the effect of spirituality and gender on the quality of life

8/13/2019 The Effect of Spirituality and Gender on the Quality of Life

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The E ffect of Spirituality and G ender on the Q uality of Lifeof Spousal Caregivers of Cancer SurvivorsLeighAnna Allen Colgrove M.P.H.

Eastern Virginia Medical SchoolYoungmee Kim Ph.D.American Cancer Society

Nancy Thompson Ph.D.Emory U niversity

ABSTRACTBackground: Research has indicated spirituality buffers

the adverse effect of stress, but few studies have examined therole of spirituality in the context of providing cancer care. Pur-pose: This study examines the moderating effects of spiritualityon the relation between caregiving stress and spousal care-givers' mental and physical health. In addition, gender differ-ences in the target moderating effects are explored. Methods: Acaregiver survey w as mailed to fam ilial caregivers nom inated bytheir respective cancer survivors including measures of spiritu-ality Functional A ssessment of Chronic Illness Therapy Spiri-tuality), caregiving stress (Pearlin Stress Scale), and mental andphysical health (MOS Short Form-36). Four hundred and threespousal caregivers provided valid information on these mea-sures. Results: Hierarchical regression analyses supported thehypothesized moderating effects of spirituality but in differentpatterns. Caregiving stress was associated with poorer mentalfunctioning, which was less prominent among caregivers with ahigh level of spirituality (stress-buffering effect). Caregivingstress was also associated with poorer physical functioning butwas only significant among caregivers with a high level of spiri-tuality (stress-aggravating effect). The same stress-buffering oraggravating effects were found for both sexes. Conclusions:The findings suggest maintaining faith and finding meaning incancer caregiving buffer the adverse effect of caregiving stresson mental health. Highly spiritual caregivers should also be en-couraged to pay more attention to their physical health whileproviding cancer care.

Ann Behav Med2007, 33(1):90-98)

This s tudy was funded by the Am erican Cancer Socie ty, Nat ionalHom e O ffice, Intramural Research. Por t ions of this s tudy were pre-sented at the 2004 Annual Meeting of the Society of Behavioral Medi-cine, Boston, Massachusetts.We e xtend our appreciat ion to Dr . Car l Thoresen for his thoughtfulcomm ents on an earlier draft; to Rachel S pillers for her support in datacollection; and to all the fam ilies who participated in this investigation.Reprint Address: Y. Kim, Ph.D., Behavioral Research Center, Ameri-can Cancer Society, 1599 Clifton Road, NE, Atlanta, GA 30329-4251.E-mail: [email protected]

2007 by The Society of Behavioral Medicine.

INTRODUCTIONAn estimated 1.4 million individuals in the United States

were diagnosed with cancer in 2006 (1), with a similar numberof family members expected to provide care or support. Familymembers often assume the role of primary caregivers of cancerpatients once they are discharged from hospital. Provision ofcancer care is a unique and specific type of stress (2), which canbe markedly different from caring for persons with other typesof illnesses due in part to the perceived threat of mortality asso-ciated with a cancer diagnosis and its treatment. The challengesassociated with providing care to cancer survivors may weigheven more on spouses, as they are typically the primary care-givers to adult patients (3-7).Research indicates that spousal caregivers who ha ve experi-enced increased caregiving stress report poor quality of life,which in this work refers to both mental and physicalwell-being. Specifically, stressed caregivers have reported poormental health, including increased anxiety and depression (5,6)and less life satisfaction (8). Mortality rates of stressed care-givers are higher than relatively stress-free caregivers ornoncaregivers 9). Comparing spouses with other familial care-givers, spouses report significantly more stress symptoms,lower levels of affect balance and life satisfaction, and poorerself-rated physical health (10).

These studies illustrate the adverse impact of caregivingstress on the caregiver's quality of life, although other studieshave failed to support the relation. Among wives caring for dis-abled spouses, Seltzer and Li (11) found that caregiving wivesdid not differ in physical outcomes compared with controls.George and Gwyther (10) also found that spousal caregivers didnot significantly differ from noncaregivers on self-rated physi-cal health.

The inconsistent findings suggest that not all caregivers ex-perience or report poorer quality of life during caregiving, un-derscoring the need to examine factors that may account for in-dividual differences in the association between caregiving stressand quality of life. The stress-coping model (12) provides a the-oretical framework to understand better the differential impactof stress depending on individual differences in various factors.Several potential moderators of the relation between caregivingstress and quality of life have been tested, including age, socialsupport, coping style, and finding meaning in caregiving (13).

The moderator of interest in this study is spirituality, whichspecifically refers to a search for peace, wholeness, or harmony

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Volume 33 Numb er 1 2007pirituality and Cancer Care1with a higher power and a sense of me aning and purpose in life(14). Because subjective feelings related to fai th and m eaningmay ar ise independent of asso ciat ion w ith an identifiable rel i-gious group or doctrine, this study focuses on spirituality ratherthan rel igiosi ty. Accum ulating evidence supports the perspec-tive that spirituality as a form of co ping buffers the ad verse im-pact of various types of stressors among a wide range of popula-tions including college students (15), patients with cancer(16-18) and ca regivers of HIV pa tients (19,20). On the othe rhand, caregivers of persons with Alzheimer 's disease who hadquestioned their faith or felt dis tant from or a ngry with G od,reported higher levels of depression as caregiving burdenincreased (21).Most of the work on spirituality, stress, and caregiving exam-ines persons providing dementia, heart failure, and stroke care(21-24), often using qualitative m ethods such a s semistructuredinterviews with caregivers (24-26). For example, female care-givers of persons with Alzheim er 's disease reported that theyused spirituality to cope and find mean ing in the situation, as anaid to look beyond the im mediate burden of the caregiving situa-tion (25). Finding meaning in caregiving ma y explain how somecaregivers of persons with dementia have posi tive outcomes inspite of significant dem ands (27,28).Spirituality appears to attenuate the relation between stressand he alth, but mixed results and n ull findings exist. For exam -ple, wives providing dementia care reported using spiritual re-sources more often than non caregivers (22). However, no rela-t ion emerged between spirituality and c aregiver depression (23).Although interest in the role of spir ituality in cancer hasbeen increasing in recent years, this area remains understudied,and extant work a lso often provides mixed results regardingspirituality 's im pact on health (29). Literature on the role o fspirituality in cancer caregiving is sparse, and even fewer stud-ies have examined the moderating effect of spirituality oncaregiving stress and quali ty of l ife amon g cancer caregivers,due in part to sample size constraints or the absence of a theoret-ical framework. This paucity is surprising given prelim inarywork indicating spirituality plays an important role in the cancercaregiving experience (30). The potentially life-threatening na-ture of cancer m ay precipitate a propensity for heightened spiri-tuality or greater recogn ition of spiritual needs (31). Taylorfound caregivers and ca re recipients with cancer voiced similarspiritual needs such as finding me aning, hope, and preparing fordeath (26). Therefore, we attempt to exam ine the mode rating ef-fect of spirituality am ong this pertinent cancer care giver sample,util izing a stress-coping framework and a large sample size toclarify conflicting results in the e xisting literature.With regard to ca regiving and spirituality, gender ma y playan a dditional, significant role. Nearly three fourths of caregiversin the United States are women (32), and women report using spir-i tual resources m ore often than m en (33). Female cancer care-givers, however, are mo re likely than their male counterparts todevelop an affective disorder (34). Female gender had been iden-tified as an independent risk factor for poor caregiver well-being(8). Although not all studies found gender differences incaregiving and spirituality (35), the findings suggest female care-

givers are a unique population with regard to the interplay of spiri-tuality, caregiving, and quality of life.In summ ary, spirituality appears to be a reasonable m odera-tor of caregiving stress, yet little work has bee n done on spiritual-i ty as a mo derator of the effect of cancer caregiving stress onspousal caregiver quality of life. This study examines the moder-ating effect of spirituality on the mental and physical health ofspousal caregivers of cancer survivors and e xplores the effect ofgender in these relations. Based on the literature previously re-viewed, we hypothesized that caregiving stress would be nega-t ively associated with the caregive r 's m ental health, and thenegative association would be less prominent among h ighly spiri-tual caregivers (Hypothesis 1). Caregiving stress would aga in benegatively associated with the caregiver's physical health, withless of a negative association among highly spiritual caregivers(Hypothesis 2). We explore the effect of gender through two re-search questions instead of generating hypotheses due to the pau-city of peer-reviewed literature on the effect of gender on the rela-t ion between stress, spirituality, and mental and physical health.Specifically, we investigated whether Hypotheses 1 and 2 wouldbe more strongly supported among female caregivers than malecaregivers (Research Question 1 on mental health and ResearchQuestion 2 on physical health).

METHODParticipants

The Am erican Cancer Society 's Quali ty of Life Survey forCaregivers was designed to assess the impact of cancer on thequality of l ife of family m embers a nd close friends who c are forcance r survivors. Data reported here a re from the first cohort ofbaseline data collection. Caregivers were nominated by cancersurvivors who participated in the Study of Cancer Survivors, asurvey of cancer survivors identified by state cancer registrieswho were asked to n om inate individuals in a fam ily-like rela-tionship who con stantly provided he lp to them . Eligibility crite-ria for the caregiver study were an age of 18 years or older, theabil ity to speak/read En glish or Spanish, and residence in theUnited States.A to ta l of 739 caregivers completed the basel ine survey(63.9% response rate), of which 461 were spouses of the cance rpatients . Of the spousal caregivers , 403 careg ivers providedvalid data for all study variables and were included in the subse-quent analyses. Caregivers with missing data (n = 58) were older(p < .001) and more l ikely to be fem ale (p < .001) than care-givers who provided c omplete da ta. Care recipients (i.e., cancersurvivors) of caregivers with com plete data reported s ignif i-cantly better quality of life (me ntal: p < .001; physical: p < .001)than those care recipients of caregivers with missing data.Can cer si tes of the survivors were prostate (26% ), breast(23% ), colorectal (15%), lung (8%), ovarian (7%), kidney (7% ),bladder (6%), and other (


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92olgrove et al nnals o Behavioral M edicineProcedureA packet containing an introductory let ter , questionnaire,self-addressed stamped e nvelope, frequently asked questionsbrochure, and a 60-min phone card as an incentive was ma iled tothe nominated careg iver. Returning the completed survey servedas informed consent to participate in the study. Reminder post-cards were mailed 2 weeks after the initial mailing. The secondpacket , which included the sam e m ater ia ls except the phonecard, was ma iled 4 weeks after the ini t ial mail ing if the nom i-nated caregivers did not respond.Measures

Caregiving stress. The extent to which c aregivers felt over-whelmed by c are tasks and responsibilit ies was measured by theStress Overload subscale of the Pearl in S tress Scale (36). Re-spondents are asked to rate how m uch each of the four s tate-ments described them in relation to their caregiving tasks usinga 4-point Likert-style format (1 = not at all, 4 = completely). Asample i tem reads, You have more things to do than you canhandle . The sum of the four i tems represented the leve l ofcaregiving stress, with higher scores reflecting greater stress.This subscale score had ac ceptable internal consistency in thepresent study (Cron bach's a = .80), identical to the level em piri-cally demo nstrated by Pearlin, Mullan, Semple, and Skaff (36).The subscale reflects the primary stressor of overload or burn-out from Pearlin's conceptual model of Alzheimer's care-givers' stress (36).

Spirituality. Individual differences in spirituality weremeasured with the 12-i tem Functional Assessment of Chron icI llness TherapySpirituality (FACITSp) (37,38), using a5-point Likert-style format (0 = not at all, 4 = very much). Th eFAC ITSp is a psychom etrically sound instrument initially de-signed to assess spiritual well-being in cancer patients (38). TheFACITSp ha s two subscales: Meaning and Peac e (8 items) andFaith in Illness (4 i tems). A sam ple i tem from the M eaning andPeace subscale reads, I feel a sense of purpose in my life. Oneof the four items from the Faith in Illness subscale states, Thisperson's i l lness has strengthened m y faith. This item and oneother were slightly rewo rded to refer to the ca re recipient's ill-ness rather tha n a personal i l lness. The com posite spir itualityscore was calculated by summ ing the 12 items after reverse cod-ing as need ed. Higher scores ref lect greater leve ls of f indingmea ning and fai th in the co ntext of dealing with a chronic i l l-ness. The two FACITSp subscales were m oderately correlatedwith each othe r (r = .52, p < .00 1) and stron gly correlated withthe total scale score (M eaning and Peace: r = .91, p < .001; Faith:r = .83, p < .001).Both conv ergent and discrim inant validity were previouslyexamined (38). The total FACITSp score was mod erately tostrongly correlated with quality of life as measured by theFAC ITGeneral (39) and the Profile of Mood States (POM S)(40) and its subscales, with better quality of life and better moodrelated to higher levels of spirituality. An inverse correlation be-tween the tota l FAC ITSp score and the POM S Depress ionsubscale supported discriminant validity. Cronbach's alphas for

the two subscales and the total scale were all acceptable, rangingfrom .81 to .88 (41). The total scale (a = .90), and both subscales(Mea ning and Peac e: a = .90; Faith: a = .88) evidenced good in-ternal consistency in this study.Quality of life. Careg ivers ' quality of l ife referred to theirmental and physical health as measured by the 36-item MedicalOutcome s Study Index Short Form (SF-36) (41). The SF-36 is awell-established instrument assessing global physical and men-tal functioning and is comm only used in the psycho-oncologyliterature as a m easure o f quality cf life (42-44). A sample itemasks In general, would you say your health is: Excellent, VeryGood, Good, Fa ir , or Poor? The menta l hea l th score was acom posite of weighted vital i ty, social functioning, role-emo-tional, and m ental health subscale scores. The physical healthscore was a com posite of weighted physical functioning, role-

physical, bodily pain, and general health subscale scores.Higher com pos i te scores ref lec ted bet ter menta l or phys icalhealth, respectively. Extensive research confirms the v alidity ofthe SF-36, including determinations of know n groups validity(45) and convergent and discriminant validity (46,47).Covariates. Caregiver age (48), education level (49),household income (50) , and the m enta l and physica l hea lth oftheir care recipient (51) we re identified in the literature as sig-nificant factors related to the quali ty of l ife of caregivers an dwere included in the analyses as covariates. The canc er survi-vor 's mental and phy sical health was also m easured using the

SF-36 (41). Active versus former caregiving s tatus was alsoconsidered. Zero-order correlat ion an alyses confirmed the in-clusion of the six covariates. Income (r = .23, p < .001), educa-tion (r= .23,p < .001), caregiver age (r= .39,p < .001), survi-vor physical health (r = .23, p < .001) and active caregiving (r =.13, p < .01) were al l significantly c orrelated with caregiverphysical health; age (r = .18, p < .001), survivor physical health(r = .18, p < .001) and survivor m ental health (r = .24, p < .001)were significantly correlated with caregiver men tal health. Can-cer site was also considered as a potential covariate but excludedafter a one-way ana lysis of variance found no significant rela-t ion between the si te of the cancer an d the level of caregivingstress (p = .59).Analysis Plan

Hypothe ses I and 2 were tested uti l izing two hierarchicalregression analyses to examine the main an d interact ion effectsof caregiving stress, spirituality, and gend er on ea ch of the twodependent variables. In Step 1, the six covariates were enteredinto the equation. The three main effects (i.e., caregiving stress,spirituality, and care giver gende r) were entered in Step 2 . Care-giver gender was coded as 1 for men and 1 for women. Care-giving stress an d spirituality scores were cen tered by subtract-ing the mean from each value to guard against multicollinearityin testing the interaction effect between the two v ariables (52).In Step 3, three two-way interac tions of caregiving stress, spiri-tuality, and caregiver gen der were entered into the equation, fol-lowed by the three-way interaction in Step 4. Interaction terms


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Volume 33, Number 1, 2007pirituality and Cancer Care3were computed as the product of the respective variables (e.g.,Caregiving Stress x Spirituality; Gender x Caregiving Stress xSpirituality).

To investigate further significant interaction effects be-tween caregiving stress and spirituality, post hoc probing as de-scribed by Aiken and W est (52) was con ducted us ing spir i tual i tyscores transformed to reflect high (1 SD) and low (-1 SD) levelsof spirituality. High spirituality was calculated by subtracting 1SD below the mean from the centered spirituality value; lowspirituality was calculated by subtracting 1 SD above the meanfrom the centered spirituality value (52). These transformedspirituality values were then used to recompute the interactionterm with caregiving stress i.e., High Spirituality x CaregivingStress; Low Spirituality x Caregiving Stress).

Significant interactions were plotted using the transformedvalues in the regression equations. The two post hoc regressionlines (one for high spirituality and the other for low spirituality)were then plotted, with mental health regressed on caregivingstress, the transformed scores for high and low levels of spiritu-ality, and the respective Spirituality-Stress interaction variables.The same post hoc regression methods were used to plot lineswith physical health as the outcome variable.

RESULTSDescriptives of the Sample

Demographic characteristics of the caregivers and descrip-tive statistics for study variables are shown in Table 1. Partici-pating spousal caregivers were primarily middle-aged, White,educated at or beyon d the high sch ool level , and rela t ively aff lu-ent, with the majority reporting annual household incomesgreater than $40,000. Forty-one percent of spouses were activecaregivers at the time of participating in the survey. The meanmenta l hea l th score of the spousal caregivers M = 50.54) did not

significantly differ from the published mean of the U.S. generalpopulation M = 50.00), t(402) = .98, p = .33 (41). The meanphysical health score of the caregivers M = 47.01) was signifi-cantly lower than the published mean of the U.S. general popu-lation M = 50.00), t 402) = -5.97, p < .001 (41), potentially be-cause our sample was older than the general population. Theleve l of men ta l hea l th of the care rec ipients M = 52.55) was sig-nificantly greater than the mean of the U.S. general population M = 50.00), t 402) = 5 .65, p < .001, whereas the level of physi-cal health of the care recipients (M = 45.08) was significantlylower than the general U.S. population norm M = 50.00) (41).

Testing of HypothesesMental health. Hypothesis 1 stated that caregiving stress

would be negatively associated with the caregiver's mentalhealth and that the association would be less prominent amonghighly spir i tual caregivers . W hether this expected pat tern wouldbe more prominent among female caregivers (Research Ques-tion 1) was also explored. The main and moderating effects ofcaregiving stress, spirituality, and gender on mental health areshown in Table 2 .The overal l mode l test ing Hypothes is 1 and Research Ques-tion 1 was significant, F(13, 379) = 23.70, p < .001, with themain effects of stress, spirituality, and gender also reaching sta-tistical significance (all ps < .02). These main effects explain31% of the overall variance in mental health. High levels ofcaregiving stress were associated with poorer mental health.Spirituality was positively associated with mental health,whereas female gender was associated with poorer mentalheal th .

The two-way interaction between caregiving stress andspirituality was significant, explaining an additional 2% of vari-ance. Pos t hoc probing rev ealed that the nega t ive associat ion be-

TABLE 1Descriptives of Study Variables, Covariates, and Other Demographics of Caregivers

M orFrequency SD

ObservedRange

Study variablesGender: Female 54.30 Caregiving stress 6.67 2.35 4-16Caregiver spirituality 35.65 8.77 5-48Caregiver mental health 50.54 11.08 10.06-65.84Caregiver physical health 47.01 10.06 12.85-66.05CovariatesCaregiver age 59.03 10.97 29-88Caregiver education (< high school diploma) 29.80 Caregiving status (active caregiving) 41.40Annual household income (< $40,000) 24.50 Survivor mental health 52.55 9.07 17.07-67.65Survivor physical health 45.08 10.64 13.93-62.61Other demographics of caregiversWhite 95.80 Employed 70.70 Note N=403


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94olgrove et al.nnals of Behavioral MedicineTABLEHierarchical Regress ion A nalyses for Va riables Predict ing C aregivers ' Qual i ty of LifeMental Health Physical Health

R2 O R 2 2 3 t R 2 A R 2tStep 1: Covariates .12 .12 .2 3 .23Caregiver age .03 .07 1.74 .13 -.36 -7.51***Caregiver education .0 1 -.03 -.78 .03 -.18 -3.76***Caregiving status (active caregiving) .02 -.08 -2.05* .01 -.03 -0.67Annual household income .00 -.02 -0.56 .01 -.05 -1.09Survivor physical health .0 1 .03 0.78 .01 .14 3.05**Survivor mental health .00 .04 0.95 .00 .08 1.59Step 2: M ain effects .43 .31 *** .26 03**

Gender G) .0 0 -.10 -2.39 .0 0 -.02 -0.35Caregiving stress (CS) .27 -.24 -4.84*** .13 -.21 -3.83***Spirituality (S) .55 .42 9.56*** .25 -.05 -0.94Step 3: Two-way interaction effects .45 .02* .28 .02**G x CS .0 9 -.08 -1.72 .0 4 -.050.98G x S .18 .0 4 1.00 .0 8 -.030.65CS x S .5 4 .11 2.32 .4 6 -.162.88Step 4: Three-way interaction effects .45 .00 .28 .00G x CS x S .1 4 -.04 -0.87 .1 4 -.02 -0.34Note. N = 403. G3 = standardized coefficient. Caregiving status (active caregiving): 0 = former and I = currently providing care; Education: 0 = high schoolgraduate or greater and I = less than high school graduate; Income: 0 = household income $40,000 or greater annually and I = less than $39,999 annually; Gen-der: -1 = male and I = female.p


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V olume 33, Num ber 1, 2007pirituality and Cancer Care5x ........ High Spirituality

Low Spirituality

6024Caregiving StressFIGURE 2 The stress-aggravating effect of spirituality on physicalhealth.

lower levels of spirituality (slope = 0.40, p = .10). Again, posthoc probing confirmed the slopes of the regression l ines repre-senting high and low levels of spir i tuali ty significantly differfrom eac h other (p < .001). This result does not support Hypoth-esis 2, indicating instead a stress-aggravating effect of spiritual-ity. The three-way interaction among caregiving stress, spiritu-ality, and gender was not significant, again suggesting that themo derating effect of spirituality on physical he alth was similarfor both sexes. All significant results for both physical and men-tal health rem ained significant when g ender interaction termswere removed from the m odels.

DISCUSSIONThis study exam ines the relations among care giving stress,gender, spirituality, and quality of l ife am ong spousal caregiversof cancer patients. Spirituality significantly m oderated the effectof caregiving stress on both physical and mental health outcome s.Although the effect size was small for both mental and physicalhealth, the m ental health findings supported the stress-bufferingeffect of spirituality, in which the neg ative impact of caregivingstress on mental health was less prominent for higher levels of

spirituality. The m oderating effect of spirituality with respect tophysical health, however, was the opposite of the hypothesizeddirection. Cancer caregivers with higher levels of spirituality ex-perienced a stress-aggravating effect, with significantly poorerphysical functioning at higher levels of caregiving stress. Mo re-over, the negative relation between stress and physical health wasonly significant for highly spiritual caregivers. Although the liter-ature indicates female caregivers use spir itual resources morethan men (33) and were m ore likely to experience negative effectsof cancer ca regiving (5 3,54), our findings indicate that the dispa-rate stress-buffering and stress-aggr avating effects of spiritualityare the case for both sexes.Cancer caregivers in this study reported a m ental health sta-tus comm ensurate with the general U.S. population. The find-ings regarding m ental health with this sample, in which higher

levels of spirituality buffered the neg ative impac t of caregivingstress on men tal functioning, are consistent with the theoreticalframework of the stress-coping mode l (12) and with a number ofprevious studies evidenc ing that spirituality is protective ofmental health during caregiving (21,55,56). Although the mainand m oderating effects of spir ituality were s ignif icant as hy-pothesized, the negative relation between caregiving stress andmen ta l hea l th pers is ts. The c l inica l implica tions for m enta lhealth are further tempered by the small effect size and the in-ability to establish causality or directionality.Can cer caregivers in this s tudy reported poorer physicalhealth than the general U.S. population. The n egative relat ionbetween careg iving stress and physical health was significant inthe overall model, but post hoc testing revealed no relation be-tween caregiving stress and physical health at low levels of spiri-tuality. The stress-aggra vating effect of higher leve ls of spiritu-ality was opposite of the hypo thesized direction, suggestinginstead that on ly higher rather than lower levels of spir i tuali tywere associated with the s tress-related physical health detr i-ments. The most parsimonious interpretation of the data is thatspirituality exace rbates the nega tive relation between stress andphysical health. This finding is inconsistent with some studiesshowing a po sitive relationship between spirituality and phy si-cal health (56-58), but these studies do no t consider the interac -t ive effects of caregiving stress.Beca use the current cross-sectional data prevent determina-tion of causal directionality, the results ma y also reflect canc ercaregivers who experienced a decl ine in physical heal th and, inturn, becam e mo re spiritual. Poorer physical health may lead toincreased spir i tuality. In this case , declines in ph ysical healthmay drive cancer caregivers to seek religious or spiritual copingstrategies to deal with their health deficits while providing can-cer care.Highly spiritual cancer caregivers may perceive caregivingas part of their spiritual duties. If so, spiritual norms of selfless-ness and caring for others m ay lead to ne glect of their own phys-ical health in pursuit of providing ca ncer care for their spouse.Cancer caregivers have been found to be in poorer phys icalheal th than their noncaregiving counterparts (59) and often ne-glect personal care (60). Indeed, Wyatt, Friedman, Given, andGiven (61) found caregivers who provided terminal care had arelatively high level of spirituality and a low level of h ealth ser-vice utilization.For highly spiritual cancer caregivers, reconciling the dis-parate results with regard to m ental and physical hea lth may liein the appra isa l cons truc ts of the s t ress-coping mo del (12) .Highly spir itual cancer caregivers may perceive caregiving aspart of their spiritual duties, yielding positive appraisals of theircaregiving experience even w hile neglecting self-care. Care-givers may experience physical detriments from providing in-tense cancer care or from a dditional stress related to acting in ac-cord with spiritual norms but still appraise the caregiving rolepositively because they are fulfilling a spiritual calling. This dy-namic m ay explain how m ental health is better maintained forhighly spir i tual cancer careg ivers, whereas physical health is


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96olgrove et al nnals of Behavioral M edicinepoorer com pared with cancer caregivers report ing low levels ofspirituality.Limitations and Future D irections

The results of this study should be interpreted in the con textof several l imitations and the respective biases introduced. First,this study bears the limitations inherent to cross-sectional, retro-spective, and self-reported da ta. Causality or the direction of theassociat ions between caregiving stress, spiri tuali ty, and func-t ional health cannot be determ ined (62). Second, the partici-pants in this study were demo graphically homog eneous. Studieshave found that African Ame rican and Hispanic informal care-givers are m ore l ikely than Wh ite caregivers to experience in-creased rel igiosity since the inception o f caregiving (63). Thesampling method of caregiver nomination by cancer patientsmay have a lso cont r ibuted to the hom ogenei ty of the sample .Careg iving dyads experiencing gre at difficulty in the caregivingor disease process may have self-selected out of the sam ple bynot responding to the survey . Indeed, as we reported in the Par-ticipants section, care recipients of caregivers with missing da tareported significantly poore r quality of life than those of care-givers with com plete data. Future s tudies should expand thesample to include minori ty groups and varying socioeconom iclevels as well as participants selected through m ethods otherthan nomination.Situational factors related to the canc er diagnosis deservefurther consideration as well. Although cancer site was not sig-nificantly related to c aregiving stress in our sam ple, cancer site,stage of cance r, and the severity of the illness ma y contribute tothe tenor of the stresshealth relation for the cancerca regivingdyad a nd warra nts inclusion in future studies.Research should a lso evaluate the caregiv ing s t ress andhealth outcomes during or directly after the canc er caregivingexperience as the salience of the cancer caregiving experiencecould wane with the passage of t ime. For exam ple, caregivingburden decreases as the time because cancer diagnosis increases(64). A sh ort recall period for careg iving stress guards against adepreciation in the appraisal of stress and limits the time to re-coup physical and men tal health function that could bias results.The mixed sam ple of act ive and former caregivers in this s tudyposes a limitation, introducing retrospective bias for variablesassessing caregiving s tress . Other potentially important va ri-ables to investigate include the duration o f cancer surviva l, be-reavement in the event or im minence of the care-rec ip ient 'sdeath, and the type and appraisal of prominent ca regiving dutiesperformed.Finally, the interaction effects of spirituality and caregivingstress for both mental and physical health, although significant,explained on ly small amo unts of addit ional var iance in the re-spective analyses. As such, the weak effect sizes further necessi-ta te cautious interpretation of the results. Future research isneeded to provide addi t iona l information on these complexissues.This study is one of the first of its kind, examining the m od-erating role o f spir i tuali ty in the well-established relat ion be-

tween care giving stress and quality of life for the spec ific popu-lat ion o f spousal cancer caregivers. The overall paucity of re-search on cancer c aregiving stress is increasingly relevant, giventhe t rend toward outpa t ient medica l m anagemen t of cancer ,which shifts the caregiver burden to families, particularlyspouses (65).Current efforts to encourage careg ivers to attend to theirown n eeds, seek health services, and m anage stress effectivelymay be part icular ly important for highly spir i tual cancer care-givers, who are prone to neglect them selves. Improved self-care,however, m ay pose significant challenges for these caregivers,because they may have to lessen the intensity of the care theyprovide. They, then, m ay feel g uilty, thereby increasing stressand potentially reducing the stress-buffering effects for mentalhealth. How best to maintain the balance between mentaland physical health while providing care is a c omplex issue, par-t icularly for highly spiritual caregive rs , and deserve s furtherinvestigation.

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