510602 research-article2013
JAGXXX10.1177/0733464813510602Journal of Applied GerontologyRathier et al.
Original Article
Religious Coping in Caregivers of Family Members With Dementia
Journal of Applied Gerontology 2015, Vol. 34(8) 977–1000 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464813510602 jag.sagepub.com
Lucille A. Rathier1,2, Jennifer Duncan Davis2,3, George D. Papandonatos2, Christine Grover2, and Geoffrey Tremont2,3
Abstract The degree of depression experienced by caregivers of individuals with dementia was examined in relation to religious coping strategies, religious practice, and spirituality in the framework of the stress and coping model. Caregivers of 191 persons with dementia completed the Religious Coping Scale, self-report measures of religious practices and spirituality, burden, and depression. There was no evidence that any religious coping strategy or religious practice moderated the relationship between caregiving stress and depression. Certain types of religious coping strategies had a direct effect on depression. Higher levels of religious coping working with God were associated with decreased depression, whereas higher levels of religious coping working through God were associated with increased depression. Higher burden, lower overall caregiver health rating, and worse reactions to memory and behavior problems were associated with higher levels of depression. Frequency of prayer and the importance of spirituality were weakly associated with lower levels of depression. Manuscript received: December 28, 2012; final revision received: August 26, 2013; accepted: October 6, 2013 1The
Miriam Hospital, Providence, RI, USA University, Providence, RI, USA 3Rhode Island Hospital, Providence, USA 2Brown
Corresponding Author: Lucille A. Rathier, Behavioral Medicine Clinical Services, The Miriam Hospital, Suite 11A, 146 West River Street, Providence, RI 02904, USA. Email: [email protected]
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Keywords religious coping, caregivers, dementia Almost 15 million Americans, primarily family members, provide unpaid care for a person with Alzheimer’s disease or any other dementia (Alzheimer’s Association, 2012). Caregiving can have a negative impact on the physical and mental health, employment, income, financial security, and leisure time of many caregivers (Gallicchio, Siddiqi, Langenberg, & Baumgarten, 2002). High levels of depression and anxiety are common in dementia caregivers, with about one third of individuals meeting diagnostic criteria for depression (Schulz & Martire, 2004). In addition, high levels of caregiver burden are related to premature institutionalization of the care recipient (Choi, Tirrito, & Mills, 2008). In caring for a family member with dementia, caregivers continually assess their coping resources and limits. Resource variables are thought to act on the relationship between the stress and burden of caregiving and depression. Coping and social support are regarded as the two principal mediators in this relationship (Pearlin, Mullan, Semple, & Skaff, 1990). The stress and coping model has been widely used to conceptualize the relationship between caregiving and adverse health outcomes (Dilworth-Anderson, Williams, & Gibson, 2002). The model proposes that objective stressors (e.g., care recipient’s cognitive functioning and behavioral problems) interact with subjective stressors (e.g., caregiver’s perceived burden) as well as with background and contextual variables, resulting in adverse outcomes (e.g., depression; Pearlin et al., 1990). Perceived control is an important factor in the relationship between psychosocial demands and personal resources that determines whether or not an event is stressful (Steptoe, 1989). Rothbaum, Weisz, and Snyder (1982) proposed that control involves two processes. The primary control process involves attempting to change the world to make it fit the needs of the self and includes beliefs that one’s actions can have a direct impact on the situation, for example, diabetics changing their diet to manage their medical condition. Secondary control processes involve accepting one’s lack of control in the situation. These include turning to others for help (vicarious control), believing in fate or luck (illusory control), reinterpreting the event to make it more acceptable (interpretive control), or attempting to predict events so that they will be easier to accept should they occur (predictive control). The pursuit of control is rarely abandoned and individuals are likely to shift from one method of striving for control to another. Differences between primary and secondary control processes should be considered as differences in emphasis.
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Optimal coping is defined as the coordination of primary (i.e., extending personal control) and secondary control processes (i.e., going outside oneself for solutions [Rothbaum et al., 1982]) for the purpose of raising the caregiver’s stress tolerance. Religion provides believers with many methods to attain a sense of control. Religious coping methods to gain control of outcomes are not exclusively secondary control processes and include access to both human initiative and divine power (Pargament, 1997, 2007). Through qualitative studies and reviews of the literature, Pargament et al. (1988), Pargament et al. (1990), and Pargament, Koenig, and Perez (2000) identified three distinct approaches in the use of religion to seek control of outcomes: a. Control centered on relationship with or working with God. Examples are collaborative religious coping, which involves seeking control in solving problems through a partnership with God, and active religious surrender, which involves using personal resources and then turning control over to God. After primary control processes have been exhausted, some people may turn to active religious surrender as a secondary process of control to avoid hopelessness. Thus, active religious surrender involves accessing both primary and secondary control processes in a sequential manner, whereas collaborative religious coping involves accessing both primary and secondary control processes simultaneously. Both of these methods use primary and secondary control processes in a balanced and coordinated way. b. Control centered on working through God. This approach favors secondary control processes, in that ultimate control and responsibility belong to God (Pargament et al., 1988). It includes pleading for direct intercession, which involves seeking control indirectly by praying for a miracle or divine intercession, and passive religious deferral, which entails waiting for God to control the situation. Using passive religious deferral, the individual delegates the responsibility to an omnipotent and benevolent being, reflecting greater secondary control and lower levels of both personal control and planful problem solving measures. Pleading for divine intercession may not be effective in controllable situations, but may prove useful in uncontrollable situations as it provides a sense of vicarious control and mastery; it may well be the coping method of last resort when psychological distress is heightened. c. Self-directed religious coping. Based upon the belief that God gives individuals the tools and resources to solve problems, control is centered on the self and sought directly via one’s own initiative. This method favors primary control processes.
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Pargament (1997) suggested that, for situations in which the individual does not have complete control, working with God is the most empowering choice. Theoretically, the use of both primary and secondary processes is more adaptive, because seeking a divine partnership to help cope with an uncontrollable event can reduce hopelessness and despair (Rothbaum et al., 1982). Extant research supports that religious coping centered on working with God is associated with lower levels of psychological distress, whereas religious coping centered on working through God is associated with higher levels of psychological distress. Collaborative religious coping in particular has been consistently associated with lower levels of psychological distress in various populations (Cardella & Friedlander, 2004; Gall, Guirguis-Younger, Charbonneau, & Florack, 2009; Koenig, Pargament, & Nielsen, 1998; Molock, Puri, Matlin, & Barksdale, 2006), as has active religious surrender (Gall, 2006; Gall et al., 2009). In contrast, pleading for direct intercession was associated with greater psychological distress in some studies (Cardella & Friedlander, 2004; Gall et al., 2009), but with both positive and negative emotions in another (Belavich & Pargament, 1995). Because primary control processes are absent, passive religious deferral has been associated with greater depressive symptoms (Koenig et al., 1998). Finally, self-directed religious coping might appear to promote functioning because of its emphasis on personal control (Lefcourt, 1976), but has been associated with greater depression in various populations (Gall, 2006; Koenig et al., 1998; Molock et al., 2006). Caregivers may also experience secondary control via religious service attendance, prayer, meditation, religious reading, and social support from church members. According to a national poll, religion/spirituality is one of the most important coping resources for caregivers, with 73% endorsing that they pray to cope with the demands of caregiving (National Alliance for Caregiving, 2004). Religious involvement and church attendance have been associated with lower perceived burden and depression in dementia caregivers (Choi et al., 2008; Hebert, Dang, & Schulz, 2007; Heo & Koeske, 2013; Herrera, Lee, Nanyonjo, Laufman, & Torres-Vigil, 2009; Leblanc, Driscoll, & Pearlin, 2004; Sun, Kosberg, Leeper, Kaufman, & Burgio, 2010). Religious attendance affords caregivers opportunities for social support from other believers (Heo & Koeske, 2013). Organizational religiosity (i.e., public practice of religious rituals) was associated with lower perceived burden, whereas non-organizational religiosity (i.e., private practice of religious rituals) was associated with poorer mental health (Herrera et al., 2009). In another study, private prayer and caregiving burden significantly influenced the variation in perceived resiliency scores (Wilks & Vonk, 2008). The frequency of religious coping may be partially a function of gender, age, ethnicity, and severity of caregiver or recipient illness (Pearce, 2005).
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Research has shown that the elderly, poor, less educated, African Americans, and women tend to be more religious than males, younger adults, and European Americans (Levin, Taylor, & Chatters, 1994; Pargament, 1997). Pargament (1997) posits that in general, these groups have less access to secular resources and power in our culture. For such caregivers, religion represents an alternative resource that is more easily accessible for the purpose of raising their stress tolerance (Heo & Koeske, 2012). Research on caregivers of dementia patients supports the extant literature demonstrating differences based on ethnicity, age, and gender. Greater reliance on spirituality was endorsed by African American and Latino caregivers in multiple studies (Napoles, Chadiha, Eversley, & Moreno-John, 2010). Participation in spiritual activities was associated with lower levels of depression among Latino caregivers, but not among Anglo caregivers (Thompson, Solano, Coon, Mausbach, & Gallagher-Thompson, 2002). Spiritual/religious coping moderated the effects of an intervention designed to reduce depression among African American caregivers but not Anglo or Latino caregivers (Lee, Czaja, & Schulz, 2010). Church attendance moderated the relationship between subjective stress and depression, in concert with a direct effect on depression in Latino caregivers (Sun & Hodge, 2012). Female caregivers of loved ones with dementia scored higher on measures of religiousness than male caregivers (Sun, Roff, Klemmack, & Burgio, 2008). Studies examining stress and coping theory (Pearlin et al., 1990) as a model for the effects of spirituality/religion on caregiver outcomes have found mixed results. Morano and King (2005) tested a multidimensional measure of spirituality/religion as a mediator in the relationship between caregiver stress and depression, but found no confirming evidence. However, they did find evidence of a direct effect on depression. In another study, prayer, religious attendance, and self-ascribed importance of religion were tested in mediation and moderation models but not confirmed (Leblanc et al., 2004). The authors did find that higher self-ascribed importance of religion was associated with higher levels of depression. Using Lazarus and Folkman’s model (1984), researchers found that caregiver burden appraisal mediated the effect of religious coping on depression with higher religious coping resulting in lowering caregiver burden and in turn, depression among African American, Latino, and White caregivers (Heo & Koeske, 2012). The ambiguous results may reflect the multiple dimensions of religion/spirituality and range of well-being outcomes examined, as well as the use of unrefined measures of religion/spirituality (e.g., use of a single item) and atheoretical approaches to studying these variables (Hebert, Weinstein, Martire, & Schulz, 2006). The purpose of this study was to investigate how religious coping strategies that varied in primary and secondary psychological control processes,
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religious practice, and spirituality related to depression in family dementia caregivers. Our analysis was guided by the stress and coping model. We examined whether religious coping strategy and/or religious practice moderated the relationship between objective and subjective stressors and caregiver depression. We hypothesized that religious coping strategies centered on working with God (i.e., collaborative religious coping and active religious surrender), engagement in greater religious practice, and higher level of spirituality would buffer the effects of caregiver stressors on depression. We also explored the influence of age and gender on these relationships.
Method Participants Participants were 191 caregivers of family members with dementia who were participating in a randomized, controlled trial of a telephone intervention to assist them in managing caregiver burden and psychological distress. Data from the previously conducted pilot trial found that the telephone delivered psychosocial intervention reduced burden in dementia caregivers (Tremont, Davis, Bishop, & Fortinsky, 2008). Caregivers were recruited from the community and memory disorder clinics. A diagnosis of dementia was made by a neurologist, geriatrician, or psychiatrist. In cases in which the diagnosis was made by a general practitioner, the study neurologist confirmed the diagnosis. All caregivers provided a minimum of 4 hours of care daily to the care recipient for at least 6 months. Caregivers were required to endorse experiencing at least two of the following at any level in a screening interview: (a) feeling overwhelmed and stressed, (b) sad mood/depression, (c) anger or frustration, (d) loss of contact with family and friends, (e) conflict in family or family stress, (f) neglecting their own health, (g) demands or pressures of caregiving are too much, (h) exhaustion and fatigue, and (i) not taking care of their own needs or other significant responsibilities. Caregivers were excluded based on the following criteria: (a) major acute medical illness, (b) English was not their primary language, (c) cognitive impairment as defined by Mini Mental State Examination score falling 1.5 or greater standard deviations below age- and education-corrected normative data, (d) no access to a telephone, (e) did not believe in God or a higher power. Based on the original sample of 210, 19 individuals were excluded because they reported having no religious or spiritual beliefs. Care recipient inclusion criteria included (a) formal Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnosis of dementia by a neurologist, psychiatrist, or geriatrician; (b) family member or other adult in caregiver role for at least 6 months,
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and who provided at least 4 hours of supervision or direct assistance per day for the person with dementia; (c) care recipient lived in the community, including senior/retirement centers, but excluding nursing homes and assisted living centers; and (d) there was no plan for the care recipient to be placed in long-term care or the caregiver to end their role within 6 months of study enrollment. Care recipients with other major medical conditions affecting independent functioning were excluded. Demographic characteristics of the sample are presented in Table 1. The majority of caregivers were female (n = 153) and Caucasian (n = 176). Their relationship to the care recipients was spouses (n = 91) and adult children (n = 86). The mean age was 62.4 years (SD = 12.38 years) and average education was 14.9 years (SD = 2.6). Caregivers had been providing care for an average of 43.86 months (SD = 33.05). The religious affiliation of most caregivers was Roman Catholic (53%) followed by Protestant (19%). Eight participants endorsed a belief in God, while not endorsing an affiliation to a specific organized religion. The Clinical Dementia Rating scale (CDR; Hughes, Berg, Danziger, Coben, & Martin, 1982) was administered at the baseline visit by a neuropsychologist and was used to measure dementia severity of the care recipient. Severity ratings were mostly in the mild range (n = 118). In addition, clinical diagnoses by the treating physician were used to identify dementia subtypes. Based on these clinical classifications, 78% of the sample comprised of care recipients with probable Alzheimer’s disease (n = 149).
Procedure As part of a baseline assessment for a large-scale psychosocial intervention study, caregivers reported on their religious or spiritual beliefs and practices as well as on how often they used specific religious coping strategies to deal with their caregiving challenges. Participants also completed a battery of self-report questionnaires pertaining to their mood, perceived burden, overall health rating, and their reactions to the care recipient’s memory and behaviors. Informed consent was obtained from all participants prior to participating in the study. The study itself was approved by the institutional review board of Rhode Island Hospital. Independent variables Participants first endorsed a specific religious or spiritual affiliation, if any. Those reporting religious beliefs were asked to respond to 10 items created by the investigators measuring one’s frequency of participating in various aspects religious practices, for example, religious or spiritual services,
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Table 1. Demographic and Caregiver Characteristics of Sample.
Gender Female Male Ethnicity Caucasian African American/Black Hispanic/Latino Native American/Alaska native Other Religious affiliation/spiritual belief system Roman catholic Protestant Jewish Greek orthodox New age Twelve step Muslim Christian scientist Buddhist Other No specific religious affiliation Relationship to care recipient Spouse Child Sibling Other relative/friend Living with care recipient Yes No Type of dementia in care recipient Alzheimer’s disease Other Care recipient clinical dementia rating Mild Moderate Severe Unknown
n
%
153 38
80.1 19.9
176 5 7 2 1
92.1 2.6 3.7 1.0 0.5
101 37 9 3 2 2 1 1 2 25 8
52.9 19.4 4.7 1.6 1.0 1.0 0.5 0.5 1.0 13.1 4.2
91 86 9 5
47.6 45.0 4.7 2.6
150 41
78.5 21.5
149 42
78.0 22.0
118 61 11 1
62.0 31.9 5.8 0.5 (continued)
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Rathier et al. Table 1. (continued)
Importance of religious faith and spirituality Not important Slightly important Somewhat important Very important Unknown Pray privately Never Less than once a month Once a month A few times a month Once a week A few times a week Once a day More than once a day
n
%
8 22 45 114 2
4.2 11.5 23.6 59.7 1.0
31 12 3 7 4 27 39 68
16.2 6.3 1.6 3.7 2.1 14.1 20.4 35.6
private prayer, reading from a holy book, and meditation. For example, “How frequently do you pray about your caregiving challenges and demands?” and “If you pray about your caregiving challenges, what is the content of your prayers?” All items were rated on a 9-point Likert-type scale (i.e., more than once a day, once a day, a few times a week, once a week, a few times a month, once a month, less than once a month, never, or not applicable). The Religious Coping Methods to Gain Control Scale (RCOPE) is one of five psychometric scales in the RCOPE test battery (Pargament et al., 2000) and measures the degree to which respondents use any of five distinct religious coping methods to gain control of outcomes. Each coping method has its own subscale made up of five items measured on a 4-point Likert scale ranging from 0 (not at all) to 3 (a great deal). Religious coping method scores can range from 0 to 15; higher scores reflect greater use of each coping method. Items include, for example, “Worked together with God to relieve my worries” (collaborative) and “Prayed for a miracle” (pleading). The internal consistency reliabilities (Cronbach’s coefficient α) for these subscales of the RCOPE ranged from .64 to .91 in our sample (collaborative religious coping = .90, active religious surrender = .91, pleading for direct intercession = .80, passive religious deferral = .64, and self-directed religious coping = .86). Factor analysis of the data as well as theoretical considerations led us to combine the first two of these coping methods into a single scale measuring coping strategies centered on working with God (α = .93) and the next two
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coping strategies into a single scale measuring coping strategies centered on working through God (α = .83). Self-directed coping was left as a separate coping method, resulting in three-factor solution. Dependent variable Center for Epidemiologic Studies–Depression Scale (CES-D). CES-D (Radloff, 1977) is a 20-item self-report questionnaire designed to measure common symptoms of depression that have occurred over the past week (Radloff, 1977). All questions are answered on 0 to 3 Likert-type scale, with 0 indicating no symptom presence and 3 representing frequent symptom presence. Higher scores indicate higher severity, with scores of 16 or higher reflecting clinical levels of depression. The CES-D had high reliability in our study (α = .88). Control variables Zarit Burden Interview (ZBI). The ZBI (Zarit, Reever, & Bach-Peterson, 1980) is a 22-item, self- report measure of perceived burden. The instrument measures caregivers’ psychological health, emotional well-being, social and family life, finances, and degree of control over one’s life. Each question is scored on a 0 to 4 Likert-type scale. Total scores range from 0 (low burden) to 88 (high burden). Internal reliability was high (α = .90). EuroQoL 5 dimension visual analog scale (EQ5D VAS). The EuroQoL questionnaire measures five distinct aspects of health-related quality of life (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) as well as an overall health rating across these domains based on a visual analog scale (“How would you rate your health on 0-100?”). We used this latter measure (EQ5D VAS; The EuroQoL Group, 1990) to assess caregiver health status. Revised Memory and Behavior Problem Checklist (RMBPC). The questionnaire is a 24-item checklist that requires caregivers to rate both the frequency of disruptive behaviors, memory difficulties, and depression in care recipients during the previous week (RMBPC-F; Teri et al., 1992), and their own reaction to each of these issues (RMBPC-R). Individual items are rated on a 5-point Likert-type scale. RMBPC-F item scores indicate frequency of patient behavior problems, ranging from 0 (never occurred) to 4 (occurs daily or more often), while RMBPC-R item scores measure severity of caregiver reaction to these problems, ranging from 0 (not at all bothered/upset) to 4 (extremely). Higher scores on RMBPC-R reflect higher levels of perceived caregiver burden. Internal consistency for frequency and reaction reached .84 and .86 for Memory-Related Problems, .75 and .77 for Disruptive Behaviors,
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and .85 and .87 for Depression, respectively. For both patient frequency and caregiver reaction, factor analysis confirmed three first-order factors, consistent with the subscales just named. Overall scale reliability across these three domains was adequate (α = .86 for RMBPC-F and α = .88 for RMBPC-R).
Statistical Analysis Descriptive statistics were calculated for demographic variables and caregiving characteristics in the sample including religious affiliation. Pearson product-moment correlations were calculated between religious coping strategies scores, religious practice, importance of spirituality, demographic and dementia severity characteristics, and depressive symptoms, caregiver burden, frequency of care recipient memory and behavior problems, and overall health rating. A series of regression analyses were used to determine whether religious coping and religious practice variables moderated the relationship between caregiving stressors and depression or had main effects on depression. After standardizing the predictors by the sample mean and standard deviation, interaction terms were created between religious coping methods and caregiver stressors, as well as between religious practice/spirituality variables and stressors. Finally, we examined whether gender and age had any effect on these relationships by including them in the regression models as both main effects and interactions.
Results Mean values and standard deviations for dependent and control are presented in Table 2. Table 3 presents correlations among religious coping methods, importance of spirituality, praying frequency, demographic and caregiving characteristics, dementia severity indicators, and measures of caregivers’ depressive symptomatology. Higher levels of religious coping strategies that centered on working with God (i.e., collaborative & active surrender) showed moderate-to-strong associations with other types of religious coping, praying frequency, and importance of spirituality (ρ = .32 – .57). There were no significant relationships between these religious coping strategies and any other caregiver or care recipient variable. In contrast, higher levels of religious coping centered on working through God (i.e., passive deferral, pleading for direct intercession) showed small-to-moderate associations with higher levels of depressive symptoms, caregiver burden, frequency of behavior problems in the care recipient, and caregiver reaction to behavior problems (ρ = .20 – .26), and lower caregiver quality of life (ρ = – .17). Greater frequency of praying and importance of spirituality was weakly associated with lower
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Table 2. Mean and Standard Deviations of Dependent and Control Variables. Variable Religious coping working with God Religious coping working through God Self-directed coping CES-Da ZBI EQ5D VAS RMBPC-Fa RMBPC-Ra CDR SOB Caregiver age Length of caregiving (months) Time since symptom onset (months)
M
SD
13.74 4.32 1.61 3.83 38.71 78.04 34.94 4.60 7.90 62.37 43.86 52.33
10.58 7.66 1.27 1.37 14.25 16.57 13.35 1.69 3.73 12.38 33.05 40.28
Note: CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; EQ5D VAS = EuroQol 5 dimension visual analog scale; RMBPC-F = Revised Memory and Behavior Problem Checklist–Frequency; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction; CDR SOB = Clinical Dementia Rating Sum of Boxes. aSquare-root transformation.
levels of depressive symptoms. Results showed that 24.6% of caregivers prayed more than once per day, 21.5% just once per day, and 25.7% a few times per week. The most frequent content of these prayers were requests for strength to handle caregiving challenges (73.8%) and for guidance from God for managing caregiving demands (48.2%). Less frequent prayers were for God to intervene (27.2%), expressions of gratitude (30.4%), and forgiveness for caregiver (15.2%). Tables 4 to 6 present results of regression analyses. We initially included objective (dementia severity, frequency of behavior problems) and subjective stressors (perceived burden, perceived health, reaction to behavior problems) in the model to test whether religious coping moderates the relationship between stressors and caregiver depression. However, dementia severity (CDR sum of boxes; CDR SOB) was not a significant predictor of depression, and frequency of behavior problems (RMBPC-F) demonstrated multicollinearity with reaction to behavior problems (RMBPC-R). In addition, results of the moderation analysis showed no significant interactions between stressors and religious coping or religious practice. For religious coping strategies, we are left with the model presented in Table 4 (R2 = .44), demonstrating that religious coping centered on working with God and religious coping centered on working through God made unique
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989
3
4
5
6
7
−.06
.05
.26**
−.12
10
−.03 −.02 .17* .09 .10 −.15* .07 −.02 −.16* .07 .01 −.10 .65** .20** .08 .36** .09 .07
.03
9
.06
8
.20**
.10
12
.18* .04 .03 .09 −.02 .01 −.22** −.14 .13 −.02 .13 .08 .11 .01 .54** .28** .42**
.26**
.07
11
.03
14
.06 .01 −.01 −.16* −.01 .07 −.04 .41** .52** .72**
−.13 .01 .14 .02 −.08 −.07 .12 −.47** −.33** −.27 −.26**
.24** −.17*
.06
13
Note: CG = Caregiver; Sx = dementia symptoms; CDR SOB = Clinical Dementia Rating sum of boxes; CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; RMBPC-F = Revised Memory and Behavior Problem Checklist–Frequency; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction; EQ5D VAS = EuroQol 5 dimension visual analog scale. *p < .05. **p < .01.
1. Religious coping .32** −.36** .54** .57** −.05 −.01 working with God 2. Religious coping .05 .15* .18* −.07 .12 working through God 3. Self-directed coping −.33** −.39** −.20** .08 .54** −.03 .04 4. Praying frequency 5. Spirituality .04 .08 6. CG age .13 7. Length of CG 8. Time since Sx onset 9. CDR SOB 10. CES-D 11. ZBI 12. RMBPC-F 13. RMBPC-R 14. EQ5D VAS
2
Table 3. Correlations Among Dependent and Control Variables.
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Table 4. Religious Coping Strategies and Subjective Stressors Predicting Caregiver Depression on the CES-D (N = 191). Variable Intercept ZBI EQ5D VAS RMBPC-Ra Religious coping working with God Religious coping working through God Self-directed copinga
B
SE B
t value
p
0.02 0.35 –0.28 0.15 –0.21 0.17 –0.04
0.06 0.07 0.06 0.07 0.07 0.07 0.07
0.42 4.84 –4.39 2.24 –3.06 2.52 –0.65
.680 .000 .000 .026 .002 .013 .519
Note: CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; EQ5D VAS = EuroQol 5 dimension visual analog scale; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction. aSquare-root transformation because of skewed distribution.
Table 5. Prayer and Subjective Stressors Predicting Caregiver Depression on the CES-D (N = 191). Variable Intercept ZBI EQ5D VAS RMBPC-Ra Frequency of prayer
B
SE B
t value
p
0.01 0.37 –0.29 0.16 –0.15
0.06 0.07 0.06 0.07 0.06
0.20 5.25 –4.84 2.35 –2.63
.843 .000 .000 .020 .009
Note: CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; EQ5D VAS = EuroQol 5 dimension visual analog scale; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction. aSquare root transformation because of skewed distribution.
contributions to the prediction of caregiver depression. That is, lower levels of religious coping centered on God and higher levels of religious coping through God were associated with increased depressive symptoms. Selfdirected religious coping did not contribute to the model. The model also shows that higher caregiver burden, lower overall health rating, and worse reaction to memory and behavior problems are associated with increases in depressive symptoms. Similarly, Table 5 shows that frequency of prayer also made a unique contribution to the prediction of caregiver depression (R2 = .41), along with the subjective stressors. However, once religious coping centered on God and religious coping through God were added to this model,
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Rathier et al. Table 6. Gender-Specific Predictors of Caregiver Depression on the CES-D (Females = 153, Males = 38). Females Variable
B
SE B t value
Males p
B
SE B t value
p
Intercept 0.05 0.06 0.67 .503 –0.15 0.16 –0.93 .361 ZBI 0.33 0.08 4.28
JAGXXX10.1177/0733464813510602Journal of Applied GerontologyRathier et al.
Original Article
Religious Coping in Caregivers of Family Members With Dementia
Journal of Applied Gerontology 2015, Vol. 34(8) 977–1000 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464813510602 jag.sagepub.com
Lucille A. Rathier1,2, Jennifer Duncan Davis2,3, George D. Papandonatos2, Christine Grover2, and Geoffrey Tremont2,3
Abstract The degree of depression experienced by caregivers of individuals with dementia was examined in relation to religious coping strategies, religious practice, and spirituality in the framework of the stress and coping model. Caregivers of 191 persons with dementia completed the Religious Coping Scale, self-report measures of religious practices and spirituality, burden, and depression. There was no evidence that any religious coping strategy or religious practice moderated the relationship between caregiving stress and depression. Certain types of religious coping strategies had a direct effect on depression. Higher levels of religious coping working with God were associated with decreased depression, whereas higher levels of religious coping working through God were associated with increased depression. Higher burden, lower overall caregiver health rating, and worse reactions to memory and behavior problems were associated with higher levels of depression. Frequency of prayer and the importance of spirituality were weakly associated with lower levels of depression. Manuscript received: December 28, 2012; final revision received: August 26, 2013; accepted: October 6, 2013 1The
Miriam Hospital, Providence, RI, USA University, Providence, RI, USA 3Rhode Island Hospital, Providence, USA 2Brown
Corresponding Author: Lucille A. Rathier, Behavioral Medicine Clinical Services, The Miriam Hospital, Suite 11A, 146 West River Street, Providence, RI 02904, USA. Email: [email protected]
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Keywords religious coping, caregivers, dementia Almost 15 million Americans, primarily family members, provide unpaid care for a person with Alzheimer’s disease or any other dementia (Alzheimer’s Association, 2012). Caregiving can have a negative impact on the physical and mental health, employment, income, financial security, and leisure time of many caregivers (Gallicchio, Siddiqi, Langenberg, & Baumgarten, 2002). High levels of depression and anxiety are common in dementia caregivers, with about one third of individuals meeting diagnostic criteria for depression (Schulz & Martire, 2004). In addition, high levels of caregiver burden are related to premature institutionalization of the care recipient (Choi, Tirrito, & Mills, 2008). In caring for a family member with dementia, caregivers continually assess their coping resources and limits. Resource variables are thought to act on the relationship between the stress and burden of caregiving and depression. Coping and social support are regarded as the two principal mediators in this relationship (Pearlin, Mullan, Semple, & Skaff, 1990). The stress and coping model has been widely used to conceptualize the relationship between caregiving and adverse health outcomes (Dilworth-Anderson, Williams, & Gibson, 2002). The model proposes that objective stressors (e.g., care recipient’s cognitive functioning and behavioral problems) interact with subjective stressors (e.g., caregiver’s perceived burden) as well as with background and contextual variables, resulting in adverse outcomes (e.g., depression; Pearlin et al., 1990). Perceived control is an important factor in the relationship between psychosocial demands and personal resources that determines whether or not an event is stressful (Steptoe, 1989). Rothbaum, Weisz, and Snyder (1982) proposed that control involves two processes. The primary control process involves attempting to change the world to make it fit the needs of the self and includes beliefs that one’s actions can have a direct impact on the situation, for example, diabetics changing their diet to manage their medical condition. Secondary control processes involve accepting one’s lack of control in the situation. These include turning to others for help (vicarious control), believing in fate or luck (illusory control), reinterpreting the event to make it more acceptable (interpretive control), or attempting to predict events so that they will be easier to accept should they occur (predictive control). The pursuit of control is rarely abandoned and individuals are likely to shift from one method of striving for control to another. Differences between primary and secondary control processes should be considered as differences in emphasis.
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Optimal coping is defined as the coordination of primary (i.e., extending personal control) and secondary control processes (i.e., going outside oneself for solutions [Rothbaum et al., 1982]) for the purpose of raising the caregiver’s stress tolerance. Religion provides believers with many methods to attain a sense of control. Religious coping methods to gain control of outcomes are not exclusively secondary control processes and include access to both human initiative and divine power (Pargament, 1997, 2007). Through qualitative studies and reviews of the literature, Pargament et al. (1988), Pargament et al. (1990), and Pargament, Koenig, and Perez (2000) identified three distinct approaches in the use of religion to seek control of outcomes: a. Control centered on relationship with or working with God. Examples are collaborative religious coping, which involves seeking control in solving problems through a partnership with God, and active religious surrender, which involves using personal resources and then turning control over to God. After primary control processes have been exhausted, some people may turn to active religious surrender as a secondary process of control to avoid hopelessness. Thus, active religious surrender involves accessing both primary and secondary control processes in a sequential manner, whereas collaborative religious coping involves accessing both primary and secondary control processes simultaneously. Both of these methods use primary and secondary control processes in a balanced and coordinated way. b. Control centered on working through God. This approach favors secondary control processes, in that ultimate control and responsibility belong to God (Pargament et al., 1988). It includes pleading for direct intercession, which involves seeking control indirectly by praying for a miracle or divine intercession, and passive religious deferral, which entails waiting for God to control the situation. Using passive religious deferral, the individual delegates the responsibility to an omnipotent and benevolent being, reflecting greater secondary control and lower levels of both personal control and planful problem solving measures. Pleading for divine intercession may not be effective in controllable situations, but may prove useful in uncontrollable situations as it provides a sense of vicarious control and mastery; it may well be the coping method of last resort when psychological distress is heightened. c. Self-directed religious coping. Based upon the belief that God gives individuals the tools and resources to solve problems, control is centered on the self and sought directly via one’s own initiative. This method favors primary control processes.
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Pargament (1997) suggested that, for situations in which the individual does not have complete control, working with God is the most empowering choice. Theoretically, the use of both primary and secondary processes is more adaptive, because seeking a divine partnership to help cope with an uncontrollable event can reduce hopelessness and despair (Rothbaum et al., 1982). Extant research supports that religious coping centered on working with God is associated with lower levels of psychological distress, whereas religious coping centered on working through God is associated with higher levels of psychological distress. Collaborative religious coping in particular has been consistently associated with lower levels of psychological distress in various populations (Cardella & Friedlander, 2004; Gall, Guirguis-Younger, Charbonneau, & Florack, 2009; Koenig, Pargament, & Nielsen, 1998; Molock, Puri, Matlin, & Barksdale, 2006), as has active religious surrender (Gall, 2006; Gall et al., 2009). In contrast, pleading for direct intercession was associated with greater psychological distress in some studies (Cardella & Friedlander, 2004; Gall et al., 2009), but with both positive and negative emotions in another (Belavich & Pargament, 1995). Because primary control processes are absent, passive religious deferral has been associated with greater depressive symptoms (Koenig et al., 1998). Finally, self-directed religious coping might appear to promote functioning because of its emphasis on personal control (Lefcourt, 1976), but has been associated with greater depression in various populations (Gall, 2006; Koenig et al., 1998; Molock et al., 2006). Caregivers may also experience secondary control via religious service attendance, prayer, meditation, religious reading, and social support from church members. According to a national poll, religion/spirituality is one of the most important coping resources for caregivers, with 73% endorsing that they pray to cope with the demands of caregiving (National Alliance for Caregiving, 2004). Religious involvement and church attendance have been associated with lower perceived burden and depression in dementia caregivers (Choi et al., 2008; Hebert, Dang, & Schulz, 2007; Heo & Koeske, 2013; Herrera, Lee, Nanyonjo, Laufman, & Torres-Vigil, 2009; Leblanc, Driscoll, & Pearlin, 2004; Sun, Kosberg, Leeper, Kaufman, & Burgio, 2010). Religious attendance affords caregivers opportunities for social support from other believers (Heo & Koeske, 2013). Organizational religiosity (i.e., public practice of religious rituals) was associated with lower perceived burden, whereas non-organizational religiosity (i.e., private practice of religious rituals) was associated with poorer mental health (Herrera et al., 2009). In another study, private prayer and caregiving burden significantly influenced the variation in perceived resiliency scores (Wilks & Vonk, 2008). The frequency of religious coping may be partially a function of gender, age, ethnicity, and severity of caregiver or recipient illness (Pearce, 2005).
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Research has shown that the elderly, poor, less educated, African Americans, and women tend to be more religious than males, younger adults, and European Americans (Levin, Taylor, & Chatters, 1994; Pargament, 1997). Pargament (1997) posits that in general, these groups have less access to secular resources and power in our culture. For such caregivers, religion represents an alternative resource that is more easily accessible for the purpose of raising their stress tolerance (Heo & Koeske, 2012). Research on caregivers of dementia patients supports the extant literature demonstrating differences based on ethnicity, age, and gender. Greater reliance on spirituality was endorsed by African American and Latino caregivers in multiple studies (Napoles, Chadiha, Eversley, & Moreno-John, 2010). Participation in spiritual activities was associated with lower levels of depression among Latino caregivers, but not among Anglo caregivers (Thompson, Solano, Coon, Mausbach, & Gallagher-Thompson, 2002). Spiritual/religious coping moderated the effects of an intervention designed to reduce depression among African American caregivers but not Anglo or Latino caregivers (Lee, Czaja, & Schulz, 2010). Church attendance moderated the relationship between subjective stress and depression, in concert with a direct effect on depression in Latino caregivers (Sun & Hodge, 2012). Female caregivers of loved ones with dementia scored higher on measures of religiousness than male caregivers (Sun, Roff, Klemmack, & Burgio, 2008). Studies examining stress and coping theory (Pearlin et al., 1990) as a model for the effects of spirituality/religion on caregiver outcomes have found mixed results. Morano and King (2005) tested a multidimensional measure of spirituality/religion as a mediator in the relationship between caregiver stress and depression, but found no confirming evidence. However, they did find evidence of a direct effect on depression. In another study, prayer, religious attendance, and self-ascribed importance of religion were tested in mediation and moderation models but not confirmed (Leblanc et al., 2004). The authors did find that higher self-ascribed importance of religion was associated with higher levels of depression. Using Lazarus and Folkman’s model (1984), researchers found that caregiver burden appraisal mediated the effect of religious coping on depression with higher religious coping resulting in lowering caregiver burden and in turn, depression among African American, Latino, and White caregivers (Heo & Koeske, 2012). The ambiguous results may reflect the multiple dimensions of religion/spirituality and range of well-being outcomes examined, as well as the use of unrefined measures of religion/spirituality (e.g., use of a single item) and atheoretical approaches to studying these variables (Hebert, Weinstein, Martire, & Schulz, 2006). The purpose of this study was to investigate how religious coping strategies that varied in primary and secondary psychological control processes,
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religious practice, and spirituality related to depression in family dementia caregivers. Our analysis was guided by the stress and coping model. We examined whether religious coping strategy and/or religious practice moderated the relationship between objective and subjective stressors and caregiver depression. We hypothesized that religious coping strategies centered on working with God (i.e., collaborative religious coping and active religious surrender), engagement in greater religious practice, and higher level of spirituality would buffer the effects of caregiver stressors on depression. We also explored the influence of age and gender on these relationships.
Method Participants Participants were 191 caregivers of family members with dementia who were participating in a randomized, controlled trial of a telephone intervention to assist them in managing caregiver burden and psychological distress. Data from the previously conducted pilot trial found that the telephone delivered psychosocial intervention reduced burden in dementia caregivers (Tremont, Davis, Bishop, & Fortinsky, 2008). Caregivers were recruited from the community and memory disorder clinics. A diagnosis of dementia was made by a neurologist, geriatrician, or psychiatrist. In cases in which the diagnosis was made by a general practitioner, the study neurologist confirmed the diagnosis. All caregivers provided a minimum of 4 hours of care daily to the care recipient for at least 6 months. Caregivers were required to endorse experiencing at least two of the following at any level in a screening interview: (a) feeling overwhelmed and stressed, (b) sad mood/depression, (c) anger or frustration, (d) loss of contact with family and friends, (e) conflict in family or family stress, (f) neglecting their own health, (g) demands or pressures of caregiving are too much, (h) exhaustion and fatigue, and (i) not taking care of their own needs or other significant responsibilities. Caregivers were excluded based on the following criteria: (a) major acute medical illness, (b) English was not their primary language, (c) cognitive impairment as defined by Mini Mental State Examination score falling 1.5 or greater standard deviations below age- and education-corrected normative data, (d) no access to a telephone, (e) did not believe in God or a higher power. Based on the original sample of 210, 19 individuals were excluded because they reported having no religious or spiritual beliefs. Care recipient inclusion criteria included (a) formal Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnosis of dementia by a neurologist, psychiatrist, or geriatrician; (b) family member or other adult in caregiver role for at least 6 months,
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and who provided at least 4 hours of supervision or direct assistance per day for the person with dementia; (c) care recipient lived in the community, including senior/retirement centers, but excluding nursing homes and assisted living centers; and (d) there was no plan for the care recipient to be placed in long-term care or the caregiver to end their role within 6 months of study enrollment. Care recipients with other major medical conditions affecting independent functioning were excluded. Demographic characteristics of the sample are presented in Table 1. The majority of caregivers were female (n = 153) and Caucasian (n = 176). Their relationship to the care recipients was spouses (n = 91) and adult children (n = 86). The mean age was 62.4 years (SD = 12.38 years) and average education was 14.9 years (SD = 2.6). Caregivers had been providing care for an average of 43.86 months (SD = 33.05). The religious affiliation of most caregivers was Roman Catholic (53%) followed by Protestant (19%). Eight participants endorsed a belief in God, while not endorsing an affiliation to a specific organized religion. The Clinical Dementia Rating scale (CDR; Hughes, Berg, Danziger, Coben, & Martin, 1982) was administered at the baseline visit by a neuropsychologist and was used to measure dementia severity of the care recipient. Severity ratings were mostly in the mild range (n = 118). In addition, clinical diagnoses by the treating physician were used to identify dementia subtypes. Based on these clinical classifications, 78% of the sample comprised of care recipients with probable Alzheimer’s disease (n = 149).
Procedure As part of a baseline assessment for a large-scale psychosocial intervention study, caregivers reported on their religious or spiritual beliefs and practices as well as on how often they used specific religious coping strategies to deal with their caregiving challenges. Participants also completed a battery of self-report questionnaires pertaining to their mood, perceived burden, overall health rating, and their reactions to the care recipient’s memory and behaviors. Informed consent was obtained from all participants prior to participating in the study. The study itself was approved by the institutional review board of Rhode Island Hospital. Independent variables Participants first endorsed a specific religious or spiritual affiliation, if any. Those reporting religious beliefs were asked to respond to 10 items created by the investigators measuring one’s frequency of participating in various aspects religious practices, for example, religious or spiritual services,
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Table 1. Demographic and Caregiver Characteristics of Sample.
Gender Female Male Ethnicity Caucasian African American/Black Hispanic/Latino Native American/Alaska native Other Religious affiliation/spiritual belief system Roman catholic Protestant Jewish Greek orthodox New age Twelve step Muslim Christian scientist Buddhist Other No specific religious affiliation Relationship to care recipient Spouse Child Sibling Other relative/friend Living with care recipient Yes No Type of dementia in care recipient Alzheimer’s disease Other Care recipient clinical dementia rating Mild Moderate Severe Unknown
n
%
153 38
80.1 19.9
176 5 7 2 1
92.1 2.6 3.7 1.0 0.5
101 37 9 3 2 2 1 1 2 25 8
52.9 19.4 4.7 1.6 1.0 1.0 0.5 0.5 1.0 13.1 4.2
91 86 9 5
47.6 45.0 4.7 2.6
150 41
78.5 21.5
149 42
78.0 22.0
118 61 11 1
62.0 31.9 5.8 0.5 (continued)
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Rathier et al. Table 1. (continued)
Importance of religious faith and spirituality Not important Slightly important Somewhat important Very important Unknown Pray privately Never Less than once a month Once a month A few times a month Once a week A few times a week Once a day More than once a day
n
%
8 22 45 114 2
4.2 11.5 23.6 59.7 1.0
31 12 3 7 4 27 39 68
16.2 6.3 1.6 3.7 2.1 14.1 20.4 35.6
private prayer, reading from a holy book, and meditation. For example, “How frequently do you pray about your caregiving challenges and demands?” and “If you pray about your caregiving challenges, what is the content of your prayers?” All items were rated on a 9-point Likert-type scale (i.e., more than once a day, once a day, a few times a week, once a week, a few times a month, once a month, less than once a month, never, or not applicable). The Religious Coping Methods to Gain Control Scale (RCOPE) is one of five psychometric scales in the RCOPE test battery (Pargament et al., 2000) and measures the degree to which respondents use any of five distinct religious coping methods to gain control of outcomes. Each coping method has its own subscale made up of five items measured on a 4-point Likert scale ranging from 0 (not at all) to 3 (a great deal). Religious coping method scores can range from 0 to 15; higher scores reflect greater use of each coping method. Items include, for example, “Worked together with God to relieve my worries” (collaborative) and “Prayed for a miracle” (pleading). The internal consistency reliabilities (Cronbach’s coefficient α) for these subscales of the RCOPE ranged from .64 to .91 in our sample (collaborative religious coping = .90, active religious surrender = .91, pleading for direct intercession = .80, passive religious deferral = .64, and self-directed religious coping = .86). Factor analysis of the data as well as theoretical considerations led us to combine the first two of these coping methods into a single scale measuring coping strategies centered on working with God (α = .93) and the next two
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coping strategies into a single scale measuring coping strategies centered on working through God (α = .83). Self-directed coping was left as a separate coping method, resulting in three-factor solution. Dependent variable Center for Epidemiologic Studies–Depression Scale (CES-D). CES-D (Radloff, 1977) is a 20-item self-report questionnaire designed to measure common symptoms of depression that have occurred over the past week (Radloff, 1977). All questions are answered on 0 to 3 Likert-type scale, with 0 indicating no symptom presence and 3 representing frequent symptom presence. Higher scores indicate higher severity, with scores of 16 or higher reflecting clinical levels of depression. The CES-D had high reliability in our study (α = .88). Control variables Zarit Burden Interview (ZBI). The ZBI (Zarit, Reever, & Bach-Peterson, 1980) is a 22-item, self- report measure of perceived burden. The instrument measures caregivers’ psychological health, emotional well-being, social and family life, finances, and degree of control over one’s life. Each question is scored on a 0 to 4 Likert-type scale. Total scores range from 0 (low burden) to 88 (high burden). Internal reliability was high (α = .90). EuroQoL 5 dimension visual analog scale (EQ5D VAS). The EuroQoL questionnaire measures five distinct aspects of health-related quality of life (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) as well as an overall health rating across these domains based on a visual analog scale (“How would you rate your health on 0-100?”). We used this latter measure (EQ5D VAS; The EuroQoL Group, 1990) to assess caregiver health status. Revised Memory and Behavior Problem Checklist (RMBPC). The questionnaire is a 24-item checklist that requires caregivers to rate both the frequency of disruptive behaviors, memory difficulties, and depression in care recipients during the previous week (RMBPC-F; Teri et al., 1992), and their own reaction to each of these issues (RMBPC-R). Individual items are rated on a 5-point Likert-type scale. RMBPC-F item scores indicate frequency of patient behavior problems, ranging from 0 (never occurred) to 4 (occurs daily or more often), while RMBPC-R item scores measure severity of caregiver reaction to these problems, ranging from 0 (not at all bothered/upset) to 4 (extremely). Higher scores on RMBPC-R reflect higher levels of perceived caregiver burden. Internal consistency for frequency and reaction reached .84 and .86 for Memory-Related Problems, .75 and .77 for Disruptive Behaviors,
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and .85 and .87 for Depression, respectively. For both patient frequency and caregiver reaction, factor analysis confirmed three first-order factors, consistent with the subscales just named. Overall scale reliability across these three domains was adequate (α = .86 for RMBPC-F and α = .88 for RMBPC-R).
Statistical Analysis Descriptive statistics were calculated for demographic variables and caregiving characteristics in the sample including religious affiliation. Pearson product-moment correlations were calculated between religious coping strategies scores, religious practice, importance of spirituality, demographic and dementia severity characteristics, and depressive symptoms, caregiver burden, frequency of care recipient memory and behavior problems, and overall health rating. A series of regression analyses were used to determine whether religious coping and religious practice variables moderated the relationship between caregiving stressors and depression or had main effects on depression. After standardizing the predictors by the sample mean and standard deviation, interaction terms were created between religious coping methods and caregiver stressors, as well as between religious practice/spirituality variables and stressors. Finally, we examined whether gender and age had any effect on these relationships by including them in the regression models as both main effects and interactions.
Results Mean values and standard deviations for dependent and control are presented in Table 2. Table 3 presents correlations among religious coping methods, importance of spirituality, praying frequency, demographic and caregiving characteristics, dementia severity indicators, and measures of caregivers’ depressive symptomatology. Higher levels of religious coping strategies that centered on working with God (i.e., collaborative & active surrender) showed moderate-to-strong associations with other types of religious coping, praying frequency, and importance of spirituality (ρ = .32 – .57). There were no significant relationships between these religious coping strategies and any other caregiver or care recipient variable. In contrast, higher levels of religious coping centered on working through God (i.e., passive deferral, pleading for direct intercession) showed small-to-moderate associations with higher levels of depressive symptoms, caregiver burden, frequency of behavior problems in the care recipient, and caregiver reaction to behavior problems (ρ = .20 – .26), and lower caregiver quality of life (ρ = – .17). Greater frequency of praying and importance of spirituality was weakly associated with lower
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Table 2. Mean and Standard Deviations of Dependent and Control Variables. Variable Religious coping working with God Religious coping working through God Self-directed coping CES-Da ZBI EQ5D VAS RMBPC-Fa RMBPC-Ra CDR SOB Caregiver age Length of caregiving (months) Time since symptom onset (months)
M
SD
13.74 4.32 1.61 3.83 38.71 78.04 34.94 4.60 7.90 62.37 43.86 52.33
10.58 7.66 1.27 1.37 14.25 16.57 13.35 1.69 3.73 12.38 33.05 40.28
Note: CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; EQ5D VAS = EuroQol 5 dimension visual analog scale; RMBPC-F = Revised Memory and Behavior Problem Checklist–Frequency; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction; CDR SOB = Clinical Dementia Rating Sum of Boxes. aSquare-root transformation.
levels of depressive symptoms. Results showed that 24.6% of caregivers prayed more than once per day, 21.5% just once per day, and 25.7% a few times per week. The most frequent content of these prayers were requests for strength to handle caregiving challenges (73.8%) and for guidance from God for managing caregiving demands (48.2%). Less frequent prayers were for God to intervene (27.2%), expressions of gratitude (30.4%), and forgiveness for caregiver (15.2%). Tables 4 to 6 present results of regression analyses. We initially included objective (dementia severity, frequency of behavior problems) and subjective stressors (perceived burden, perceived health, reaction to behavior problems) in the model to test whether religious coping moderates the relationship between stressors and caregiver depression. However, dementia severity (CDR sum of boxes; CDR SOB) was not a significant predictor of depression, and frequency of behavior problems (RMBPC-F) demonstrated multicollinearity with reaction to behavior problems (RMBPC-R). In addition, results of the moderation analysis showed no significant interactions between stressors and religious coping or religious practice. For religious coping strategies, we are left with the model presented in Table 4 (R2 = .44), demonstrating that religious coping centered on working with God and religious coping centered on working through God made unique
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989
3
4
5
6
7
−.06
.05
.26**
−.12
10
−.03 −.02 .17* .09 .10 −.15* .07 −.02 −.16* .07 .01 −.10 .65** .20** .08 .36** .09 .07
.03
9
.06
8
.20**
.10
12
.18* .04 .03 .09 −.02 .01 −.22** −.14 .13 −.02 .13 .08 .11 .01 .54** .28** .42**
.26**
.07
11
.03
14
.06 .01 −.01 −.16* −.01 .07 −.04 .41** .52** .72**
−.13 .01 .14 .02 −.08 −.07 .12 −.47** −.33** −.27 −.26**
.24** −.17*
.06
13
Note: CG = Caregiver; Sx = dementia symptoms; CDR SOB = Clinical Dementia Rating sum of boxes; CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; RMBPC-F = Revised Memory and Behavior Problem Checklist–Frequency; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction; EQ5D VAS = EuroQol 5 dimension visual analog scale. *p < .05. **p < .01.
1. Religious coping .32** −.36** .54** .57** −.05 −.01 working with God 2. Religious coping .05 .15* .18* −.07 .12 working through God 3. Self-directed coping −.33** −.39** −.20** .08 .54** −.03 .04 4. Praying frequency 5. Spirituality .04 .08 6. CG age .13 7. Length of CG 8. Time since Sx onset 9. CDR SOB 10. CES-D 11. ZBI 12. RMBPC-F 13. RMBPC-R 14. EQ5D VAS
2
Table 3. Correlations Among Dependent and Control Variables.
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Table 4. Religious Coping Strategies and Subjective Stressors Predicting Caregiver Depression on the CES-D (N = 191). Variable Intercept ZBI EQ5D VAS RMBPC-Ra Religious coping working with God Religious coping working through God Self-directed copinga
B
SE B
t value
p
0.02 0.35 –0.28 0.15 –0.21 0.17 –0.04
0.06 0.07 0.06 0.07 0.07 0.07 0.07
0.42 4.84 –4.39 2.24 –3.06 2.52 –0.65
.680 .000 .000 .026 .002 .013 .519
Note: CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; EQ5D VAS = EuroQol 5 dimension visual analog scale; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction. aSquare-root transformation because of skewed distribution.
Table 5. Prayer and Subjective Stressors Predicting Caregiver Depression on the CES-D (N = 191). Variable Intercept ZBI EQ5D VAS RMBPC-Ra Frequency of prayer
B
SE B
t value
p
0.01 0.37 –0.29 0.16 –0.15
0.06 0.07 0.06 0.07 0.06
0.20 5.25 –4.84 2.35 –2.63
.843 .000 .000 .020 .009
Note: CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; EQ5D VAS = EuroQol 5 dimension visual analog scale; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction. aSquare root transformation because of skewed distribution.
contributions to the prediction of caregiver depression. That is, lower levels of religious coping centered on God and higher levels of religious coping through God were associated with increased depressive symptoms. Selfdirected religious coping did not contribute to the model. The model also shows that higher caregiver burden, lower overall health rating, and worse reaction to memory and behavior problems are associated with increases in depressive symptoms. Similarly, Table 5 shows that frequency of prayer also made a unique contribution to the prediction of caregiver depression (R2 = .41), along with the subjective stressors. However, once religious coping centered on God and religious coping through God were added to this model,
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Rathier et al. Table 6. Gender-Specific Predictors of Caregiver Depression on the CES-D (Females = 153, Males = 38). Females Variable
B
SE B t value
Males p
B
SE B t value
p
Intercept 0.05 0.06 0.67 .503 –0.15 0.16 –0.93 .361 ZBI 0.33 0.08 4.28
