health promot. int. 2002 tang 329 39

8/2/2019 Health Promot. Int. 2002 Tang 329 39

1/12

HEALTH PROMOTION INTERNATIONAL Vol. 17, No. 4 Oxford University Press 2002. All rights reserved Printed in Great Britain

329

INTRODUCTION

Since 1982, cerebrovascular disease has been thesecond leading cause of death for persons of allages and the leading cause of death for thoseaged 65 years or over in Taiwan (National HealthAdministration, 2000). A hospital-based strokeregistry revealed that among 2640 stroke casesin northern Taiwan, the long-term survival rate

after a stroke was 84.6% for the first month,74.3% for the first year and 67.7% for the secondyear (Hung and Chen, 1993). Lee reported that31% of stroke survivors had functional impair-ments, resulting in partial to total dependenceon others for completion of daily activities (Lee,1989). Formal health care and social serviceresources for post-stroke care in Taiwan are limited.

Most post-stroke patients are not institution-alized and remain at home (Hu et al., 1992).

A significant source of care for disabled peoplein Taiwan are patients families, because socialvalues are such that families are responsible fortheir disabled family members. The demands ofcaregiving may cause insufficient rest, inter-rupted sleep, chronic fatigue, economic hardshipand depressionall of which place caregivers

at risk for emotional and physical problems(George and Gwyther, 1986; Decker and Young,1991; Williams, 1994). In addition, caregivers mayneglect or postpone care for themselves.

The benefits of adopting a health lifestyleinclude enhancing the quality of life, increasinglongevity, decreasing health care costs, andincreasing productivity by decreasing illnessand absenteeism. While much has been researchedand published regarding the need for and

Key words: caregiving; health promotion; self-efficacy; social support

SUMMARY

The purpose of this study was to explore the relationship

between and among the caregivers personal factors, thecare recipients functional status, the caregivers perceived

self-efficacy, social support, reactions to caregiving, and

health promotion behaviors in family caregivers of community-

dwelling stroke patients in Taiwan. A structured home-

interview survey methodology was used to collect data from

134 primary caregivers responsible for care of stroke

patients in Taipei, Taiwan. The study results indicated that,

in general, caregivers were female spousal caregivers (mean

age 52 years, average caregiving period 24 months).

Regression analyses revealed that the caregivers health status

was the strongest positive predictor of caregiver self-efficacy.Spousal caregivers with a better-perceived health status were

more satisfied with their resources of social supports. Spousal

caregivers with poor perceived health status had a higher

level of caregiving strain. Results for the overall model

indicated caregivers social support and the care recipients

functional status made significant contributions in explaining

the caregivers health promotion behaviors. Implications for

further practice suggest establishing community training

programs and support groups for family caregivers.

Health promotion behaviors in Chinese familycaregivers of patients with stroke

YU-YING TANG and SHU-PI CHEN1

School of Nursing, National Defense Medical Center, Taipei, Taiwan and 1School of Nursing, St. XavierUniversity, Chicago, IL, USA


2/12

benefits of health promotion, caregivers have notbeen the major focus of research in health pro-motion. Among many key factors affecting thecaregivers health promotion practices are care-giving self-efficacy, social support and reactionsto caregiving. Burton and colleagues (Burtonet al., 1997) found that caregivers with a low level

of caregiving self-efficacy had negative healthbehaviors compared with caregivers with a highlevel of self-efficacy. Health promotion practicesof caregivers may contribute to the health andwell-being of caregivers and the welfare of strokepatients. Unfortunately, health care providersoften neglect health promotion and diseaseprevention for family caregivers (Jackson andCleary, 1995). Thus, the purposes of the presentstudy were to explore the predictors of care-giving self-efficacy, social support and reactionsto caregiving, and to investigate factors related tohealth promotion behaviors in family caregiversof stroke patients.

PREVIOUS RESEARCH ANDVARIABLES UNDER INVESTIGATION

Individual characteristics and experiences

Key characteristics of the caregiver are knownto influence caregiving and its consequences.Particularly important is poor health, which hasbeen associated with caregiving strain, lessconfidence in caregiving tasks, dissatisfaction

with social support, and less participating healthpromotion behaviors (George and Gwyther,1986; Killeen, 1989; Schumacher et al., 1993;Haley et al., 1996). Additionally, Killeen foundthat the older, more educated caregivers, whohad provided care for shorter periods of time,reported engaging in more health promotionbehaviors (Killeen, 1989). Employment status ofthe caregiver (Stull et al., 1994) and relationshipwith the care recipient (Horowitz, 1985; Pruchnoet al., 1990) were also included because employedwives involved themselves less frequently in

health promoting behaviors (OBrien, 1993).Household income was investigated because highincome, which may assist caregivers to purchasemore social support services, allows caregivers toengage in health promotion activities (Pohl et al.,1994; Allen-Holmes, 1997).

Research on the impact of illness character-istics of care recipient on caregiver outcome ismixed. Some investigators have found thatseverity of care recipient impairment contributes

to caregiver strain and burden (Wu et al., 1992;Lalonde and Kasprzyk, 1993; Stull et al., 1994;Dorfman et al., 1996). Other investigators, incontrast, reported that the care recipients func-tional status had no relationship to the care-givers reactions (Zarit et al., 1980; Given et al.,1990). In fact, OBrien found that wives who

were caring for husbands with more physicallimitations reported less participation in healthpromotion activities than wives who were caringfor less impaired husbands (OBrien, 1993).

Behavior-specific cognitions

Gillis completed an integrative review of theresearch literature, published between 1983and 1991, which focused on identifying thedeterminants of a health-promoting lifestyle(Gillis, 1993). The results indicated that self-efficacy was the strongest predictor of a health-promoting lifestyle. Dorfman and colleaguesexamined the factors relating the satisfaction andstrain in wife caregivers of frail elderly veterans,suggesting that self-efficacy is important to thecaregivers general sense of life satisfaction(Dorfman et al., 1996). Archbold and colleagues(Archbold et al., 1990) and Mowat andLaschinger (Mowat and Laschinger, 1994) alsofound that caregivers who exhibited higherlevels of self-efficacy demonstrated lower levelsof depression. In general, the literature supportsthe relevance of enhancing self-perception of

efficacy in an attempt to affect health positively.We therefore predicted that confidence in abil-ity to manage caregiving tasks would be positivelyrelated to health promotion behaviors amongfamily caregivers of stroke patients. Examiningthe influence of caregiver self-efficacy on healthpromotion behaviors will broaden the existingknowledge base in this area.

An increasing body of knowledge suggests thatcaregivers of stroke patients who have beenproviding care for an extended time and whohave low social support may be at high risk for

psychological distress or depression. Based onprevious research (Alexy, 1991; Tuohing, 1991;Wyatt, 1991; Stuifbergen, 1995; Terborg et al.,1995), investigators suggest that the perceivedlevel of social support has a strong positive asso-ciation with participation in health promotionpractices.

From the association posited by Pender (Pender,1996), the reactions to caregiving reflect the care-giving environment affecting the caregiver.

330 Y.-Y. Tang and S.-P. Chen
http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/


3/12

Some studies suggest that reactions to caregivinghave been conceptualized negatively as burdens,strains or stressors, producing negative psycho-logical responses (Montgomery et al., 1985;Lawton et al., 1989; Given et al., 1990). Archboldet al. conducted interviews with six families, eachwith a dependent elder at home, in an attempt to

identify problems generated by the caregivingsituation (Archbold et al., 1990). The majorproblems stemming from the caregiving rolewere lifestyle change, ambivalent feelings towardthe elder, decision making and lack of support.We, therefore, predicted that reactions to care-giving would be negatively related to health pro-motion behaviors among family caregivers.

CONCEPTUAL FRAMEWORK ANDHYPOTHESES

Using the Health Promotion Model (Pender,1996) as a reference, a modified model (Figure 1)is proposed to examine relationships amongspecific determinants of health promotion behav-iors of family caregivers. The model consists ofthree major factors: (i) individual characteristicsand experiences, (ii) behavior-specific cognitions,and (iii) behavioral outcome. Individual charac-teristics and experiences have included caregiversage, gender, education, income, employment status,relationship with the patient, number of health

problems, health status, length of caregiving andcare recipients functional status. Behavior-specificcognitions have included caregiver self-efficacy,social support and reactions to caregiving. Healthpromotion behaviors is the outcome variable(Figure 1).

The proposed hypotheses were developed based

on findings from previous empirical research(Archbold et al., 1990; Alexy, 1991; Haley et al.,1996) and on the Penders Health PromotionModel (Pender, 1996). Hypothesis 1 is that care-giver self-efficacy is predicted by the caregiverspersonal factorsincluding age, gender, edu-cation, income, employment status, relationshipwith the patient, number of health problems,health status, and length of caregivingand bythe care recipients functional status (Barneset al., 1992; Lin and Chiou, 1995; Moen et al.,1995; Dorfman et al., 1996; Haley et al., 1996).Hypothesis 2 is that social support is predictedby the caregivers personal factors and by thecare recipients functional status (Miller, 1987;Winslow and OBrien, 1992; Bergman-Evans,1994; Pohl et al., 1994; Robinson and Steele,1995). Hypothesis 3 is that reaction to caregivingis predicted by the caregivers personal factorsand by the care recipients functional status(Oberst et al., 1989; Given et al., 1990; Careyet al., 1991; Periard and Ames, 1993; Dorfmanet al., 1996; Fredriksen, 1996; Keefe andMedjuck, 1997).

Health promotion in Chinese family caregivers 331

Fig. 1: A conceptual model of health promotion behaviors in Chinese family caregivers of stroke patients.
http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/


4/12

Penders model of health promotion postulatesthat individual characteristics and experiencesaffect the health promotion behaviors directlyas well as indirectly through behavior-specificcognitions (Pender, 1996). Behavior-specific cog-nitions are assumed to influence health promotionbehaviors directly. From this model, Hypothesis

4 proposes that caregiver self-efficacy, socialsupport and reactions to caregiving have adirect effect on the caregivers health promotionbehaviors, while controlling for the caregiverspersonal factors and the care recipients functionalstatus.

METHODS

Sample

A convenience sample of 134 family caregivers ofpatients with stroke was recruited from threehospitals and four home health care agencies inTaiwan. The director of each medical clinic andhome health care agency was provided with acopy of the purpose of the study, the researchquestions, the questionnaires and the consentform. After permission was granted to accessnames, caregivers were contacted by telephone.If family caregivers agreed to participate inthe study, the researcher scheduled an in-homevisit with the primary caregivers to conduct theappropriate interviews. Eligibility criteria forthe study were that the caregiver must: (i) be a

family member of a patient with stroke and livein the same house as them; (ii) assume majorresponsibility in the caregiving; (iii) live in Taipei;and (iv) be able to understand the Chinese lan-guage. Caregivers were excluded if stroke patientsstayed in nursing homes or hospitals.

The ages of the caregivers ranged from 21 to90 years [mean standard deviation (SD)52.2 14.6 years] and 75.4% were female. Therelationship of the caregivers to the patients withstroke were spouse (49.3%), daughter (20.1%),daughter-in-law (14.9%), son (12.7%) or other

relative (3.0%). Approximately 31% of therespondents had annual household incomesbetween $7229 and $14 458. The sample wasprimarily unemployed and retired (54.5%). Thirty-eight percent of caregivers had no education oronly primary school education. The duration ofcaring for the care-receiver ranged from 1 monthto 15 years (mean 24.1 months). Most of thecaregivers rated their health as fair (51.5%).The Barthel Index scores ranged from 0 to 100.

The mean score for the care recipients was 63.5(SD 34.6). Thirty-one percent of the care recipientswere bedridden and needed full nursing care,13% were bedridden and needed partial nursingcare, 37% could perform some self-care or wereindependent in a wheelchair, and 19% could liveby themselves and were completely independent.

Measures

The functional status of the care recipients wasmeasured with the Barthel Index (Mahoney andBarthel, 1965). The Barthel Index is a 10-itemGuttman scale, with scores ranging from 0 to 100.Granger and colleagues (Granger et al., 1979)reported a testre-test reliability of 0.89. Constructvalidity was support by factor analysis and yieldeda single domain. The Cronbachs alpha value forthe Barthel Index in this study was 0.95.

Caregiver self-efficacy was measured by theCaregiver Self-Efficacy (CSE) instrument. Thiswas derived from the measure of caregiver self-efficacy used by Haley et al. (Haley et al., 1987),which drew on Banduras (Bandura, 1982) workon self-efficacy. Using the instrumental activitiesof daily living (IADL) and the Barthel Index,caregivers rated their confidence in their abilityto manage problems successfully. This 17-itemscale has scores ranging from 17 to 68. Constructvalidity was supported by hypothesis testing inwhich the CSE predicted depression (Haleyet al., 1987). The alpha value for CSE in this study

was 0.93.Social support was measured by the Personal

Resource Questionnaire (PRQ-85)-Part 1 (Brandtand Weinert, 1987). The PRQ-85-Part 1 presented10 situational problems for which an individualmight seek tangible help. The caregiver was thenasked to answer the questions of (i) whether ornot the situation had arisen within the previous6 months, and (ii) how satisfied the caregiver waswith any help received, using a six-point scale.McNair and colleagues (McNair et al., 1981)reported convergent validity, as evidenced by

moderately high intercorrelations with five othersupport scales, and discriminant validity wasestablished by low correlation with the Profile ofMood States (POMS). The alpha value for PRQ-85-Part 1 in this study was 0.72.

Reactions to caregiving were measured by theCaregiver Reactions Assessment (CRA), whichmeasures the objective as well as the subjectivestrains and reactions to the role of caregiver.Developed by Given and colleagues (Given et al.,

http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/


5/12

1992), the CRA is a 24-item scale consistingof five-point responses. Scores range from 24to 120.

The internal consistency reliability ranged from0.80 to 0.90 for five subscales (caregiver esteem,lack of family support, impact on finances, impacton schedule and impact on caregiver health).

Construct validation of the CRA involved factoranalysis (Given et al., 1992). In this study, CRAhad an alpha value of 0.75.

Caregivers health promotion behaviors weremeasured by the Health-Promoting LifestyleProfile II (HPLP-II), which has reported internalconsistency (Cronbachs alpha value) of 0.94(Walker et al., 1987). The HPLP-II is a 52-itemscale consisting of four-point responses; scoresrange from 52 to 208. The construct validity wasconfirmed through factor analysis (Walker et al.,1987). The Cronbachs alpha for HPLP-II was0.95 for this study.

Data analysis

Bivariate correlations were used to investigatethe relationship between each of the independentvariables and health promotion behaviors infamily caregivers. Multiple linear regressionanalyses were performed to obtain the best fittinglinear regression equations for predicting healthpromotion behaviors from a set of the independ-ent variables. Intercorrelations, means and stand-ard deviations for all variables are given in Table 1.

For the analyses that follow, the relationship ofthe caregiver with the stroke patient was scoredas 0 (spousal caregiver) or 1 (non-spousal care-giver). Employment status was scored as 0(without job) or 1 (with job) (Table 1).

Due to the large number of independentvariables, only the most theoretically important

variables and variables that were significantlyrelated to at least one of the three mediatingfactors and caregivers health promotion behav-iors in the bivariate analyses were included in theequations to predict all of three mediating factors(caregiver self-efficacy, social support and reac-tions to caregiving) and caregivers health pro-motion behaviors. Caregivers age was droppedfrom the equation because it was not significantlyrelated to mediating factors and health outcomein the bivariate analysis, and because of its highcorrelation with relationship to the patient withstroke (r = 0.74). Caregiver employment statuswas dropped from the equation because it isnot a key variable in caregiver health promotionbehaviors (Killeen, 1989; OBrien, 1993). Care-giver gender was included because of its import-ance in predicting health promotion practices(OBrien, 1993; Allen-Holmes, 1997; Burtonet al., 1997). Intercorrelations between variableswere almost all 0.50. Residual analysis andexamination of measures of collinearity did notreveal any serious violations of the assumptionsof multiple regression analysis (Kleinbaum et al.,1988).


Table 1: Bivariate correlations among variables

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1 1.002 0.18a 1.003 0.26b 0.30b 1.004 0.11 0.12 0.36b 1.005 0.52b 0.07 0.18a 0.14 1.006 0.74b 0.04 0.40b 0.22a 0.42b 1.007 0.45b 0.10 0.23b 0.26b 0.37b 0.36a 1.008 0.11 0.09 0.07 0.04 0.07 0.17a 0.16 1.00

9 0.08 0.08 0.11 0.37b 0.22a 0.17 0.33b 0.11 1.0010 0.07 0.02 0.03 0.17a 0.11 0.04 0.15 0.25b 0.46b 1.0011 0.17 0.01 0.13 0.03 0.11 0.21a 0.21a 0.13 0.06 0.04 1.0012 0.13 0.14 0.02 0.06 0.01 0.18a 0.01 0.05 0.18a 0.10 0.29b 1.0013 0.04 0.09 0.02 0.27a 0.13 0.07 0.19a 0.18a 0.43b 0.33b 0.01 0.30b 1.0014 0.12 0.03 0.26b 0.26a 0.10 0.14 0.15 0.06 0.36b 0.27b 0.16 0.40b 0.09 1.00

1 = caregiver age; 2 = caregiver gender; 3 = caregiver education; 4 = household income; 5 = caregiver employment status;6 = relationship with care recipient; 7 = number of caregiver health problems; 8 = length of caregiving; 9 = caregiver healthstatus; 10 = care recipient functional status; 11 = caregiver self-efficacy; 12 = social support; 13 = reactions to caregiving;14 = caregiver health promotion behaviors.ap 0.05; bp 0.01.
http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/


6/12

RESULTS

Predicting caregiver self-efficacy

Bivariate correlations between variables in theanalyses that follow may be found in Table 1.Caregivers self-efficacy was correlated signifi-cantly with caregivers personal factors, such that

family caregivers had a high level of caregivingself-efficacy when the caregivers were spousaland when they had a higher number of healthproblems. A multiple regression analysis enter-ing variables simultaneously identified predictorsof caregiver self-efficacy. Results indicated thatthese variables accounted for 6.1% (adjusted R2)of the variance [F(8,125) = 2.09, p 0.05], withthe only significant predictor being caregivershealth status (see Table 2).

Predicting caregivers social support

Bivariate correlations revealed that social sup-port was correlated significantly with caregiverspersonal factors. Family caregivers were satisfiedwith the resources of social support when theywere spousal caregivers, and they rated their ownhealth as good. Results reported in Table 2 of amultiple regression analysis entering all variablessimultaneously indicated that these variablesaccounted for 4% (adjusted R2) of the vari-ance in caregiver social support [F(8,125) = 1.98,

p 0.05], with significant predictors being

relationship to the patient (spousal) and care-giver health status (better).

Predicting reactions to caregiving

The bivariate correlations indicated that familycaregivers had a higher level of negative reac-tions to caregiving when the caregivers had a lowincome, a high number of health problems, a longlength of caregiving time or poor health status,and when care recipients had a low level of

functional status. A multiple regression analysis(see Table 2) indicated that significant predictorsof reactions to caregiving included whether thefamily caregivers were spouses and whether theyrated themselves as having a high health status.Together, the predictive variables explained 23%(adjusted R2) of the variance in reactions tocaregiving [F(8,125) = 5.92,p 0.001].

Predicting caregivers health promotionbehaviors

Bivariate correlations indicated that greaterparticipation in health promotion activities wasassociated with higher education, higher income,better perceived health status, more satisfactionwith social support, and the care recipient havinga better functional status.

Hierarchical regression was used to assess theeffects of mediating factors (self-efficacy, socialsupport, reactions to caregiving) that may in-crease participation in health promotion behav-iors. The caregivers personal factors (gender,education, income, relationship with patient,

number of health problems, length of caregiving,caregivers health status) and the care recipients


Table 2: Summary of multiple regression analyses predicting caregiver self-efficacy, social support andreactions to caregiving

Variable Caregiver self-efficacy Social support Reactions tocaregiving

a R2 F a R2 F a R2 F

Caregiver gender 0.04 0.13 0.08

Caregiver education 0.06 0.05 0.10Household income 0.06 0.01 0.17Relationship with care recipient 0.10 0.21b 0.18b

Number of caregiver health problems 0.18 0.01 0.10Length of caregiving 0.16 0.03 0.11Caregiver health status 0.25b 0.21b 0.30b

Care recipient functional status 0.04 0.06 0.120.06 2.09b 0.04 1.98b 0.23 5.92c

aDenotes the standardized partial regression coefficients; unstandardized partial regression coefficients are available uponrequest.bp 0.05; cp 0.001.
http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/


7/12

functional status was entered first into theequation as a block, followed by the caregiversself-efficacy, social support and reactions to care-giving. Standardized regression (beta) coefficientsare reported from the end of block entry, with allvariables in the equation (Table 3).

Individual characteristics and experiences

The beta coefficients in Table 3 indicate thatcaregivers educational level and perceivedhealth status, and the care recipients functionalstatus were significant positive predictors of care-giver health promotion behaviors, as measuredby the HPLP-II. Family caregivers with a higherlevel of education, better perceived health status,and who cared for stroke survivors with lessdisability in activities of daily living reportedmore participation in health promotion activities.Individual characteristics and experiences as aset contributed a significant percentage (17%) toexplained variance in caregiver health promotionbehaviors.

Behavior-specific cognitions

Social support was a positive predictor ofcaregiver health promotion behaviors. In fact,satisfaction with social support was the strongestpredictor of caregiver health promotion behav-iors ( = 0.40,p 0.001). Additionally, reaction

to caregiving was a significant positive predictorof caregiver health promotion. Behavior-specificcognitions as a set contributed a significant per-centage (13%) to explained variance in caregiverhealth promotion behaviors.

DISCUSSION

This study contributes to the understanding ofhealth promotion behaviors of family caregivers,which have not been adequately studied (Killeen,1989). Results from this study provide baselineinformation about the relationship of self-efficacy, social support and reactions to care-giving with health promotion behaviors of familycaregiving, and information is needed that mightsuggest new and more appropriate interventionsto help them remain healthy.

Comparing hypotheses 1, 2 and 3, thecaregivers health status influenced all threemediating factors. The relationship with thepatient influenced the caregivers social supportand reactions to caregiving, but not the caregiversself-efficacy. In previous studies, investigatorsfound that the health status of caregivers wasrelated to the caregivers self-efficacy (Dorfmanet al., 1996; Haley et al., 1996). The results ofthe present study showed that the caregiversself-rated health was a significant predictor forcaregiver perceived self-efficacy. This finding


Table 3: Summary of multiple regression analysis predicting health promotion behaviors among familycaregivers of patients with stroke

Variable a R2 R2 change F

Individual characteristics and experiencesCaregiver gender 0.10Caregiver education 0.21b

Household income 0.09Relationship with care recipient 0.07Number of caregiver health problems 0.01Length of caregiving 0.10

Caregiver health status 0.22bCare recipient functional status 0.20b

0.17 0.17 4.45c

Behavior-specific cognitionsCaregiver self-efficacy 0.01Caregiver social support 0.40c

Reactions to caregiving 0.18b

0.30 0.13 6.27c

aDenotes the standardized partial regression coefficients; unstandardized partial regression coefficients are available uponrequest.bp 0.05; cp 0.001.
http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/


8/12

indicated that the caregivers with better self-rated health reported more confidence in managingcaregiving tasks, and that these caregivers mightassist stroke survivors in activities of daily living.

Caregivers satisfied with the resources ofsocial support had the following characteristics incommon: they were spousal caregivers and they

rated their own health as good. The results of thepresent study showed that the spousal caregiverswere more satisfied with their social support thanthe non-spousal caregivers. Possibly the spousesbelieved their roles were to care for their ill spouseand not to expect others to help, therefore theywere more satisfied with their social supports.Another possibility is that spousal caregivers mighthave felt obliged to give a socially acceptableanswer to show their appreciation that their care-giving was supported. Previous studies showedthat the health status of caregivers was related tothe caregivers satisfaction with social support(George and Gwyther, 1986; Gatz et al., 1990;Neary, 1990; Robinson and Steel, 1995). Theresults of the present study showed that the care-givers with poor self-rated health reported lesssatisfaction with their social support. Caregiverswho had good health would probably be betterable to function in various social roles and toobtain support from their social network whenneeded.

The caregivers who rated their health as beingpoor would perceive more strain in caregiving.Previous studies found that the health status

of the caregivers was related to the caregiversreactions to caregiving (Pratt et al., 1987; Pruchnoand Resch, 1989; Given et al., 1990; Lalonde andKasprzky, 1993; Pohl et al., 1994; England, 1996).The present study indicated that the caregiverswith a poor self-rated health status reportedmore strain concerning caregiving, and morenegative effects on finances and schedules as wellas feelings of abandonment (by other familymembers) and resentment. Perceived poorhealth may have prolonged the time it took toperform caregiving tasks, resulting in more inter-

ruption to the daily schedule of the caregivers.Previous studies have shown that the relation-ships with the patients are related to reactions tocaregiving (Barnes et al., 1992). The results ofthe present study showed that non-spousal care-givers felt greater strain than spousal caregivers.It may be that spouses feel it is their roles to carefor their ill spouse or do not expect others to helpand therefore feel less abandoned than the childcaregivers, at least initially.

In terms of the caregivers health promotionbehaviors, results reveal that family caregiverswho cared for stroke survivors with lessdisability, those with a higher level of education,with better perceived health status, with greatersatisfaction with the resources of social supportand with a higher level of negative reactions to

caregiving reported more participation in healthpromotion behaviors. The findings indicated thatsocial support was the strongest positive pre-dictor of caregivers health promotion behaviors,which suggests that social support is importantto caregivers health promotion behaviors.This result is consistent with the findings ofprevious studies conducted in the United States(Muhlenkamp and Sayles, 1986; Riffle et al.,1989; Alexy, 1991; Wyatt, 1991; Terborg et al.,1995). Previous studies have indicated that care-givers satisfied with their social-support resourceswould engage in health promotion behaviors.

The relationship between the reactions tocaregiving and health promotion behaviors hasnot been found. The results of the present studyshow that the caregivers who felt strain, due totheir role as a caregiver, would engage in healthpromotion behaviors. This finding is difficult toexplain. Perhaps caregivers feeling the strain ofthe role of caregiving responsibility mayparticipate in health promotion activities tomaintain their own health. Further research isneeded to confirm and explain this relationship.

Some investigators cited self-efficacy as a

potential psychosocial predictor of caregiveroutcomes (Archbold et al., 1990; Mowat andLaschinger, 1994; Dorfman et al., 1996; Gallantand Connell, 1998). Caregiver self-efficacy, i.e.confidence in managing caregiving tasks, con-trary to expectations, did not affect caregivershealth promotion behaviors in the present study.It is possible that the caregivers confidence in-creases their ability to manage the caregivingtasks. However, the linkage between effectivemanagement of caregiving tasks and increasedhealth promotion behaviors of caregiving is un-

clear. The concept of health promotion is relativelynew in Taiwan, and additional time might beneeded for caregivers to learn the importance ofhealth promotion to their own health.

Limitations of the study are described as fol-lows. The cross-sectional design did not explaincausation. Because a convenience sample wasused, the findings cannot be generalized to otherpopulations with characteristics dissimilar to thesample in this study.

http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/


9/12

Implications for practice

When a family member has a stroke, the entirefamily often suffers. The situation is especiallydifficult if only one family member is the care-giver. Social support is an important conceptfor the health professionals caring for the familycaregivers because a caregiver needs as much

support as possible from others. Nurses, socialworkers, counsellors, family life educators andother practitioners can refer clients to, or evenestablish, community training programs andsupport groups for stroke survivors as well asfamily caregivers. In the support groups, care-givers could work on problems together anddevelop new friendships. In addition, nursesand other health professionals can suggest thatcaregivers ask their family members and friendsto help in specific ways and to commit to certaintimes to help. This gives others an opportunity to

help in useful ways and to provide the caregiversrelief from some caregiving responsibility.Among the individual characteristics, the

results indicated that the health of family care-givers was associated with their confidence inmanaging caregiving tasks (self-efficacy), socialsupport, strain and health promotion behaviors.These findings indicated the need to follow upwith caregivers and to refer them to appropriatehealth care services where necessary. Servicessuch as home-based and hospital-based respitecare are examples of important resources for

caregivers who are experiencing health problemsor burnout.Many stroke survivors can be helped by

rehabilitation. The findings showed that carerecipients with a higher functional status engagedin more health promotion activities. This suggeststhat health professionals can help stroke survivorsdecide about and choose the right rehabilitationservices or program. The practitioners can edu-cate caregivers about how to help patients withoutallowing the patients to become too dependenton the caregivers services. The practitionersshould also advise family caregivers to engage inhealth promotion practices.

Address for correspondence:Dr Yu-Ying TangSchool of NursingNational Defense Medical Center, 4F, 161, Section 6Min-Chuan E. RoadTaipeiTaiwan 114

REFERENCES

Alexy, B. B. (1991) Factors associated with participationor nonparticipation in a workplace wellness center.Research in Nursing and Health, 14, 3340.

Allen-Holmes, L. M. (1997) The Role of Physical Health,Mental Health, and Help Orientation in the HealthPromotion Behaviors of Informal Caregivers of Impaired

Elders. Unpublished doctoral dissertation, Case WesternReserve University, Cleveland, OH.Archbold, P. G., Stewart, B. J., Greenlick, M. R. and

Harvath, T. (1990) Mutuality and preparedness aspredictors of caregiver role strain. Research in Nursingand Health, 13, 357384.

Bandura, A. (1982) Self-efficacy mechanism in humanagency.American Psychologist, 37, 122147.

Barnes, C. L., Given, B. A. and Given, C. W. (1992) Care-givers of elderly relatives: spouses and adult children.Health and Social Work, 17, 282289.

Bergman-Evans, B. F. (1994) Alzheimers and relateddisorders: loneliness, depression, and social support ofspousal caregivers.Journal of Gerontological Nursing, 3,615.

Brandt, P. A. and Weinert, C. (1987) The PRQ-A socialsupport measure. Nursing Research, 36, 273277.

Burton, L. C., Newsom, J. T., Schulz, R., Hirsch, C. H.and German, P. S. (1997) Preventive health behaviorsamong spousal caregivers. Preventive Medicine, 26,162169.

Carey, P. J., Oberst, M. T., McCubbin, M. A. and Hughes, S.H. (1991) Appraisal and caregiving burden in familymembers caring for patients receiving chemotherapy.Oncology Nursing Forum, 18, 13411348.

Decker, S. D. and Young, E. (1991) Self-perceived needs ofprimary caregivers of home-hospice clients. Journal ofCommunity Health Nursing, 8, 147154.

Dorfman, L. T., Holmes, C. A. and Berlin, K. L. (1996) Wifecaregivers of frail elderly veterans: correlates of caregiver

satisfaction and caregiver strain. Family Relations, 45,4655.

England, M. (1996) Caregiver burden, strain and perceivedhealth of adult children caring for a neurologicallyimpaired parent. Geriaction, 14, 1119.

Fredriksen, K. I. (1996) Gender differences in employmentand the informal care of adults. Journal of Women and

Aging, 8, 3553.Gallant, M. P. and Connell, C. M. (1998) The stress process

among dementia spouse caregivers. Research on Aging,20, 167197.

Gatz, M., Bengston, V. L. and Blum, M. J. (1990) Caregivingfamilies. In Bitten, J. E. and Schaie, K. W. (ed.)Handbook of the Psychology of Aging, 3rd edition.Academic Press, San Diego, CA.

George, L. K. and Gwyther, L. (1986) Caregiver well-being: a multidimensional examination of familycaregivers of demented adults. The Gerontologist, 26,253259.

Gillis, A. J. (1993) Determinants of a health-promotinglifestyle: an integrative review. Journal of AdvancedNursing, 18, 345353.

Given, B., Stommel, M., Collins, C., King, S. and Given,C. W. (1990) Responses of elderly spouse caregivers.Research in Nursing and Health, 13, 7785.

Given, C. W., Given, B., Stommel, M., Collins, C., King, S.and Franklin, S. (1992) The caregiver reaction assessment

http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/


10/12

(CRA) for caregivers to persons with chronic physicaland mental impairments. Research in Nursing and Health,15, 271283.

Granger, C. V., Albrecht, G. L. and Hamilton, B. B. (1979)Outcome of comprehensive medical rehabilitation:measurement by PULSES Profile and Barthel Index.

Archives of Physical Medicine and Rehabilitation, 60,145154.

Haley, W. E., Levine, E. G. and Brown, S. L. (1987) Stress,

appraisal, coping, and social support as predictors ofadaptational outcome among dementia caregivers.Psychology and Aging, 2, 323330.

Haley, W. E., Roth, D. L., Coleton, M. I., Ford, G. R., West,C. A. C., Collins, R. P. et al. (1996) Appraisal, coping,and social support as mediators of well-being in blackand white family caregivers of patients with Alzheimersdisease. Journal of Consulting and Clinical Psychology,64, 121129.

Horowitz, A. (1985) Sons and daughters as caregivers toolder parents: differences in role performance andconsequences. The Gerontologist, 6, 612617.

Hu, H. H., Sheng, W. Y., Chu, F. L., Lan, C. F. and Chiang,B. N. (1992) Incidence of stroke in Taiwan. Stroke, 23,12371241.

Hung, T. P. and Chen, S. T. (1993) Cerebral hemorrhage inTaiwan. Journal of Formos Medication Association, 92,S161S168.

Jackson, D. G. and Cleary, B. L. (1995) Health promotionstrategies for spousal caregivers of chronically ill elders.Nurse Practitioner Forum, 6, 1018.

Keefe, J. M. and Medjuck, S. (1997) The contribution oflong term economic costs to predicting strain amongemployed women caregivers. Journal of Women and

Aging, 9, 325.Killeen, M. (1989) Health promotion practices of family

caregivers. Health Values, 13, 310.Kleinbaum, D. G., Kupper, L. L. and Muller, K. E. (1988)

Applied Regression Analysis and Other MultivariableMethods, 2nd edition. PWS-Kent Publishing Co., Boston,

MA.Lalonde, B. and Kasprzyk, D. (1993) Correlates of caregiver

strain in home health care. Home Health Care ServicesQuarterly, 14, 97110.

Lawton, M. P., Kleban, M. H., Moss, M., Rovine, M. andGlicksman, A. (1989) Measuring caregiving appraisal.

Journal of Gerontology: Psychological Sciences, 44,6171.

Lee, K. E. (1989) Assessment of Twenty Nursing CareCenters in Su-Ling, Pa-Tuo, and Nei-Hu Areas. ResearchReport No. 1989-4. Taipei Yan-Ming MunicipalHospital.

Lin, M. N. and Chiou, C. J. (1995) The quality of family carefor the elderly homebound stroke victim. NursingResearch, 3, 138148 (in Chinese).

Mahoney, G. I. and Barthel, D. W. (1965) Functionalevaluation: the Barthel Index. Maryland State Medical

Journal, 14, 6165.McNair, D. M., Lorr, M. and Droppleman, L. F. (1981) Edits

Manual for the Profile of Mood States. Educational andIndustrial Testing Service, San Diego, CA.

Miller, B. (1987) Gender and control among spouses of thecognitively impaired: a research note. Gerontologist, 27,447453.

Moen, P., Robison, J. and Dempster-McClain, D. (1995)Caregiving and womens well-being: a life course approach.

Journal of Health and Social Behavior, 36, 259273.

Montgomery, R., Stull, D. E. and Borgatta, E. F. (1985)Measurement and the analysis of burden. Research on

Aging, 7, 137152.Mowat, J. and Laschinger, H. K. S. (1994) Self-efficacy

in caregivers of cognitively impaired elderly people:a concept analysis. Journal of Advanced Nursing, 19,11051113.

Muhlenkamp, A. and Sayles, J. A. (1986) Self esteem, socialsupport and positive health practices. Nursing Research,

35, 334338.Nation Health Administration (2000) Health Statistics,Republic of China. National Health Administration,Taipei.

Neary, M. A. (1990) Buffering Effect of Social Support onPrimary Caregivers Health After Nurse Home Admissionof Elderly Family Member. Unpublished doctoral dis-sertation, State University of New York at Buffalo, NY.

Oberst, M. T., Thomas, S. E., Gass, K. A. and Ward, S. E.(1989) Caregiving demands and appraisal of stress amongfamily caregivers. Cancer Nursing, 4, 209215.

OBrien, M. T. (1993) Multiple sclerosis: Health-promotingbehaviors of spousal caregivers. Journal of NeuroscienceNursing, 25, 105112.

Pender, N. J. (1996) Health Promotion in Nursing Practice,

3rd edition. Appleton and Lange, Connecticut.Periard, M. E. and Ames, B. D. (1993) Lifestyle changes and

coping patterns among caregivers of stroke survivors.Public Health Nursing, 10, 252256.

Pohl, J. M., Given, C. W., Collins, C. and Given, B. A. (1994)Social vulnerability and reactions on caregiving indaughters and daughters-in-law caring for disabledaging parents. Health Care for Women International, 15,385395.

Poulshock, S. W. and Deimling, G. T. (1984) Families caringfor elders in residence: Issues in the measurement ofburden.Journal of Gerontology, 39, 230239.

Pratt, C., Wright, S. and Schmall, V. (1987) Burden, coping,and health status: a comparison of family caregiversto community dwelling and institutionalized Alzheimers

patients. Gerontological Social Work with Families, 10,99112.

Pruchno, R. A. and Resch, N. L. (1989) Husbands and wivesas caregivers: antecedents of depression and burden. TheGerontological Society of America, 29, 159165.

Pruchno, R. A., Kleban, M. H., Michaels, E. and Dempsey,N. P. (1990) Mental and physical health of caregivingspouses: development of a causal model. Journal ofGerontology, 45, 192199.

Riffle, K. L., Yoho, J. and Sams, J. (1989) Health-promotingbehaviors, perceived social support, and self-reportedhealth of Applachian elderly. Public Health Nursing, 6,204211.

Robinson, K. M. and Steele, D. (1995) The relationshipbetween health and social support in caregiving wives as

perceived by significant others. Journal of AdvancedNursing, 21, 8894.

Schumacher, K. L., Dodd, M. J. and Paul, S. M. (1993) Thestress process in family caregivers of persons receivingchemotherapy. Research in Nursing and Health, 16,395404.

Stuifbergen, A. K. (1995) Health-promoting behaviors andquality of life among individuals with multiple sclerosis.Scholarly Inquiry for Nursing Practice, 9, 3155.

Stull, D. E., Boxman, K. and Smerglia, V. (1994) Women inthe middle: a myth in the making? Family Relations, 43,319324.

http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/http://heapro.oxfordjournals.org/


11/12

Terborg, J. R., Hibbard, J. and Glasgow, R. E. (1995)Behavior change at the worksite: does social supportmake a difference?American Journal of Health Promotion,10, 125131.

Tuohing, G. M. (1991) Health behaviors in elderly life-styles. Unpublished doctoral dissertation, University ofUtah.

Walker, S. N., Volkan, K., Sechrist, K. R. and Pender, N. J.(1987) Health-promoting lifestyles of older adults:

comparisons with young and middle-aged adults,correlates and patterns.Advances in Nursing Science, 11,7690.

Williams, A. (1994) What bothers caregivers of strokevictims?Journal of Neuroscience Nursing, 26, 155161.

Winslow, B. and OBrien, R. (1992) Use of formal com-munity resources by spouse caregivers of chronically illadults. Public Health Nursing, 9, 128132.

Wu, S. L., Chang, Y. J., Lin, F. H. and Yao, K. M. (1992) Astudy on the burdens and demands of primary caregiversof frail elderly in the community of Taiwan province.Public Health, 19, 166177 (in Chinese).

Wyatt, J. S. (1991) Family coping and level of health ofparents with technology assisted home bound children

with respiratory disabilities. Unpublished doctoraldissertation, Uni

health promot. int. 2002 tang 329 39

Documents