemployed, and
OBJECTIVES. This study examined gender dif- primary caregivers; provide more intensive
ferences among informal caregivers in caregiv- and complex care; have difficulty with care
provision and balancing caregiving with other
ing activities, intensity, challenges, and coping
strategies and assessed the differential effects
family and employment responsibilities; suf-
of caregiving on their physical and emotional fer from poorer emotional health secondary to
well-being. caregiving; and cope with caregiving responsi-
RESEARCH DESIGN. Cross-sectional study con- bilities by forgoing respite participation and
ducted between May and September 1998. engaging in increased religious activities.
SUBJECTS. Telephone interviews were con- CONCLUSIONS. Informal caregivers, particu-
ducted with a randomly selected, nationally larly women, are under considerable stress to
representative sample of 1002 informal provide a large volume of care with little
caregivers. support from formal caregivers. Program plan-
MEASURES. Caregivers' sociodemographic, ners, policy makers, and formal care providers
and physical and emotional health characteris- must act together to provide accessible, afford-
tics; caregiving type and intensity; formal care able, and innovative support services and pro-
support; difficulty with care provision; unmet grams that reduce family caregiving strain.
needs; coping strategies; and the care recipi- Key words: Caregiving; informal care; gen-
ents' health and relationship with caregiver der. (Med Care 2002;40:1249-1259)

National projections estimate that older adults As the population ages, demands for dependent
will continue to be the fastest growing sector of care from both formal (ie, paid health care profes-
the US population during the next two decades, sionals or paraprofessionals) and informal (ie,
with women comprising most aging Americans.1"2 unpaid family and friends) caregivers are likely to

From the Center for Home Care Policy and Research,
Visiting Nurse Service of New York, New York.
Supported by the Henry J. Kaiser Family Foundation
and Visiting Nurse Service of New York.
Earlier versions of this paper were presented at the
annual meetings of the American Public Health Associ-
ation, Atlanta, GA, October 2001, and the American
Psychological Association, Washington, DC, October
2001.
Address correspondence and reprint requests to: Maryam
Navaie-Waliser, DrPH, Senior Research Associate, Center for
Home Care Policy and Research, Visiting Nurse Service of
New York, 5 Penn Plaza, 11th Floor, New York, NY 10001.
E-mail: maryam.navaie@vnsny.org
Received August 28, 2001; initial review October 25,
2001; accepted June 3, 2002.
DOI: 10.1097/01.MLR.0000036408.76220.1F

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NAVAIE-WALISER ET AL MEDICAL CARE

increase. In light of limited access, availability, givers'

and experiences. Within one study, they do not
affordability of formal care services, the currentlycomprehensively examine differences in caregiv-
estimated 15 to 25 million informal caregivers inintensity, care provision supplemental to ADLs
ing
the United States are likely to continue bearing and the IADLs to both elderly and nonelderly care
overwhelming responsibility for the provision of
recipients, challenges of caregiving, difficulty and
home and long-term care services.3-5 perceived needs with care provision, and the ef-
Differences in caregiving between the genders
fects of care provision on the caregivers' own
are of high interest among consumers, advocates,
physical and emotional well-being.
and service providers. Past research consistently
The purpose of the present study is to extend
past research by using a large, nationally-
has found that informal caregiving is dominated
by women, who comprise nearly three-quarters of
representative sample of informal caregivers to
the total number of caregivers.6-8 The literature
address the following research questions: (1) are
suggests that compared with men, women are
there gender differences among caregivers in care
more likely to take on the role of a primary provision type, complexity, and intensity as mea-
caregiver,9-13 care for a spouse or a parent,'1,1314
sured by care volume, frequency, and duration; (2)
spend considerably more hours caring for sick are there gender differences among caregivers in
relatives,9-13 and provide more hands-on care
the type, complexity and intensity of care provided
with activities of daily living (ADL), instrumental
to nonelderly as compared with elderly care recip-
activities of daily living (IADL),1014-18 housework,
ients; (3) are there gender differences in the chal-
and meal preparation.9"14,17,19 Studies also havelenges caregivers face, such as lack of adequate
shown that women's mental health is more likely support from formal care providers, difficulties
to be adversely affected by caregiving than men's,
with rendering care, and unmet perceived needs
as evidenced by greater feelings of burden, stress,
with care provision; (4) are there gender differ-
ences
anxiety, and depression.8,13,16,1719-24 In addition to among caregivers in the physical and emo-
suffering from poor mental health, women care-
tional health effects experienced secondary to
givers also tend to have exacerbated physical
caregiving; and (5) are there gender differences in
ailments associated with caregiving suchcoping as strategies used by caregivers to handle
chronic fatigue, sleeplessness, stomach problems,
caregiving responsibilities.
and weight change.25,26 Moreover, compared with
men caregivers, women caregivers are less likely to
practice health promoting behaviors,27 with fewer Materials and Methods
health behaviors observed as caregiving burden
intensifies.28-30
Study Design and Sample
Although past studies provide insightful details
about the differential experiences of women and An equal probability for selection method
men as informal caregivers, most have limitations
(EPSEM) sampling technique was used to perform
in methodology, in the populations examined,Randomor Digit Dialing. Telephone interviews were
in content, which limits generalizability of study
conducted with a nationally representative cross-
findings. With regard to methodology and sample section of 4874 households between May and
selection, past studies generally have been con-September 1998. Eligibility for study inclusion was
restricted to persons 18 years of age or older who
ducted on relatively small, nonrepresentative, con-
venience samples of caregivers. Moreover, these were directly providing unpaid care or arranging
for paid care to a relative or friend for anytime
studies primarily have focused on populations that
provide care to friends and relatives with severe
during the 12 months preceding the study. A
randomly-selected respondent within each house-
debilitating illnesses, such as dementia or Alzhei-
mers disease. Studies that have focused specifi- hold completed a structured, pretested survey
questionnaire. Interviews were conducted in En-
cally on gender differences in caregiving generally
center only on either spouse caregivers or parent-glish and Spanish and were, on average, 24 min-
child dyad relationships and examine principally utes in duration.
care provided to elderly care recipients (ie, persons
By applying the American Association for Pub-
65 years of age or older). With regard to contentlic Opinion Research's response rate calculations
limitations, past studies provide a relatively nar-
(available from the authors or via the organiza-
row comparative view of women and men care- tion's Web site [www.aapor.org/ethics/stddef-

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Vol. 40, No. 12 INFORMAL CAREGIVING BY GENDER

.html]), a 65% participant response rate (propor- tions), bivariate analyses (eg, Mantel Haenszel X2
tion of participants of unknown eligibility who test), and multivariate modeling. Using logistic
agreed to be screened) was calculated using an regression, a series of models was used to assess
overall screen-in (eligibility) "incidence" ratethe of degree to which gender was an independent
20% and "accuracy of sample" rate of 47% (ie, the predictor of several dependent variables including
proportion of telephone numbers never reached difficulty with care provision, perceived unmet
that could have been households with or without needs with providing care, reported decline in
physical health as a consequence of caregiving,
caregivers). In addition, an overall caregiver coop-
eration rate (proportion of all caregivers inter- difficulty balancing caregiving with other family
responsibilities, difficulty balancing caregiving
viewed of all eligible caregivers ever contacted) of
83% was obtained. After initial screening, 1002 with employment responsibilities, losing temper
(54% women and 46% men) individuals who met with family and friends as a consequence of
caregiving, losing temper with care recipient as a
the eligibility criteria gave verbal consent to par-
ticipate in the study. consequence of caregiving, forgoing respite activ-
ities to take on caregiving role, and experiencing
increased religiosity since becoming a caregiver.
Data Collection Each of the models controlled for the potential
confounding effects of the care recipient's physical
Data were collected by interviewers who re-
health; caregiving intensity; being a primary care-
ceived intensive training on participant recruit-
giver; and the caregiver's age, race/ethnicity, mar-
ment techniques, telephone interviewing strate-
ital status, and employment status. In addition,
gies, and appropriate response coding from
four interaction terms between gender and other
researchers at the National Opinion Research
independent variables including marital status, the
Center (NORC) in Chicago, IL. A wide range of
care recipient's health status, caregiving intensity,
data was collected by the trained interviewers
and being a primary caregiver were tested in each
including: (1) sociodemographic characteristics of
of the models to explore potential mechanisms
caregivers and care recipients; (2) relational char-
through which gender may affect caregiving re-
acteristics of caregivers and care recipients; (3)
sponsibilities and outcomes but none was found
type of care provided specific to activities of daily
to be statistically significant.
living (ADLs), instrumental activities of daily living
Crude and adjusted odds ratios (ORs), 95%
(IADLs), and other complex tasks including dress-
confidence intervals (CIs), and P values were com-
ing changes, assistance with use of medical equip-
puted. Poststratification weight adjustments rang-
ment, and help in administering prescription med-
ing in value from 0.05 to 7.76 were constructed
ications; (4) hours of care provided per week; (5)
using the following five variables with specified
duration of care; (6) use of formal caregivers (ie,
categories: age 18-29, 30-39, 40-49, 50-64, 65
paid health care professionals or nonprofession-
and older, sex (male; female), race (white; black;
als) by the care recipient; (7) difficulty with care
other), education (less than high school; high
provision; (8) perceived unmet needs with care
school and some college; college graduate and
provision; (9) the caregivers' physical well-being;
more), and Region (Northeastern; Midwestern;
(10) the caregivers'emotional well-being; and (11)
South; West). All the analyses were weight-
the care recipients' physical well-being.
The Level of Care Index6 was used to determine adjusted to represent the general population using
the aforementioned variables to measure repre-
caregiving intensity. This index combines the
sentativeness.31,32 Marginal distributions were es-
number of ADLs and IADLs performed by the
timated using 1996 Population Estimates gener-
caregivers with the hours of care provided weekly
ated by the Bureau of Census.33
to generate a composite score based on a 5-point
scale where 1 = least intensive and 5 = most
intensive.
Results

Statistical Analyses Descriptive Analysis

SPSS software was used to perform descriptive Sociodemographic, Relational, and Physical
statistics (eg, frequencies, means, standard devia- Health Characteristics of Caregivers and Care

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NAVAIE-WALISER ET AL MEDICAL CARE

Recipients. As shown in Table 1, women care- adjusting for being a primary caregiver and strat-
givers were significantly more likely than men ifying the data by caregiver gender and the care
caregivers to be 65 years of age or older, black, recipients' age, significant patterns of care were
married, better educated, and unemployed. The observed among caregivers. Women caregivers
average age of women caregivers was 46 years (SD were more likely than men caregivers to focus
= 16), as compared with men caregivers, which IADL care provision toward the elderly, whereas
was 40 years (SD = 17) (P = 0.012). In examining assistance with LADLs provided by men caregivers
were more equally distributed between nonelderly
the caregiver-care recipient's relationship, the re-
and elderly care recipients. Although fewer differ-
sults revealed that most the caregivers were family
ences between genders were observed in ADL
members of the care recipient, although women
care provision, as compared with men caregivers,
were more likely than men to be primary caregiv-
ers. Most women and men caregivers (64% and women caregivers were more likely to provide
66%, respectively) were providing care to care assistance with bathing and dressing to both non-
recipient's who were 65 years of age or older. Theelderly and elderly care recipients. In addition,
average age of care recipients was 66 years (SDwomen= caregivers were more likely than men
22). No significant differences were observed caregivers
in to provide care with incontinence and
living arrangements between women and men ambulating to nonelderly care recipients. Further-
caregivers and their care recipients. An examina- more, as compared with men caregivers, women
caregivers were more likely to assist elderly care
tion of the caregivers' and care recipients' physical
health revealed that women caregivers were not recipients with medical equipment use, nonelderly
only more likely than men caregivers to be caring care recipients with polypharmacy, and both el-
derly and nonelderly care recipients with dressing
for a sicker population of care recipients, but they
themselves were more likely to be in poorer
changes. Moreover, although both genders were
health. more likely to render higher intensity care to
Activities and Challenges of Caregivers.
nonelderly care recipients, women caregivers pro-
After adjusting for being a primary caregiver,vided more highly intensive care to all care recip-
ient, irrespective of age, as compared with men
women caregivers were significantly more likely
caregivers.
than men caregivers to be providing more inten-
sive care including assistance with nearly every
ADL and IADL and with relatively complex tasks
Multival ate Analis
including dressing changes, assistance with med-
ical equipment use, and polypharmacy. Moreover,
women caregivers were more likely than men After adjusting for the potential confounding ef-
fects of selected caregiver characteristics, being a
caregivers to report difficulty with care provision
and to have unmet needs with providing care. primary caregiver, the care recipient's health, and
However, men caregivers were as likely as women caregiving intensity, results from logistic regression
caregivers to be providing care for 20 or more analyses revealed significant gender differences
hours per week and to be long-term care provid- among caregivers in care provision challenges, emo-
tional well-being, and coping strategies. With regard
ers; that is, providing care for one or more years.
Furthermore, nearly 80% of women and mento care provision challenges, female gender was a
significant predictor of experiencing difficulty with
informal caregivers received no support in render-
ing care from formal care providers. providing care and perceiving unmet need with care
Proportional Differences in Care Provision
provision. In addition, women caregivers were more
Activities and Intensity for Nonelderly and
likely than men caregivers to experience greater
Elderly Care Recipients By Caregiver Gender.emotional challenges stemming from difficulties
Although most caregivers were providing care with to balancing caregiving and other familial and
employment obligations. Moreover, the finding sug-
elderly care recipients (ie, 65 years of age or older;
comprising 65% of care recipients), a significant gested that, as compared with men caregivers,
fraction of the support they provided was to women caregivers' approach to handling caregiving
nonelderly care recipients (ie, younger than responsibilities
65 more often resulted in forgoing re-
years of age), 20% of whom were younger than spite
50 activities and increasing involvement in reli-
years of age and another 15% were between 50gious activities. Although interaction effects between
and 64 years of age. As shown in Table 3, after
gender and marital status, the care recipient's health

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Vol. 40, No. 12 INFORMAL CAREGIVING BY GENDER

TABLE 1. Sociodemographic, Relational, and Physical Health Characteristics of Informal Caregiv

Care Recipients

Characteristic Women n (%) Men n (%) OR (95% CI)t?

Sociodemographic Characteristics
Informal Caregivers
Age (years)
<65 482 (85) 438 (90) Referent
>65 83 (15) 48 (10) 1.57 (1.08, 2.29)t
Race/Ethnicity
Non-Hispanic, White 437 (77) 380 (78) Referent
Black 82 (14) 40( 8) 1.78 (1.19, 2.67)t
Hispanic 43( 8) 56 (12) 0.67 (0.44, 1.02)
Other 6( 1) 11( 2) 0.47 (0.17, 1.23)
Marital status?
Not married 204 (36) 219 (45) Referent
Married 365 (64) 270 (55) 1.45 (1.13, 1.89)t
Education levelq
> High school graduate 299 (53) 225 (46) Referent

- High school graduate 269 (47) 264 (54) 0.70 (0.60, 0.97)*
Employment status (part or full time)[
Unemployed 246 (43) 142 (29) Referent

Employed 323 (57) 346 (71) 0.54 (0.42, 0.70)t

Care Recipients
Age (years)
<65 202 (36) 163 (34) Referent
-65 359 (64) 321 (66) 0.90 (0.70, 1.17)
Sex
Male 188 (33) 181 (37) Referent
Female 383 (67) 311 (63) 1.19 (0.92, 1.53)
Relational Characteristics between Car
Affiliation with care recipient
Non-Family 67 (12) 61 (12) Referent
Family 503 (88) 432 (88) 1.06 (0.73, 1.54)
Primary caregiver
No 202 (39) 272 (60) Referent
Yes 317 (61) 179 (40) 2.38 (1.84, 3.09)t
Care recipient's living arrangement
Lives with 171 (30)
caregiver 132 (27) Referent
Lives alone 196 (34) 193 (39) 0.78 (0.58, 1.06)
Otherll 203 (36) 165 (34) 0.95 (0.79, 1.29)
Physical Health Characteristics
Informal Caregivers
Reports fair/poor health 106 (19) 67 (14) 1.45 (1.04, 2.02)*
Has a serious medical illness 208 (36) 135 (27) 1.52 (1.17, 1.97)t
Care Recipients
Reports fair/poor health 339 (60) 251 (51) 1.40 (1.10, 1.79)t
Has a serious medical illness 425 (81) 298 (66) 2.18 (1.63, 2.91)t

Denotes statistical significance (Cochran Mantel-Haenszel chi-square test) at *P <.05 and tP <.01.
tCrude (unadjusted) odds ratio; CI = confidence interval.
?Data have been weight-adjusted.
[Results reported on available data; <1% participant data are missing.
IlIncludes living with someone other than the care recipient such as a friend or other relatives or residing in
assisted living or other formal setting.

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NAVAIE-WALISER ET AL MEDICAL CARE

TABLE 2. Activities and Challenges of Caregivers

Women Men Adjusted Odds Ratio

Variable n (%) n (%) (95% CI)t?
Caregiver Activitiesq
Type of care provided
Activities of Daily Living
Bathing 183 (35) 68 (15) 2.57 (1.86, 3.54)t
Dressing 265 (50) 143 (32) 2.08 (1.59, 2.71)t
Feeding 103 (20) 61 (13) 1.62 (1.14, 2.32)t
Incontinence 110 (21) 59 (13) 1.55 (1.09, 2.21)t
Transferring 219 (42) 177 (39) 1.09 (0.84, 1.42)
Ambulating 204 (39) 133 (29) 1.65 (1.25, 2.18)t
Instrumental activities of daily living
Shopping 503 (88) 398 (81) 1.53 (1.07, 2.20)t
Housework 425 (74) 331 (67) 1.18 (0.84, 1.50)
Preparing meals 385 (68) 244 (50) 1.67 (1.28, 2.20)t
Transportation 436 (76) 368 (75) 0.95 (0.70, 1.29)
Telephone calls 409 (72) 221 (45) 3.00 (2.29, 3.94)t
Managing finances 318 (56) 193 (39) 1.59 (1.21, 2.09)t
Government program assistance 191 (34) 121 (25) 1.29 (0.96, 1.75)
Complex care
Dressing changes 128 (25) 57 (12) 1.96 (1.38, 2.78)t
Medical equipment use 93 (18) 50 (11) 1.52 (1.04, 2.21)*
Assist with >2 medications 463 (90) 337 (76) 2.81 (1.95, 4.06)*
Provides ?20 hours/wk of carel 248 (45) 165 (35) 1.25 (0.94, 1.64)
Has been providing care for >1 years[ 450 (79) 377 (77) 1.03 (0.75, 1.40)
Caregiver Challenges[
Provides more intensive carell 244 (47) 141 (31) 1.64 (1.25, 2.16)t
Has no help from formal caregivers 440 (77) 406 (83) 1.22 (0.88, 1.71)
Has difficulty providing care 296 (52) 155 (32) 2.23 (1.70, 2.93)t
Has unmet needs with care provision 124 (22) 66 (13) 1.64 (1.56, 2.31)t

Denotes statistical significance at *P <.05 and tp <.01.

tOdds ratio have been adjusted for being a primary caregiver; CI = confidence interval.
?Data have been weight-adjusted.
TResults reported on available data; <1% participant data are missing.
IIA composite measure that combines the number of activities of daily living and instrumental activities of daily
living performed by the caregiver with the hours of care provided weekly.

status, caregiving intensity, and being a primary date, few studies have had an adequate sample in
caregiver were tested to explore potential mecha- size and representativeness to conduct compara-
nisms through which gender may have affected each tive analyses between women and men caregivers.
of the dependent variables modeled, none was The relatively large proportion of men caregivers
found to be statistically significant (results not in the present study provided a good opportunity
shown). to compare caregiving activities, challenges, and
effects from a gender-specific perspective. The
results revealed both commonalities and differ-
Conclusion
ences between women and men caregivers. Irre-
spective of gender, most caregivers were family
Because most unpaid caregivers are women,
most studies of caregiving are about women. To
members of the care recipient, had been providing

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Vol. 40, No. 12 INFORMAL CAREGIVING BY GENDER

TABLE 3. Proportional Differences in Care Provision Activities and Intensity for Non-Elderly a
Elderly Care Recipients by Caregiver Gender

Women Caregiverst Men Caregiverst

Care Recipient's Age Care Recipient's Age
<65 years -65 years <65 years -65 years
(n = 202) (n = 359) (n = 163) (n = 321)
Variable % % % %

Activities of Daily Li
Bathingt 37 30 17 13
Dressingt 53 43 31 29
Feeding 17 18 12 13
Incontinence* 22 18 10 13
Transferring 41 37 34 37
Ambulating* 36 36 24 29
Instrumental Activities of Daily Liv
Shopping* 83 92 76 83
Housework* 81 71 72 65

Preparing mealst 73 65 55 48
Transportation* 70 80 79 72
Telephone callst 69 75 38 49
Managing financest 57 55 41 39
Assist with government programs* 33 34 21 27
Complex care
Dressing changest 28 19 16 9
Medical equipment use* 18 15 13 9
Assist with -2 medications* 85 79 63 72
Provides more intensive caret[ 50 39 35 26

tData have been weight-adjusted and control for being

[A composite measure that combines the number of act
living performed by the caregiver with weekly hours
comparisons within care recipient age strata.

a large volume of care to nonelderly

juggling and life
one's own elderly
in t
relatives and friends for an one
loved extended
in poor period of
health.6,
time (one or more years), Several
and had possible
little support
mechani
from formal care providers. Findings
plain why these of gender
gender di
differences in caregivingamong
suggested
caregivers
that women
and how
spond
caregivers were more likely thandifferently
men caregiversto care
to
be 65 years of age or older,
First, married,
women and primary
men ca
their views
caregivers, in poorer emotional health;andto approache
care for
a sicker population of care recipients;
Findings from to provide
this study
more intensive assistance withthat
shown ADLs, IADLs,
women areandm
other complex tasks; to experience difficulty
primary caregiver with
role whi
providing care; to perceive unmet
more needs intensive
hand-on with care c
also havechallenges
provision; face greater emotional shown that wom
stem-
ming from difficulties likely
with balancing
to solicit caregiving
support fr
and other familial and employment
caregivers9'19 obligations;
and formal ca
and to forgo respite participation
possible that, andcompared
engage in w
women
increased religious activities as acaregivers may se
means of coping
caregiving career
or handling caregiving responsibilities. when t
Although
considerably more comprehensive in scope,
limits of their these
personal en
findings support previousthatobservations on the
has been reported in
complexities of caregiving
one and
whichthe may
dynamics
explain of w

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NAVAIE-WALISER ET AL MEDICAL CARE

TXBLE 4. Logistic Regression Models: Female Sex as a Predictor of Difficulty With Care Provision
Perceived Unmet Needs, Pbor Physical and Emotional Well-being and Coping Strategies among Careg

Sample Adjusted Odds Ratio

Dependent Variablet Size Pfemale (SE)? (95% CI)?
Care provision challenges
Reports difficulty with care provision 896 0.693 (0.148) 2.00 (1.50, 2.67)t
Has perceived unmet needs with care provision 897 0.432 (0.190) 1.54 (1.06, 2.23)*
Physical and emotional well-being
Reports decline in physical health as a consequence of 892 0.264 (0.184) 1.30 (0.91,1.87)
caregiving
Has difficulty balancing caregiving with other family 893 0.845 (0.164) 2.33 (1.69, 3.21)t
responsibilities
Has difficulty balancing caregiving and employment 893 0.919 (0.210) 2.56 (1.66, 3.78)t
responsibilities
Has lost temper with family/friends as a consequence of 891 0.496 (0.165) 1.64 (1.19, 2.27)t
caregiving
Has lost temper with care recipient 894 0.166 (0.174) 1.18 (0.84,1.66)
Coping strategies
Has given up respite activities in order to take on 895 0.556 (0.222) 1.74
caregiving role
Has experienced increased religiosity since becoming a 891 0.399 (0.141) 1
caregiver

Denotes statistical significance at *P <.05 and tp <.01.

tGender (0 = male, 1 = female) was examined as the independent predictor of several dependent variables
including difficulty with care provision (0 = not at all/not very, 1 = somewhat/very); perceived unmet needs with
providing care at anytime in the past one year (0 = no, 1 = yes); decline in physical health as a consequence of
caregiving, difficulty balancing caregiving with other family responsibilities, difficulty balancing caregiving with
employment responsibilities, losing temper with family and friends as a consequence of caregiving, losing temper
with care recipient as a consequence of caregiving, forgoing respite activities in order to take on caregiving role,
and experiencing increased religiosity since becoming a caregiver (all were coded as 0 = strongly disagree/disagree/
neither disagree nor agree, 1 = agree/strongly agree).
?Models adjusted for care recipient's physical health status (0 = good/excellent health, 1 = fair/poor health),
caregiving intensity (higher intensity = 1 for Level of Care Index scores 4, 5 or lower intensity = 0 for Level of
Care Index scores 1, 2, 3), being a primary caregiver (0 = no, 1 = yes), and the caregiver's age (continuous), race
(0 = White, 1 = non-White), marital status (0 = not married, 1 = married), and employment status (0 =
unemployed, 1 = employed).
P,sex = parameter estimate for female sex, SE = standard error.

report a greater degree of unmet needs with care care. Recent reports have documented the multi-
provision than men caregivers in the present tude of challenges faced by most informal caregiv-
study. Another important dimension of care man- ers in carrying out these difficult tasks with little or
agement is the type of care being provided. Find- no training.6'37 These observations raise concerns
ings from this study concur with past studies6,1217 regarding caregiver burout and point to a need
in suggesting that women caregivers are more for formal training in care provision.
likely to provide a greater degree of assistance A second possible mechanism at play may be
with ADL and IADL tasks. Two additional and that women caregivers process and handle stress
more unique findings of this study were that associated with caregiving differently than men
women caregivers also were more likely than mencaregivers. Although studies have examined bio-
caregivers to perform relatively complex tasks logical
(ie, indicators of stress between women and
dressing changes, assistance with medical equip-
men, social and behavioral indicators of this phe-
nomenon have not been explored as thorough-
ment use, and administration of multiple prescrip-
tion medications) and to deliver more intensively.1216,24,40 This study's results suggest that one

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Vol. 40, No. 12 INFORMAL CAREGIVNG BY GENDER

method of coping that women caregivers engage Despite its limitations, the present study extends
previous research on caregiving in several ways. First,
in more frequently than men caregivers is reallo-
cation of time spent on noncaregiving activitiesunlike past surveys, which generally have been con-
(eg, employment and respite participation) to ducted on convenience (nonrandom and nonrepre-
caregiving activities. Although such decisions sentative) samples of informal caregivers, this study
was based on data obtained from randomly selected
leading to decreased social participation are in-
nationally-representative samples of households
tended to resolve the conflicting demands of mul-
with informal caregivers. Second, this study is one of
tiple roles,7'41 their effects have proven to be less
than desirable, particularly among women, often the first comparative studies to broadly gender dif-
resulting in increased stress caused by financial ferences in the experiences, challenges, and effects of
instability and social isolation.13,1619,22'42-44 caregiving
A to elderly as well as nonelderly care
more positive approach for coping with caregiving recipients. Taken together, the present study ad-
stress and strain recently documented amongdresses many of the methodological and content
women is increased reliance on religious institu- limitations in the caregiving literature by providing
tions,612,28,45,46 an observation concurred by themore generalizable results and additional insight
present study. Although data limitations did not into the world of caregivers.
permit a more in-depth analysis of this finding,
the potential buffering effects of religiosity against
caregiving stressors is an important topic that
Implications for Policy, Practice, and
warrants further research. Research

With an aging population, demands on infor-

Study Limitations and Strengths
mal caregivers, who are already providing an
estimated $196 billion in uncompensated care,47
This study's findings must be viewed in light of
are likely to grow in the future. Thus, formal care
several survey limitations. First, it should be noted
that the study was vulnerable to nonsampling errors providers, program planners, and policy makers
need to implement practices and policies cogni-
such as nonresponse bias, coverage bias, item re-
zant of the challenges and needs of informa
sponse bias, and question order and context effects.
caregivers. Despite copious studies on caregiving
The margin of error for estimates in this survey was
3%. Efforts were taken to minimize sources of errorburden and stress, informal caregivers continue to
face a host of problems associated with lack of
including pilot testing of the survey instrument with
information, training, support, and respite ser-
focus groups, devising alternative forms of the
screening instrument, conducting pilot-tests, train-vices. Policy makers can address these systemic
issues by funding broad range caregiver support
ing interviewers, and providing extensive supervision
during the data collection phase of the study. More-programs as part of long-term care policies,
over, depending on response patterns, up to 50 thereby enabling capacity in the formal health care
system. The recent establishment of the Nationa
attempts were made to contact selected eligible
participants. Second, there was no information per- Family Caregiver Support Program under the
taining to the care recipients' cognitive functioning,Older Americans Act is a positive step forward in
the presence of co-morbidities or other relevant offering a more formal approach to addressing the
attributes such as racial/ethnic differences that affect
needs of informal caregivers. However, the initia-
dependence on and use of formal and informal care. tive allows states a considerable degree of leniency
and it remains to be seen whether it will result in
Third, even with the broad eligibility criteria used in
this study, the results were based on a 17% caregiv-the implementation of equitable and systematic
ing prevalence rate, a rate lower than the 23% programs across states.
reported national estimate of caregiving prevalence Other avenues of supporting caregivers is
through direct interventions by service providers,
by another recent study.6 Fourth, this study's findings
were based on 65% response and 83% cooperation such as those aimed at helping caregivers better
rates, rates that although comparable to other na- handle the negative emotions associated with
tional surveys,6 were not optimal. However, the caregiving burden, counseling that teaches care-
random design with which data were collected pro- givers to view their situation in a more positive
vides reasonable assurance that the rates were not manner, and support groups that allow caregivers
differentially biased by gender. to share their concerns with others would be

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NAVAIE-WALISER ET AL MEDICAL CARE

4. Ory MG, Hoffman RR III, Yee JL, et al. Prev-

useful in helping caregivers to manage stress and
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alence and Impact of Caregiving: A. detailed comparison
between dementia and nondementia caregivers. Geron-
effective if frontline workers, such as hospital
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themselves, and to discourage caregivers from can Association for Retired Persons. Family caregiving
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relinquishing involvement in respite activities.
Alliance for Caregiving and American Association for
However, these interventions need to be gender-
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language used by service providers is especially 7. Stone R, Cafferata G, Sangl J. Caregivers of the
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Acknowledgments
14. Dwyer JW, Coward RT. A multivariate com-
The authors thank Dr. Karen Donelan, from the parison of the involvement of adult sons versus daugh-
Harvard School of Public Health, for overseeing the ters in the care of impaired parents. J Geron Soc Sci
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