ARTICLE IN PRESS

Relationships among Communication Self-Efficacy,

Communication Burden, and the Mental Health of the Families
of Persons with Aphasia

Hiroshi Tatsumi, PhD,* Shutaro Nakaaki, MD, PhD,† Masayuki Satoh, MD, PhD,‡
Masahiko Yamamoto, MD, PhD,* Naohito Chino, PhD,§ and
Kazuo Hadano, MD, PhD‖

Background: The purpose of this study was to elucidate the relationships among
communication self-efficacy (SE), communication burden, and the mental health
of the families of persons with aphasia using structural equation modeling (SEM).
Methods: This study examined 110 pairs of persons with aphasia receiving home
care and 1 family caregiver per person with aphasia. The survey items for this
study consisted of the Communication Self-efficacy Scale, the Communication Burden
Scale, the Geriatric Depression Scale—Short Form—Japanese, and the Health-
Related Quality of Life: SF-8 Health Survey. The relationships between the constructive
concept of “communication self-efficacy” and “communication burden,” and “mental-
health status” were analyzed using SEM. Results: The results of the SEM analysis
revealed that a high communication SE of the families was associated with low
burden of communication and good mental-health status. Conclusions:
Psychoeducational programs that address the communication SE of family care-
givers may have the potential to reduce the burden of communication and to improve
the mental health of caregivers. These programs could lead to an enhanced quality
of life for both persons with aphasia and their families. Key Words: Aphasia—family
caregiver—communication self-efficacy—communication burden—mental health.
© 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Introduction listening, reading, speaking, and writing. Furthermore,

Aphasia is an acquired language impairment caused by
organic brain damage. Persons with aphasia have impair-
ments in all aspects of language modalities including
From the *Department of Health Science, Aichi Gakuin University,
Japan; †Department of Neuropsychiatry, Keio University School of
Medicine, Japan; ‡Department of Neurology, Mie University School
of Medicine, Japan; §Department of Psychology, Aichi Gakuin
University, Japan; and ‖Department of Social Welfare, Bukkyo
University, Japan.
Address correspondence to Hiroshi Tatsumi, PhD, Department of
Health Science, Aichi Gakuin University, 12 Araike, Iwasaki-cho,
Nisshin City, Aichi 470-0195, Japan. E-mail: ta23164@gmail.com.
Received July 31, 2015; revision received September 7, 2015; accepted
September 19, 2015.
1052-3057/$ - see front matter
© 2015 National Stroke Association. Published by Elsevier Inc. All
rights reserved.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.09.018
sufficient time and much effort are needed to recover from
aphasia, and a complete recovery of language functions
is often not obtained. Therefore, aphasia leads to a marked
deterioration in the quality of life (QoL) of persons with
aphasia.1-4
Given the above, a communication environment con-
ducive to coping with aphasia may be necessary to
maximize communication skills and to improve the QoL
of persons with aphasia. Under these circumstances, family
caregivers may struggle to provide a better communi-
cation environment for persons with aphasia under their
care. However, families often feel very embarrassed and
may find it difficult to communicate with persons with
aphasia.5 The high stress and anxiety levels of family care-
givers can negatively influence their care burden and
mental health.6 In turn, the high care burden and poor
mental health of the family caregivers may further de-
teriorate the communication environment surrounding

Journal of Stroke and Cerebrovascular Diseases, Vol. ■■, No. ■■ (■■), 2015: pp ■■–■■ 1
 ARTICLE IN PRESS
2 H. TATSUMI ET AL.
persons with aphasia and disrupt the relationship
between persons with aphasia and their families. This
situation suggests that in the treatment of aphasia, the
emphasis of not only functional training to improve
the language impairments in persons with aphasia but
also systematic specialized interventions to resolve the
psychosocial problems of family caregivers may be
important.7
To reduce the care burden and to maintain the good
mental-health status of family caregivers, it is crucial to
increase their stress tolerance during their communica-
tion with persons with aphasia and to improve their
communication skills. Self-efficacy (SE) is a psychologi-
cal factor that strongly affects the stress tolerance and
communication skills of family caregivers. Bandura8 pro-
posed the concept of SE in his social learning theory. SE
represents a person’s anticipation of the possibility of re-
alizing an action. This factor strongly enhances the
motivation for action, improves the learning efficiency,
and reduces the levels of depression, anxiety, and sense
of disappointment in families.9 Therefore, SE is ex-
pected to have the potential to improve the care of persons
with aphasia. Family caregivers with high SE may be better
equipped to understand the linguistic impairments of in-
dividuals with aphasia fully and to acquire appropriate
communication skills, which are not necessarily easy for
ordinary families. Communication SE is an indicator of
the families’ expectations of “to what extent they can com-
municate patiently with persons with aphasia.” Tatsumi
et al10 created a scale to assess the communication SE (Com-
munication Self-Efficacy Scale [CSES]) of family caregivers.
The reliability and validity of CSES have been verified,
and its clinical utility has been confirmed. However, the
relationships among the CSES, the burden of communi-
cation and mental health remain unclear in the family
caregivers for persons with aphasia.
The purpose of this study was to verify the relation-
ships among communication SE, communication burden,
and the mental health of family caregivers using struc-
tural equation modeling (SEM).
Materials and Methods
Participants
This study was conducted in 110 pairs of persons with
aphasia receiving home care and 1 caregiver per person
with aphasia. The inclusion criteria for persons with aphasia
in this study were as follows: (1) age of 30 years or older,
(2) aphasia caused by a language-dominant-hemisphere
stroke, (3) cohabitation with 1 or more family members
at home, (4) attendance at an outpatient clinic, and (5)
no history of mental illness. Medical information about
the person with aphasia was obtained from the pe-
rson’s speech language pathologist. The severity of aphasia
was assessed using the Boston Diagnostic Aphasia
Examination (BDAE) scale (a severity scale graded
from 0 to 5). BDAE scores of 4 and 5 were defined as
mild aphasia, scores of 2 and 3 were defined as moder-
ate aphasia, and scores of 0 and 1 were defined as severe
aphasia.11 For the questionnaire survey for the family care-
givers, questionnaires were handed to the family caregivers.
The completed questionnaires were then collected on the
day of request or within a few days.
Procedures and Assessments
The survey items consisted of the basic characteristics
(age, gender, and years of education) of the persons with
aphasia and of the family caregivers, the family relation-
ship between the 2 individuals, and the period of care.
The CSES was used to assess the SE of communication,
the Communication Burden Scale (COM-B) was used to
assess the burden of communication,12 the Geriatric De-
pression Scale (GDS)-15 was used to assess depression,13
and the 8-item Short-Form Health Survey (SF-8) was used
to assess the health-related QoL.14
The CSES is an SE scale consisting of 16 items related
to communication with persons with aphasia. To measure
the degree of certainty with which respondents believes
that they can execute particular communication actions,
that is, a sense of “confidence of being able to realize,”
they are required to rate each item using an 11-point scale,
ranging from 0 to 10. A higher total score indicates a higher
SE (minimum of 0 to a maximum of 160 points). The re-
liability and validity of this scale have been verified, and
a factor analysis has confirmed that the CSES can be cat-
egorized into 3 subscales: consideration of the speech
environment, consideration of the confirmation of intent,
and consideration of the communication tool. This English
version of CSES is given in Appendix S1.
The COM-B is a specialized family care burden scale
for the communication disorders of persons with aphasia.
It consists of a total of 30 items, and the respondent is
required to rate each item using a 5-point scale (1-5 points).
A higher total score indicates a heavier care burden
(minimum of 0 to a maximum of 150 points). A factor
analysis has revealed that the COM-B can be classified
into 4 subscales: caregivers’ activity restriction, lan-
guage impairment, cognitive and emotional impairment,
and responsibility for household management.
The GDS-15 is a scale for assessing depression (minimum
of 0 to a maximum of 15 points). Persons with a score
of 11 or higher are assessed as being in a very de-
pressed state, those with a score of 10-6 as having a
tendency toward depression, and those with a score of
5 or less as having no tendency toward depression.
The SF-8 is an abridged version of the SF-36, which
is a health-related QoL scale. Its reliability and validity
have been demonstrated. The assessment is based on
mental and physical summary scores that are deter-
mined using special scoring software for SF-8.
 ARTICLE IN PRESS
COMMUNICATION SELF-EFFICACY AND BURDEN
Statistical Analysis
This study was conducted as a cross-sectional study.
General Characteristics of CSES
The basic characteristics of the subjects, including the
primary disease, the severity and type of aphasia in the
persons with aphasia, and the period of care by the family
caregivers, were investigated, in addition to the age, gender,
years of education of both the persons with aphasia and
the family caregiver, and the family relationship between
the 2 individuals. Differences in the results of the as-
sessment scores for the CSES, COM-B, GDS-15, and SF-8
between male and female family caregivers were com-
pared using Student’s t-test. The results of assessment
scores for the CSES were compared using one-way anal-
ysis of variance according to the family relationships and
the severity and type of aphasia. Tukey’s test was used
for multiple comparisons. Furthermore, Pearson’s corre-
lation coefficients (r) and P values were calculated for
comparisons of the age and the severity of aphasia of
the persons with aphasia with the age, years of educa-
tion, period of care, and the COM-B, GDS-15, and SF-8
scores of the caregivers.
SEM
SEM is a statistical method used to examine the rela-
tionships among multiple constructs. We conducted a SEM
analysis using a model that assumed that communica-
tion SE affects the communication burden and mental
health of family caregivers.
Three latent variables, “communication self-efficacy,”
“communication burden,” and “mental-health status,”
were established as constructs. “Communication self-
efficacy” was used as the independent variable, and
“communication burden” and “mental-health status” were
used as dependent variables. For “communication self-
efficacy,” scores on the 3 CSES subscales were adopted
as the observed variables. For “communication burden,”
scores on the 4 COM-B subscales were used as the ob-
served variables. For “mental-health status,” the GDS-
15 and SF-8 mental summary scores were used as the
observed variables. An Amos minimized discrepancy chi-
square criterion (CMIN; χ2 test) was used to test the
goodness-of-fit of the whole model. The goodness-of-fit
index (GFI), adjusted goodness-of-fit index (AGFI), com-
parative fit index (CFI), and root mean square error of
approximation (RMSEA) were entered as the goodness-
of-fit indicators.
SPSS Version 20.0 for Windows (IBM SPSS Inc, Chicago,
IL, USA) was used for the statistical analyses. The SEM
analysis was performed using SAS Version 9.3 (SAS In-
stitute, Cary, NC, USA). The statistical significance was
set as a P value less than .05.
3
Ethical Considerations
The study protocol conformed to the ethical guidelines
of the 1975 Declaration of Helsinki and was conducted with
the approval of the Ethics Committee of the Faculty of Psy-
chological and Physical Science, Aichi Gakuin University.
Results
Basic Characteristics of the Subjects with Aphasia and
Their Families
The mean age of the persons with aphasia was 65.7 years
(standard deviation [SD]: 10.6 years; range, 31-87 years),
as shown in Table 1. Of the total, 71 were male and 39
were female. The primary brain diseases were cerebral in-
farction in 53 patients and cerebral hemorrhage in 39 patients.
Regarding the severity of aphasia, 53 persons with aphasia
had mild aphasia, 38 had moderate aphasia, and 19 had
severe aphasia. Regarding the types of aphasia, almost half
(58) of the persons with aphasia enrolled in this study had
Broca’s aphasia, 19 had Wernicke’s aphasia, and 33 had other
types of aphasia (conduction aphasia, amnesic aphasia, etc.).
The mean age of the family caregivers was 61.2 years
(SD: 13.2 years; range, 27-84 years), as shown in Table 1.
Of the total, 82 were female and 28 were male. The mean
years of education were 13.1 years (SD: 2.4 years). The mean
period of care was 88.7 months (SD: 57.8 months). Overall,
77% of the family caregivers were the spouses of the patients.
Results of the Questionnaire Surveys and Gender
Differences among the Family Caregivers
Table 2 shows the results of the CSES, COM-B, GDS-
15, and SF-8 assessments. The mean total CSES score was
105.5 (SD: 27.5). The mean scores for the consideration of
the speech environment, the consideration of the confir-
mation of intent, and the consideration of the communication
tool subscales were 50.3 (SD: 14.5), 42.5 (SD: 10.9), and 12.6
(SD: 4.9), respectively. The scores for the COM-B subscales
for caregivers’ activity restriction, language impairment, cog-
nitive and emotional impairment, and responsibility for
household management were 19.7 (SD: 7.9), 30.3 (SD: 9.9),
13.1 (SD: 5.6), and 6.4 (SD: 3.2), respectively. The GDS-15
score was 4.7 (SD: 3.8). The scores were 11 or more in 10
adults, and 6-10 or lower in 33 adults. Subjects assessed
as having “depression” or a “tendency toward depres-
sion” accounted for 39% of all the subjects. The SF-8 physical
and mental summary scores were 47.8 (SD: 7.0) and 47.7
(SD: 7.1), respectively. A gender difference was observed
only in the SF-8 score for “general health.”
Communication SE of the Family Caregivers of Persons
with Aphasia
The CSES scores according to family relationship and
the severity/type of aphasia are shown in Table 3. We
found no differences in the CSES scores according to the
 ARTICLE IN PRESS
4 H. TATSUMI ET AL.
Table 1. Demographic data of persons with aphasia and their family caregivers

Adults with Family

aphasia caregivers
(n = 110) (n = 110)

Variables Mean SD Mean SD

Age (year) 65.7 10.6 61.2 13.2

Educational level (year) 13.3 2.8 13.1 2.4
Caregiving duration (month) — — 88.7 57.8

Numbers % Numbers %

Gender Male 71 64.5 28 25.5

Female 39 35.5 82 74.5
Etiology of disease Cerebral infarction 53 48.2 — —
Cerebral hemorrhage 39 35.5 — —
Subarachnoid hemorrhage 9 8.2 — —
Cerebral trauma 7 6.4 — —
Others 2 1.8 — —
Aphasia severity Mild 53 48.2 — —
(BDAE) Moderate 38 34.5 — —
Severe 19 17.3 — —
Aphasia type Broca’s aphasia 58 52.7 — —
Wernicke’s aphasia 19 17.3 — —
Other aphasias 33 30.0 — —
Conduction aphasia, — —
amnesic aphasia, etc.
Family relationship Spouse — — 85 77.3
Children — — 16 14.5
Others — — 9 8.2
Parents, daughter-in-law, etc.

Abbreviations: BDAE, Boston Diagnostic Aphasia Examination; SD, standard deviation.

The severity of aphasia was assessed using the BDAE scale.
In regard to classification of the severity of aphasia, grades 4 and 5 on the scale were rated as representing mild aphasia, grades 2 and 3 as
representing moderate aphasia, and grades 0 and 1 as representing severe aphasia.

family relationships, but significant differences were ob- tool” did not differ according to either the aphasia se-
served in the total CSES scores and the scores of two of verity or the aphasia type (Table 3).
the subscales according to the severity and type of aphasia.
Multiple comparisons among the severity groups re- Correlations of the Variables with the CSES Scores for
vealed that the scores were significantly higher in the the Family Caregivers of Persons with Aphasia
“mild” aphasia group than in the “moderate” or “severe”
Table 4 shows Pearson’s correlation coefficients (r) and
aphasia groups (total CSES score: F [2.107] = 8.41, mean
P values between the CSES scores and other items. The
square error [MSE] = 5584.0, P < .001; concerns of the speech
total CSES score and the scores on two of the subscales
environment: F [2.107] = 9.08, MSE = 1656.2, P < .001; and
were positively correlated with the severity of aphasia,
concerns of the confirmation of intent: F [2.107] = 8.67,
and were negatively correlated with the scores on 4 COM-B
MSE = 904.5, P < .001). Moreover, multiple comparisons
subscales and the GDS-15. A negative correlation between
among the aphasia groups divided according to the aphasia
the CSES subscale for the consideration of the commu-
type showed that the scores were significantly higher in
nication tool and the COM-B subscale for “responsibility
the “group with other types of aphasia” than in the “Broca
for household management” was also observed.
aphasia group” or the “Wernicke aphasia group” (total
CSES score: F (2.107) = 6.87, MSE = 4678.5, P = .002; con-
SEM as Covariance for Family Caregivers of Persons
cerns of the conversation environment: F (2.107) = 7.46,
with Aphasia
MSE = 1397.9, P < .001; concerns of the confirmation of
intent: F (2.107) = 6.37, MSE = 691.3, P = .002). The score A total of 83 subjects, excluding 27 with missing SF-8
on the subscale for the “consideration of the communication data, were analyzed using SEM. A model with paths from
 ARTICLE IN PRESS
COMMUNICATION SELF-EFFICACY AND BURDEN 5
Table 2. Results of CSES, COM-B, GDS-15, and SF-8 in family caregivers

Total Male Female

(n = 110) (n = 28) (n = 82)

Measures Mean SD Mean SD Mean SD T values P

CSES Total score 105.5 27.5 105.9 31.0 105.4 26.3 .08 .94
Consideration of the 50.3 14.5 50.1 16.4 50.4 13.9 −.11 .91
speech environment
Consideration of the 42.5 10.9 43.1 12.0 42.4 10.6 .30 .77
confirmation of intent
Consideration of the 12.6 4.9 12.7 5.5 12.6 4.7 .10 .92
communication tool
COM-B Caregivers’ activity 19.7 7.9 19.3 8.5 19.8 7.7 −.29 .77
restriction
Language impairment 30.3 9.9 29.0 10.5 30.7 9.8 −.82 .42
Cognitive and emotional 13.1 5.6 11.6 5.6 13.5 5.6 −1.54 .13
impairment
Responsibility for 6.4 3.2 5.8 3.0 6.6 3.2 −1.25 .21
household management
GDS-15 Total score 4.7 3.8 4.1 4.6 4.9 3.6 −.89 .38

Total Male Female

(n = 83) (n = 20) (n = 63)

SF-8 Physical functioning 48.5 7.5 50.3 4.8 47.8 8.2 1.43 .16
Role—physical 48.5 7.7 49.6 6.7 48.1 8.1 .78 .44
Bodily pain 48.7 8.4 51.5 7.6 47.5 8.5 1.96 .06
General health 48.8 6.6 51.1 6.7 47.9 6.4 2.07 .04*
Vitality 50.5 6.1 52.4 5.1 49.7 6.4 1.80 .07
Social functioning 46.8 9.4 47.7 9.3 46.4 9.5 .58 .56
Role—emotional 48.4 7.5 49.5 6.7 48.0 7.8 .87 .39
Mental health 48.4 6.8 49.9 7.4 47.7 6.5 1.32 .19
Physical summary scores 47.8 7.0 49.8 5.0 46.9 7.6 1.75 .08
Mental summary scores 47.7 7.1 48.6 7.7 47.3 6.9 .74 .46

Abbreviations: CSES, Communication Self-Efficacy Scale; COM-B, Communication Burden Scale; GDS, Geriatric Depression Scale;
SD, standard deviation; SF-8, 8-item Short-Form Health Survey.
Student’s t-test was used for the certification of the difference by a family caregiver’s gender.
*Significant at P < .05.

the latent variable of “communication self-efficacy” to the
other latent variables of “communication burden” and
“mental-health status,” and from “communication burden”
to “mental-health status” showed the best goodness-of-
fit (Fig 1). A goodness-of-fit test of this model gave a CMIN
value of 2.6149 (df = 24, P = .995). Goodness-of-fit indi-
cators for this model yielded the following values:
GFI ≈ .993, AGFI ≈ .972, CFI ≈ 1.00, and RMSEA ≈ .000. All
the goodness-of-fit indicators were statistically signifi-
cant. The estimated path coefficient from “communication
self-efficacy” to “mental-health status” had a P value of
.015, while all the other estimated path coefficients had
P values less than .001.
Regarding the relations between the constructs, the path
coefficient from “communication self-efficacy” to “com-
munication burden” was −.430 (P < .001), indicating that
a high SE reduces the care burden. In addition, the path
coefficient from “communication burden” to “mental-
health status” was −.568 (P < .001), suggesting the strong
influence of the burden of communication on the mental-
health status. Furthermore, the path coefficient from
“communication self-efficacy” to “mental-health status”
was −.231 (P = .015), implying that SE had a minimal effect
on mental health.
Among the relationships between the constructs (latent
variables) and the observed variables, “communication
self-efficacy” was affected by each of the observed vari-
ables for the consideration of the speech environment (path
coefficient, .998; P < .001), the consideration of the con-
firmation of intent (path coefficient, .789; P < .001), and
the consideration of the communication tool (path coef-
ficient, .557; P < .001).
“Communication burden” closely reflected the lan-
guage impairment (path coefficient, .957; P < .001), the
 6
Table 3. The general characteristics of the CSES in family caregivers

CSES

Consideration Consideration Consideration

of the of the of the
speech confirmation communication
Total score environment of intent tool

ARTICLE IN PRESS
Variables Numbers Mean SD Mean SD Mean SD Mean SD

Family Spouse 85 105.54 28.30 50.42 15.04 42.40 11.31 12.72 4.94
relationship Children 16 108.13 25.70 50.94 12.94 44.75 9.32 12.44 5.57
Others (parents, 9 100.56 24.23 48.44 12.65 39.89 9.97 12.22 3.96
daughter-in-law, etc.)
F (2.107) = .21, F (2.107) = .91, F (2.107) = .59, F (2.107) = .06,
P = .806 P = .913 P = .553 P = .946
Aphasia Mild 53 117.95 24.56 57.16 13.19 47.47 8.72 13.33 5.41
severity Moderate 38 99.42 20.66 ** ** 46.55 10.48 ** ** 40.58 8.77 * ** 12.3 4.35
Severe 19 95.68 31.17 45.38 16.23 38.21 12.93 12.09 4.85
F (2.107) = 8.41, F (2.107) = 9.08, F (2.107) = 8.67, F (2.107) = .71,
P < .001 P < .001 P < .001 P = .497
Aphasia Broca’s aphasia 58 99.45 27.98 47.21 14.50 40.28 11.67 11.97 4.89
type Wernicke’s aphasia 19 98.41 28.43 ** 45.88 14.08 ** 39.59 11.02 ** 12.94 4.66
* * *
Other aphasias 33 119.00 21.21 57.69 11.98 47.71 7.46 13.60 5.08
(conduction aphasia,
amnesic aphasia, etc.)
F (2.107) = 6.87, F (2.107) = 7.46, F (2.107) = 6.37, F (2.107) = 1.24,
P = .002 P < .001 P = .002 P = .292

Abbreviations: ANOVA, analysis of variance; CSES, Communication Self-Efficacy Scale; SD, standard deviation.
The differences in each group of aphasia severity, type, and family relationship were analyzed by one-way ANOVA.

H. TATSUMI ET AL.
The multiple comparison was carried out by Tukeys’ test.
*Significant at P < .05; **significant at P < .01.
 ARTICLE IN PRESS
COMMUNICATION SELF-EFFICACY AND BURDEN 7
Table 4. Correlation between CSES and other variables

Consideration Consideration Consideration

Total of the speech of the confirmation of the
score environment of intent communication tool

Variables r r r r

Patient’s age .036 .084 .023 −.096

Aphasia severity .347 ** .350 ** .361 ** .107
Caregiver’s age −.016 .065 −.069 −.125
Educational level of family caregivers .004 −.006 .061 −.096
Caregiving duration −.170 −.194 * −.095 −.167
COM-B Caregivers’ activity restriction −.215 * −.261 ** −.158 −.078
Language impairment −.359 ** −.391 ** −.305 ** −.180
Cognitive and emotional impairment −.358 ** −.363 ** −.337 ** −.180
Responsibility for household management −.329 ** −.341 ** −.275 ** −.220 *
GDS-15 Total score −.208 * −.189 * −.199 * −.164
SF-8 Physical summary scores .161 .153 .165 .081
Mental summary scores .063 .066 .056 .030

Abbreviations: COM-B, Communication Burden Scale; CSES, Communication Self-Efficacy Scale; GDS, Geriatric Depression Scale; r,
Pearson’s correlation coefficient; SF-8, 8-item Short-Form Health Survey.
*Significant at P < .05; **significant at P < .01.

Figure 1. Structural equation modeling as covariance in the family caregivers for aphasia. Fit summary: χ2 = 2.6149 (P = .995), GFI = .993, AGFI = .972,
CFI = 1.000, RMSEA = .000. *P < .001, **P = .015. Error variables are omitted. Abbreviations: AGFI, adjusted goodness-of-fit index; CFI, comparative fit
index; COM-B, Communication Burden Scale; CSES, Communication Self-Efficacy Scale; GDS, Geriatric Depression Scale; GFI, goodness-of-fit index;
RMSEA, root mean square error of approximation; SF-8, 8-item Short-Form Health Survey.
 ARTICLE IN PRESS
8 H. TATSUMI ET AL.
activity restriction (path coefficient, .717; P < .001), the cog-
nitive and emotional impairment (path coefficient, .943;
P < .001), and the responsibility for household manage-
ment (path coefficient, .848; P < .001) subscales of the COM-
B. Finally, the “mental-health status” was positively
correlated with the SF-8 mental summary scores (path
coefficient, .888; P < .001) and was negatively correlated
with the GDS-15 scores (path coefficient, −.568; P < .001)
(Fig. 1).
Discussion
In this study, we clarified the relationships between the
CSES of the family caregivers of persons with aphasia
and their care burdens for communication disorders as
well as their mental health using a SEM path analysis.
The study revealed that the communication SE of the care-
givers differed depending on the severity and type of the
aphasia experienced by the persons with aphasia under
their care. The SEM analysis revealed that a high com-
munication SE was associated with low caregiver burden
for communication disorders and good mental-health status
of the family caregivers. These results suggested that sys-
tematic and specialized interventions for the families of
persons with aphasia with the intention of increasing their
communication SE might contribute to a reduction in their
care burden for communication disorders.
General Characteristics of Communication SE
Statistically significant differences were found for the
total CSES score and the scores for two of the CSES
subscales according to the severity and type of aphasia,
but not according to the family relationships. Regard-
ing the significant difference in the CSES scores according
to the type of aphasia, the percentage of cases with mild
aphasia in the “other aphasia” group was relatively higher,
so the significance of this result may reflect the severity
of aphasia. No significant difference in the CSES score
was observed between the group with Broca’s aphasia
and the group with Wernicke’s aphasia, suggesting that
the type of aphasia may not have a direct effect on the
communication SE of the family caregivers. Based on the
absence of a significant difference in the CSES scores of
the family caregivers depending on their relationship with
the persons with aphasia, SE may have universal char-
acteristics that transcend family relationships. Consideration
of the communication tool, which is one of the lower items
of the CSES, was not affected by the severity of aphasia.
In other words, the family caregivers can respond with
constant confidence, regardless of the severity of aphasia,
to the practical use of a substitution tool for communi-
cation. Regarding the other evaluation criteria, the total
CSES score and the scores on 2 subscales showed mod-
erately negative correlations with the score on the COM-B
and a weak negative correlation with the score on the
GDS-15. There results suggest the existence of relationships
between the CSES of the family caregivers and their com-
munication burden and mental health. One characteristic
of concern about caregivers is their gender. In this re-
search, there were no significant differences in the scores
on the CSES, COM-B, GDS-15, or SF-8 scale between the
2 genders, except for the score on 1 subscale, namely,
“general health.” The issue of caregiver characteristics has
been studied intensively for many years in relation to
persons caring for dementia.15,16 Gallicchio et al17 pointed
out that a female caregiver is stronger against the neg-
ative impact of depression or anxiety than a male caregiver.
We may need to accumulate a larger number of cases
and reexamine the problem of the relationship between
stress and gender.
Relationships among Communication SE, Care Burden
for Communication Disorders, and Mental Health
In the present SEM analysis, paths were drawn between
the following constructs: from “communication self-
efficacy” to “communication burden” and from
“communication burden” to “mental-health status,” im-
plying that a high communication SE diminishes the care
burden for communication disorders and that a reduced
care burden for communication disorders in turn pro-
motes the maintenance of good mental health. Therefore,
our analysis revealed that specialized interventions to in-
crease communication SE have a positive effect on both
the care burden and the mental health of the family care-
givers. However, it should be noted that the path from
“communication self-efficacy” to “mental-health status”
had a negative coefficient, although the value was very
small. It is possible that a high communication SE may
lead the family caregivers to pursue an excessive level
regarding the communication environment, thereby in-
creasing their psychological burden. This issue will require
further investigation using a larger data sampling.
Limitations of the Study
The limitations of the present study were as follows:
(1) No clear causal relationships could be established
because of the cross-sectional design of the ques-
tionnaire survey used in the study.
(2) The relationships among communication SE, com-
munication burden, and mental health could not
be examined according to the gender of the family
caregivers, the family relationships, or the severity/
type of aphasia.
(3) CSES is an SE scale created for Japanese individu-
als, and the clinical utility of CSES should be
investigated in other cultural spheres among sub-
jects speaking other languages.
 ARTICLE IN PRESS
COMMUNICATION SELF-EFFICACY AND BURDEN
(4) The evaluation of burden used in this study was
based on a specialized burden related to commu-
nication disturbances, and a survey using different
variables of caregiving burden, such as the Zarit
Burden Interview,18 is needed to determine the in-
fluence of communication SE on the general
caregiving burden, and caregiver burden tends to
be influenced by physical functions and/or activi-
ties of daily living (ADLs) of the patient.19,20 However,
in the present study, there was no approach on phys-
ical dysfunctions and ADLs of persons with aphasia.
We considered that it is necessary to investigate rel-
evant factors to the general care burden in persons
with aphasia.
(5) The subjects were limited to persons with aphasia
who could attend a hospital or institution, which
may not be a precisely representative group.
(6) The analyses were performed without controlling
for the state of use of formal social services and
the level of ADLs.
Longitudinal interventional studies examining a larger
number of cases are needed in the future to address these
study limitations.
Despite these limitations, this is the first study, to our
knowledge, to investigate the relationships among com-
munication SE, care burden for communication disorders,
and the mental health of the family caregivers of pa-
tients with aphasia. This study also presents new
suggestions for the development of specialized
interventional methods intended for the welfare of both
persons with aphasia and family caregivers. Based on the
fundamental knowledge obtained in this study, we suggest
that it is important to design psychoeducational pro-
grams that take into consideration the communication SE
of the family caregivers and to conduct more intensive
research toward reducing the care burden for commu-
nication disorders and promoting the maintenance of good
mental health, so as to improve the QoL of both persons
with aphasia and their families.
Conclusions
The communication SE of the family caregivers of
persons with aphasia is universally significant to health
professionals because it is crucial for providing the best
possible communication environment for persons with
aphasia. Regarding the treatment approach, consider-
ation of the communication environment of persons with
aphasia as well as the communication SE and the mental
health of the family caregivers is important.
Appendix: Supplementary Material
Supplementary data to this article can be found online
at doi:10.1016/j.jstrokecerebrovasdis.2015.09.018.
9
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