Clinical Gerontologist

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Stress-buffering effect of coping strategies on interrole conflict among family caregivers of people with dementia Hiroshi Morimoto, Nobuo Furuta, Mitsue Kono & Mayumi Kabeya To cite this article: Hiroshi Morimoto, Nobuo Furuta, Mitsue Kono & Mayumi Kabeya (2017): Stress-buffering effect of coping strategies on interrole conflict among family caregivers of people with dementia, Clinical Gerontologist, DOI: 10.1080/07317115.2017.1368764 To link to this article: http://dx.doi.org/10.1080/07317115.2017.1368764

Accepted author version posted online: 23 Aug 2017.

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Date: 26 August 2017, At: 07:43

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Running head: Stress-buffering effect of coping on interrole conflict

Stress-Buffering Effect of Coping Strategies on Interrole Conflict among Family Caregivers of People with Dementia

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Faculty of Psychology, Hiroshima International University, Hiroshima, Japan

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Yokufukai Hospital, Tokyo, Japan

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Correspondence concerning this article should be addressed to Hiroshi Morimoto, Faculty of Psychology, Meiji Gakuin University, 1-2-37, Shirokanedai, Minato Ward, Tokyo,

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108-8636, Japan. Email: [email protected] Author note

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Hiroshi Morimoto is now with the Faculty of Psychology, Meiji Gakuin University, Tokyo, 108-8636, Japan. Mayumi Kabeya is now with the Makita General Hospital, Tokyo,

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143-0016, Japan.

Funding

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This work was supported by a Grant-in-Aid for Young Scientists B [15K17313] from the Japan Society for the Promotion of Science, Japan.

Disclosure statement

The authors report no potential conflicts of interest.

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Hiroshi Morimoto1 PhD, Nobuo Furuta2 MD, Mitsue Kono2 MA, and Mayumi Kabeya2 MA

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Abstract Objectives: To examine the stress-buffering effect of coping strategies on the adverse effects of interrole conflict on the mental health of employed family caregivers, and clarify the moderating role of attentional control on this stress-buffering effect. Methods: Data were drawn from a two-wave longitudinal online survey of employed

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Japanese family caregivers of people with dementia (263 males, 116 females; age 51.54 ±

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health variables (psychological strain and quality of life), and confounding factors.

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Results: Hierarchical regression analyses controlled for sociodemographic factors found formal support seeking had a stress-buffering effect for strain- and behavior-based caregiving

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interfering with work (CIW) only on psychological strain, and was moderated by attentional control. Single slope analysis showed higher CIW was related to higher psychological strain

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in those with greater use of formal support seeking and lower attentional control, but not in

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those with higher attentional control.

Conclusions: Greater use of formal support seeking weakens the adverse effects of strain-

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and behavior-based CIW on psychological strain in people with high attentional control. Clinical implications: Attentional control is a key factor in the stress-buffering effect of formal support seeking on strain- and behavior-based CIW.

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9.07 years). We assessed interrole conflict, coping strategies, attentional control, mental

Keywords: interrole conflict, coping strategy, stress-buffering effect, mental health, family caregivers, dementia

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Stress-Buffering Effect of Coping Strategies on Interrole Conflict Among Family Caregivers of People With Dementia

Introduction Interrole conflict refers to the extent to which a person experiences pressures in one role that

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are incompatible with those in another (Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964).

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providing care for people with dementia (Carradice, Beail, & Shankland, 2003; Martire &

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Stephens, 2003; Pearlin, Mullan, Semple, & Skaff, 1990). Interrole conflict among employed

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family caregivers is conceptualized as bidirectional (Gordon, Pruchno, Wilson-Genderson, Murphy, & Rose, 2012; Hepburn & Barling, 1996): caregiving interfering with work (CIW)

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and work interfering with caregiving (WIC). Interrole conflict contributes to deterioration of family caregivers’ mental health and work performance (Carradice et al., 2003; Martire &

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Stephens, 2003; Stephens, Townsend, Martire, & Druley, 2001; Stone & Short, 1990), meaning they often need to rearrange their work schedules (Hepburn & Barling, 1996; Stone

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& Short, 1990).

The stress process model for family caregivers (Pearlin et al., 1990) considers interrole

conflict as a secondary stressor resulting from caregiving demands, such as the care-recipient’s decreased abilities in activities of daily living (ADL)/instrumental ADL

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This conflict is often experienced among family members who combine working and

(IADL), and the behavioral and psychological symptoms of dementia (BPSD). The model assumes interrole conflict mediates the link between caregiving demands and family caregivers’ psychosocial adjustment (Gordon et al., 2012; Pearlin et al., 1990; Stephens et al., 2001). Job demands (e.g., work overload and workplace interpersonal conflict) are also considered significant antecedents of interrole conflict (Gordon et al., 2012; Martire & Stephens, 2003). Coping strategies, or cognitive and behavioral strategies used to adapt to

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stressful situations (Lazarus & Folkman, 1984), and social support may moderate the relationship between caregiving/job demands and interrole conflict (Barrah, Schultz, Baltes, & Stolz, 2004; Brown & Pitt-Catsouphes, 2016; Pearlin et al., 1990; Scharlach, 1994). The importance of these factors in ameliorating family caregivers’ psychosocial adjustment has been highlighted in a model of stress and coping among caregivers (Haley, Levine, Brown, &

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Bartolucci, 1987; Goode, Haley, Roth, & Ford, 1998).

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Over the past 30 years, attention has been directed to exploring coping strategies that

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effectively ameliorate the mental health of family caregivers in cross-sectional (e.g., Cooper et al., 2010; Knight, Silverstein, McCallum, & Fox, 2000) and longitudinal studies (e.g.,

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Cooper, Katona, Orrell, & Livingston, 2008; Powers, Gallagher-Thompson, & Kraemer, 2002). Several coping strategy typologies have been proposed (Skinner, Edge, Altman, &

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Sherwood, 2003), including problem- or emotion-focused coping (Lazarus & Folkman,

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1984); Carver’s (1997) classification of problem- (active coping and instrumental support) and emotion-focused coping (positive reframing and emotional support); and

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dysfunction/avoidant coping (behavioral disengagement and denial). The latter classification is often used for family caregivers of people with dementia because of its good psychometric properties (Cooper et al., 2008). Meta-analyses of previous studies found better mental health among family caregivers was related to more use of emotion-focused coping strategies and

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Coping Strategies

less use of dysfunctional/avoidant coping strategies, whereas problem-focused strategies showed inconsistent effects (Kneebone & Martin, 2003; Li, Cooper, Bradley, Shulman, & Livingston, 2012). Pruchno and Resch (1989) proposed three models to interpret the effect of coping

strategies: a main effects model, a moderator model, and a mediator model. The main effects model assumes coping strategies have uniform effects on mental health regardless of the

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degree of stressfulness. The moderator model refers to a stress-buffering effect, in which the coping strategy moderates the impact of stressors differently depending on the degree of stressfulness. The mediator model views coping strategies as mediators of the relationship between stressors and mental health. Many previous studies used the main effects model (e.g., Cooper et al., 2008; Herrera, Lee, Nanyonjo, Laufman, & Torres-Vigil, 2009) or the mediator

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model (e.g., García-Alberca et al., 2012). However, studies based on the moderator model are

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programs for family caregivers (Okabayashi et al., 2003).

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effects of stressors arising in the caregiving context is important to inform effective support

Previous studies involving family caregivers based on the moderator model examined

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the stress-buffering effect of coping strategies on caregiving demands. However, few studies examined this stress-buffing effect on interrole conflict. The effect of coping strategies on

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mental health differs across stressful situations (Gottlieb & Gignac, 1996; Lazarus &

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Folkman, 1984; Terry, 1994), and interrole conflict is assumed to be inherently different from other caregiving/job demands (Gordon et al., 2012; Martire & Stephens, 2003; Pearlin et al.,

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1990). The increased number of family caregivers who combine working and providing care (Shoptaugh, Visio, & Phelps, 2012) means it is important to examine the stress-buffering effect of coping strategies on interrole conflict. Previous studies based on the moderator model reported inconsistent results. For

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limited (Okabayashi et al., 2003). Exploring effective coping strategies that prevent adverse

example, Pruchno and Resch (1989) found problem- and emotion-focused coping had no stress-buffering effect on the adverse effects of the severity of a care-recipient’s dementia symptoms on caregivers’ depression and anxiety. Goode et al. (1998) also found

problem-focused coping showed no stress-buffering effect on the impact of care-recipients’ BPSD and ADL/IADL deficits on caregivers’ depression. However, Okabayashi et al. (2003) found that a “keeping their own pace” strategy, an avoidant coping and behavioral strategy

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caregivers used to avoid becoming too involved with the caregiving role and to secure their own life and health (Okabayashi et al., 2008), buffered the adverse effect of caregiving captivity (i.e., degree to which caregivers provide care to their care recipient on a daily basis) on burnout. Papastavrou et al. (2011) reported that problem-focused coping buffered the adverse effect of burden on caregivers’ depression. These inconsistent results may be

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attributable to consideration of different caregiving demands and mental health variables.

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contribute to developing effective support programs for employed family caregivers.

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Moderators of the Stress-Buffering Effect of Coping Strategies

In this study, we considered attentional control as a potential moderator for the

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stress-buffering effect of coping strategies on interrole conflict. Attentional control refers to a person’s capacity to focus and shift attention flexibly when necessary (Derryberry & Reed,

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2002; Evans & Rothbart, 2007). Attentional control is a subcomponent of effortful control,

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which is central to self-regulation (Evans & Rothbart, 2007; Rothbart, Ahadi, & Evans, 2000; Rothbart & Bates, 2006). High attentional control enables individuals to focus their attention

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on appropriate stimuli and ignore distractions (Derryberry & Reed, 2002). Impaired attentional control has been implicated in psychopathologies such as depression (Depue & Collins, 1999; Gotlib & Cane, 1987; Strauman, 2002) and anxiety (Mathews & Macleod, 1985; Wells, 2002).

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Exploring family caregivers’ psychosocial resources as a potential confounding factor may

The transactional theory of stress and coping (Lazarus & Folkman, 1984) suggests

coping is process-oriented and includes appraisal of stressors and one’s resources, selection of a coping strategy, and reappraisal. Attentional control may play an important role in these processes by serving as a resource for appraising problems and planning a coping strategy in a thoughtful manner (Kimura, Shudo, & Sakai, 2011). For example, family caregivers with poor attentional control who want to resolve interrole conflict may have difficulty evaluating

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their problem and planning a solution, as they may fixate on distractions (e.g., worries) because of limited attentional resources; in turn, this leads to ineffective problem-focused coping strategies. Limited attentional resources may also reduce the effectiveness of a coping strategy through dysfunctional reappraisal, which focuses a family caregiver’s attention on negative (rather than positive) aspects of the results of their coping effort. Dysfunctional

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reappraisal can therefore reduce the beneficial effect of a coping strategy (Lazarus &

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caregivers that have high attentional control, but not those with low attentional control.

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The Present Study

This study aimed to examine the stress-buffering effect of coping strategies on the

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adverse effects of interrole conflict on the mental health of employed family caregivers. We also examined the moderating effect of attentional control on this stress-buffering effect

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(Figure 1). To achieve this, we used an original coping strategy scale developed specifically

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for this study. Coping methods differ by situational demands; those for specific stressors are stable (Dolan & White, 1988; Gottlieb & Gignac, 1996; Gottlieb & Wolfe, 2002; Lazarus &

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Folkman, 1984; Stone & Neale, 1984), whereas interrole conflict is assumed to differ from caregiving/job demands (Gordon et al., 2012; Martire & Stephens, 2003; Pearlin et al., 1990). There is no available scale that assesses coping strategies for interrole conflict among family caregivers of people with dementia. Using scales designed to assess coping strategies for

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Folkman, 1984). This suggests coping strategies may ameliorate the mental health of family

caregiving/job demands to evaluate coping strategies for interrole conflict may not accurately capture the methods employed family caregivers use to deal with interrole conflict. We developed two hypotheses. (1) Coping strategies would have a moderating effect on the relationship between interrole conflict and the mental health of employed family caregivers; specifically, that greater use of coping strategies weakens adverse effects of interrole conflict on mental health. (2) Attentional control would have a moderating effect on

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the moderating role of coping strategies (i.e., second order interaction between interrole conflict × coping strategies × attentional control); specifically, that the moderating effect of coping strategies would be seen in those with high attentional control, but not in those with low attentional control. Few studies have examined the effect of coping strategies for interrole conflict in family caregivers of people with dementia and the stressor-specific nature

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of coping (Gottlieb & Gignac, 1996; Gottlieb & Wolfe, 2002). Therefore, we did not set any

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Participants and Procedure

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Methods

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We used data from a two-wave longitudinal online survey of employed Japanese family caregivers of people with dementia (N = 456) (Morimoto, Furuta, Kono, & Kabeya, 2017a,

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2017b), which was approved by the local Ethics Committee of Hiroshima International University. Each year, many employed family caregivers in Japan leave their jobs (Ministry

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of Internal Affairs and Communications, 2013). Therefore, a 3-month survey interval was used to minimize loss of participants between surveys and reduce recall bias. Data were

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collected by an online research provider, Cross Marketing (Tokyo, Japan), through their web panel. At Time 1, questionnaires (including an informed consent form) were distributed to potential participants via a listserv. Those who agreed to participate and responded to the Time 1 survey were invited to complete the Time 2 survey via the listserv.

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hypothesis regarding specific types of coping strategies.

Although online surveys enable collection of data from difficult-to-reach populations

(Reips & Buffardi, 2012), they have shortcomings, particularly in data reliability (Aust, Diedenhofen, Ullrich, & Musch, 2013). We checked user seriousness using the method described by Aust, Diedenhofen, Ullrich, and Musch (2013). On a single page at the end of the survey, we asked respondents to select “I have just clicked through, please discard my

data” or “I have responded seriously.” We discarded those who gave the first response as

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potentially unreliable. After excluding potentially unreliable data (15 participants), data for 379 participants who completed both Time 1 and 2 surveys (263 males aged 53.14 ± 8.28 years, 116 females aged 47.92 ± 9.77 years) were analyzed. Measures Sociodemographic variables. In the Time 1 survey, participants reported their sex, age,

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occupation, employment status (full- or part-time), relationship to the care recipient, and the

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age, type of dementia, whether they used public long-term care insurance (LTCI), and if so,

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the level of care needed.

Interrole conflict. We used the Caregiving–Work Conflict Scale (CWCS; Morimoto et

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al., 2017a), comprising 20 items in five subscales corresponding to the bidirectional construct of interrole conflict: time-based CIW (time spent caregiving makes it difficult to participate in

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work); strain-based CIW (the strain of caregiving interferes with participation in work);

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behavior-based CIW (specific behaviors required for caregiving interfere with work, such as flexible work to suit day-care service pick-up times); WIC; and work and caregiving

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interfering with personal life (lack of personal time, such as for rest/housekeeping, stemming from combining caregiving and work). All items were rated by frequency of experience and degree of concern: frequency on a three-point scale (0: never, 1: sometimes, 2: often) and concern on a four-point scale (0: never, 1: slightly, 2: considerably, 3: extremely). Participants

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length of time they had been a caregiver. Participants also reported the care recipient’s sex,

were asked to rate their experience over the last 3 months. For the analyses, the product of the

frequency of experience and degree of concern were calculated using Time 2 data. Higher scores indicate higher interrole conflict. For this study, the Cronbach’s alpha coefficients for the five subscales were .92, .90, .84, .78, and .93. Caregiving demands. Caregiving demands were assessed with the Caregiver Burden Scale (CBS; Niina, Yatomi, & Homma, 1992) that assesses demands experienced by family

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caregivers in caring for people with dementia. The CBS is based on the transactional theory of stress and coping (Lazarus & Folkman, 1984) and comprises 26 items on seven subscales: support for daily life (support for care-recipient with ADL/IADL deficits), handling of dementia symptoms (core symptoms of dementia and BPSD), concern about the future, interpersonal problems (e.g., low social support), constraint on personal and social activities,

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lack of social services, and economic cost. At Time 1, participants were asked to rate their

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1: a little, 2: quite a bit, 3: extremely). This study excluded the constraint on personal and

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social activities subscale as it assesses whether caregiving interferes with other roles (Niina et al., 1992) and partially overlaps interrole conflict. Subscale scores were summed for the

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analyses (α = .90). Higher scores indicate higher caregiving demands.

Job demands. The Job Demands Scale (JDS) from the New Brief Job Stress

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Questionnaire (Inoue et al., 2014) was used to assess job demands. The JDS comprises 19

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items on eight subscales: quantitative job overload, qualitative job overload, physical demands, interpersonal conflict, poor physical environment, emotional demands, role conflict,

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and work-self balance (negative). At Time 1, participants were asked to rate their working conditions over the last 3 months on a four-point scale from 0 (disagree) to 3 (agree). This study excluded the work-self balance (negative) subscale as it assesses work interference with personal life and partially overlaps interrole conflict. Subscale scores were summed for the

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degree of concern about each item over the last 3 months on a four-point scale (0: not at all,

analyses (α = .90). Higher scores indicate higher job demands. Coping strategies. We used an original scale developed specifically for this study to

assess family caregiver’s coping strategies for interrole conflict. We initially drew on the 109 items described by Morimoto, Furuta, Kono, and Kabeya (2015), which asked employed Japanese family caregivers of people with dementia to describe their efforts to deal with interrole conflict. However, that study included a small number of participants (N = 47) and

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was limited in scope. Therefore, we also included three items from the coping scale for caregiving demands (Okabayashi et al., 2008) and eight items from the coping scale for other types of interrole conflict (e.g., work-family conflict) (Kato & Kanai, 2006) to enhance the item pool and content validity. These additional coping strategies were not discussed by Morimoto et al. (2015), but were assumed apply to interrole conflict experienced by family

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caregivers of people with dementia. The final 120 items were sorted in terms of similarity by

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42 items were used. At Time 1, according to the procedure used by Midorikawa (1993),

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participants were asked to rate the degree to which they usually used each coping strategy for interrole conflict on a three-point scale (0 = rarely used, 1 = sometimes used, 2 = often used).

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After excluding the item “I go to family caregiver gatherings such as family gatherings of those with dementia,” to which ≥80% of participants responded “rarely used,” a series of

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exploratory factor analyses with the remaining 41 items (maximum likelihood method with

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Harris–Kaiser rotation) indicated a five-factor solution with 25 items best fit the data (χ2 = 468.58, df = 185, p < .01, CFI = 0.90, RMSEA = 0.06). All items were highly loaded on their

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factors (i.e., more than .40), with no notable cross-loading (i.e., less than .30). Factor 1 comprised eight items representing adjustment of schedules (α = .81). Factor 2 comprised six items representing emotion-focused coping (α = .78). Factor 3 comprised four items representing informal support seeking (α = .74). Factor 4 comprised four items representing

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two clinical psychology graduate students. After merging and eliminating duplicated items,

reducing caregiving load (α = .66), and Factor 5 comprised three items representing formal support seeking (α = .64). All items are listed in the Appendix. The scale was cross-validated with data from this study and data drawn from another survey involving employed Japanese family caregivers of people with dementia (N = 352) using multiple group structural equation modeling, which set equality constraints on factor loadings, factor variance and covariance, and variance of error terms. The results indicated

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the five-factor model had a low but acceptable fit for the data (TLI = 0.82, CFI = 0.83, RMSEA = 0.05), given the criterion described by Marsh, Hau, and Wen (2004) and Browne and Cudeck (1993). Attentional control. This was assessed with the attentional control subscale of the Japanese version of the Effortful Control Scale (Yamagata, Takahashi, Shigemasu, Ono, &

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Kijima, 2005). The scale has 35 items on three subscales: inhibitory control, activation

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4 (agree). This study only used the attentional control subscale (α = .90). Higher scores

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indicate higher attentional control.

Mental health. We assessed family caregivers’ mental health using psychological strain

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as a negative aspect and quality of life (QOL) as a positive aspect. Participants were asked to rate their condition in the previous month in both Time 1 and 2 surveys. Psychological strain

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was measured with the Stress Response Scale (Suzuki et al., 1997), comprising 18 items

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across three subscales: depression/anxiety, irritability/anger, and helplessness. Items are rated on a four-point scale from 0 (disagree) to 3 (agree). Higher scores indicate higher

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psychological strain (α = .95). QOL was measured using the Japanese version of the SF-8 Health Survey (Fukuhara & Suzukamo, 2004). We used the formula described by Fukuhara and Suzukamo (2004) to calculate summary scores normalized for a Japanese population: physical component scores (PCS) and mental component scores (MCS). Higher PCS and

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control, and attentional control. All items are rated on a four-point scale from 1 (disagree) to

MCS indicate higher physical and psychological functioning. Cronbach’s alpha coefficients for PCS and MCS cannot be calculated because the formula to calculate PCS and MCS uses all SF-8 items (Fukuhara & Suzukamo, 2004). Therefore, we calculated the Cronbach’s alpha coefficient for the total SF-8 score (α = .90).

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Statistical Analyses A series of hierarchical regression analyses was conducted based on the mental health variables. Before analysis, indicator variables were centered. Because there were moderate to strong correlations between CWCS subscale scores (r = .30 to .84, ps < .01), we conducted hierarchical regression analyses according to five types of interrole conflict to avoid

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multicollinearity (15 models were tested in total). In the regression model, control variables

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care-recipient’s sex and age, caregiving demands, job demands, and mental health variables

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in Time 1) were entered in the first step. In the second step, the main effect of the five types of coping strategy, attentional control, and interrole conflict were entered. In the third step, to

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test hypothesis 1, first order interaction terms between coping strategy, attention control, and interrole conflict were entered. Finally, to test hypothesis 2, second order interaction terms

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among coping strategy, attention control, and interrole conflict were entered in the fourth step.

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In cases of significant interaction, single slope analysis was conducted using the method of Aiken and West (1991).

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Results

Male caregivers outnumbered female caregivers (69.39%). The most common kinship

between caregiver and care recipient was son/parent (56.46%). Most caregivers worked full-time (81.00%), and the largest occupation category was office worker (35.62%). The

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(caregiver’s sex, age, state of employment, length of time they had been a caregiver,

mean time from starting to provide care was 59.46 ± 46.64 months. There were more female (70.18%) than male care-recipients, and care recipients’ mean age was 81.98 ± 9.21 years. Most suffered from Alzheimer’s dementia (73.35%), with the largest group certified as having mid-level care requirements under Japan’s LTCI system (24.27%) (Ministry of Health, Labour and Welfare, 2006). Detailed information regarding sociodemographic variables for the sample is presented elsewhere (Morimoto et al. 2017b).

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Table 1 shows the means and standard deviations (SD) for the indicator variables. Correlation analysis showed that greater use of coping by adjustment of schedules (psychological strain r = .15 to .23, p < .01; PCS at Time 1 r = −.15, p < .01; MCS r = −.25 to −.23, p < .01) and reducing caregiving load (psychological strain r = .15 to .18, p < .01; PCS r = −.17, p < .01; MCS r = −.19 to −.12, p < .05) were related to poorer mental health. In

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contrast, greater use of emotion-focused coping was related to better mental health

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to .16, p < .05). Informal and formal support seeking coping strategies were not related to any

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mental health variables, except for a negative correlation between formal support seeking and MCS at Time 1 (r = −.12, p < .05). High attentional control was related to better mental

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health (psychological strain r = −.58 to −.48, p < .01; PCS r = .16 to .18, p < .01; MCS r = .35 to .40, p < .01).

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For hypothesis 1, the series of hierarchical regression analyses showed that there were no significant increments in step 3 in all regression models. For hypothesis 2, increments in

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step 4 were observed in the strain- and behavior-based CIW model (ΔR2 = .02, ΔF = 2.39, p

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< .05 and ΔR2 = .02, ΔF = 2.82, p < .05, respectively) for psychological strain, whereas there were no significant increments in step 4 for PCS (ΔR2 = .00 to .01, ΔF = 0.34 to 1.93, ns.) or MCS (ΔR2 = .01, ΔF = 0.82 to 1.65, ns.). In these models, second order interaction terms of strain-based CIW × formal support seeking coping × attentional control (β = −.12, |t| = 2.16, p

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(psychological strain r = −.16 to −.14, p < .01; PCS at Time 2 r = .10, p < .05; MCS r = .11

< .05) and behavior-based CIW × formal support seeking coping × attentional control (β = −.18, |t| = 3.01, p < .01) were significant (Table 2). The results of single slope analyses for these interactions are depicted in Figures 2 and 3. For strain-based CIW, greater use of formal support seeking coping was associated with higher psychological strain in those with low attentional control (−1 SD, β = .25, |t| = 3.34, p < .01), but not in those with high attentional control (+1 SD, β = .12, |t| = 0.97, ns.) Less use

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of formal support seeking coping was associated with higher psychological strain in those with low attentional control (−1 SD, β = .15, |t| = 2.08, p < .05) and high attentional control (+1 SD, β = .38, |t| = 3.25, p < .01). For behavior-based CIW, greater use of formal support seeking coping was associated with higher psychological strain in those with low attentional control (−1 SD, β = .15, |t| = 1.97, p < .05), but not in those with high attentional control (+1

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SD, β = .09, |t| = 0.87, ns.). Less use of formal support seeking coping was associated with

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Discussion

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< .01), but not in those with low attentional control (−1 SD, β = .06, |t| = 0.82, ns.).

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Greater use of emotion-focused coping and less use of coping by adjusting schedules and reducing caregiving load were directly related to better mental health among employed

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family caregivers. In contrast, informal and formal support seeking coping were not generally and directly related to better mental health in this population. As adjustment of schedules and

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reducing caregiving load represent efforts to directly resolve interrole conflict (i.e., problem-focused coping), these results are generally consistent with those of previous

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meta-analyses (Kneebone & Martin, 2003; Li et al., 2012). In terms of our hypotheses, the hierarchical regression analyses showed that only formal support seeking had a stress-buffering effect on strain- and behavior-based CIW, which was moderated by attentional control. This moderation effect suggests greater use of formal support seeking

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higher psychological strain in those with high attentional control (+1 SD, β = .52, |t| = 4.36, p

prevents adverse effects of strain- and behavior-based CIW on psychological strain in

caregivers with high attentional control. These results support hypothesis 2, but not hypothesis 1. In this study, the formal support seeking coping strategy represents instrumental support seeking, and is therefore part of problem-focused coping (Carver, 1997). Okabayashi et al. (2008) found that instrumental support seeking had no beneficial effect on caregiver

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burden. They also argued that their results must be interpreted cautiously because “provision of these supports were not seen as dependable or efficacious enough for caregivers to feel comfortable taking their own time away from their frail older care-recipients.” This means that poor quality formal support services may negatively impact family caregivers. However, our results suggest that poor attentional control also reduces the beneficial effect of formal

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support seeking for caregivers, particularly for strain- and behavior-based CIW.

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anxiety/worry about the care-recipient (Morimoto et al., 2017a). Although family caregivers

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receive adequate formal support (e.g., visiting nurses and day care) during their working time, those with poor attentional control might experience difficulty moving their attention from

an

worry about their care-recipient. Behavior-based CIW refers to conflict stemming from specific behaviors required for caregiving, such as returning home from work early because

M

of the day-care transportation schedule (Morimoto et al., 2017a). Family caregivers with poor

ed

attentional control may experience challenges in adjusting their work schedule to suit day-care transportation schedules. This may become more pronounced as use of formal

ce pt

support seeking increases, and may reduce the beneficial effect of formal support seeking on psychological strain.

A moderating effect of attentional control on stress-buffering effects was found for

psychological strain, but not for QOL. The positive psychology literature suggests a

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Strain-based CIW refers to the conflict stemming from caregiving strains such as

decreased negative affect does not necessarily mean an increase in positive psychosocial functions, such as QOL (Seligman & Csikszentmihalyi, 2000). Given that some family caregivers experience positive outcomes in combining caregiver and worker roles, such as accomplishment and enhanced interpersonal relationships (Martire & Stephens, 2003; Scharlach, 1994), further exploration of moderators that may enhance the beneficial effect of coping strategies on QOL is needed.

16

This study has several limitations. First, participants were limited in scope and differed from a typical representative sample of employed family caregivers in Japan (e.g., male caregivers outnumbered female caregivers). However, the sociodemographic characteristics of care recipients in this study were comparable with a representative sample in Japan. The global trend toward an aging population has increased the number of male caregivers

ip t

(Coltrane, 1998; Ministry of Internal Affairs and Communications, 2013); differences in

cr

the recruitment strategy used in this study (i.e., online survey) is an issue. Online surveys

us

enable collection of data from difficult-to-reach populations (Reips & Buffardi, 2012), but the characteristics of registered members of the online research provider’s web panel are not

study, and limit the generalizability.

an

necessarily comparable with those not registered. This might have affected the results of this

M

Second, the relatively small sample size prevented us from testing our hypotheses

ed

against sociodemographic variables. It is possible that the moderating effect of attentional control on the stress-buffering effect of coping strategies differs by sociodemographic

ce pt

characteristics of family caregivers and care recipients. Third, the short survey interval (3 months) prevented us from examining the long-term stress-buffering effects of coping strategies on the mental health of employed family caregivers. Finally, internal consistency for reducing caregiving load and formal support seeking

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family caregivers’ sociodemographic characteristics in this study may reflect this. In addition,

coping were relatively low. Items on these subscales were more specific than those on other subscales, and the use of each strategy may differ by the caregiver’s financial circumstances and the care recipient’s level of cognitive function. For example, to reduce the caregiving load, caregivers with more financial resources may be able to prepare furnishings and equipment to enable their care recipient to do housework (i.e., item 19 on the subscale), which may not be possible for caregivers with less economic resources. Caregivers of people

17

with more severe dementia may also use day services more than those who care for someone with a moderate level of dementia (i.e., item 24). This diversity might have affected our results. Therefore, the relatively low data fit showed by testing cross-validation requires further research to examine the replicability of the factor structure for the coping scale. Despite these limitations, our study provided initial evidence that coping strategies have

ip t

a stress-buffering effect on interrole conflict. Attentional control may be a key factor in

cr

behavior-based CIW. Attentional control may be improved by methods such as training in

us

mindfulness (Chambers, Lo, & Allen, 2008) or attentional control (Papageorgiou & Wells, 2000). Such training may also improve mental health (Fergus & Bardeen, 2016; Sedlmeier et

an

al., 2012). Including mindfulness/attentional control training in psychoeducation programs, such as Coping with Caregiving (Au et al., 2010), may help employed family caregivers

M

combine caregiving and work while maintaining better mental health. Other types of coping

ed

strategies showed no significant stress-buffering effect or moderating effect of attentional control. Further study is necessary to explore factors that improve the effect of coping

ce pt

strategies for interrole conflict.

Clinical Implications



Attentional control is a key factor in the stress-buffering effect of formal support seeking coping for strain- and behavior-based CIW.

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enhancing the beneficial effects of formal support seeking coping for strain- and



Encouraging use of formal support seeking among those with higher attentional control may prevent adverse effects of strain- and behavior-based CIW on psychological strain.



Mindfulness or attentional control training may have benefits in improving attentional control in those with lower attentional control.

18

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Appendix Coping scale for interrole conflict among employed family caregivers

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an

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Emotion-focused coping 9. I think, “Overall, the situation is not that bad.” 10. I think, “Providing nursing care will get easier.” 11. I think, “It is all right if I cannot do this properly.” 12. I try not to think too deeply about what will happen in the future. 13. I do fun activities or take mental breaks. 14. I maintain my existing lifestyle.

ed

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Informal support seeking 15. I ask family or friends for advice. 16. I ask family, friends, or neighbors for help. 17. I ask people in similar situations for advice. 18. I ask family for understanding about what I want to do.

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Reducing caregiving load 19. I prepare furnishings, electronics, equipment, and so on, so that the care recipient can do housework. 20. I ask the care recipient for help with housework when possible. 21. I make lunch bags for the care recipient’s lunch. 22. I move items around the house or tell the care recipient not to do certain things, so the care recipient is not at risk when I am out. Formal support seeking 23. I ask specialists such as the family doctor and care manager for advice. 24. I use specialized services such as visiting nurses, day care, short stay services, and the nursing care insurance system. 25. When I am out or at work, I have care managers or home helpers check on the care recipient.

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Adjustment of schedules 1. After work, I go straight home and do housework. 2. I cut back on work or do not work overtime. 3. I get up early in the morning and do housework so that it does not affect my job. 4. I decide days and times to work. 5. I try to establish a balance between nursing care and work. 6. I work during breaks from providing nursing care. 7. I change my lifestyle to conform to providing nursing care. 8. I condense my cleaning schedule to specific days.

28

T1 Job demands

21.53

10.08

T1 Adjustment of schedules

6.86

4.03

T1 Emotion-focused coping

6.15

3.06

T1 Informal support seeking

2.56

2.08

T1 Reducing caregiving load

2.14

1.97

T1 Formal support seeking

2.98

1.70

19.53

6.68

T2 Time-based CIW

4.62

7.32

T2 Strain-based CIW

2.56

T2 Behavior-based CIW

2.10

T2 WIC

1.39

T2 WCIP

3.65

2.73

6.61

8.21

18.37

12.65

M

T1 Psychological strain T1 PCS

3.86

an

T1 Attentional control

45.56

8.52

41.80

8.65

T2 Psychological strain

17.62

12.63

T2 PCS

45.58

8.55

41.98

8.58

ce pt

T2 MCS

ed

T1 MCS

ip t

9.69

cr

24.81

us

T1 Caregiving demands

Notes. CIW = caregiving interfering with work, MCS = mental component scores, PCS = physical component scores, SD = standard deviation, T1 = Time 1 survey, T2 = Time 2 survey, WCIP = work and caregiving interfering with personal life, WIC = work interfering with

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Table 1 Means and standard deviations for indicator variables M SD

caregiving.

29

Table 2 Results of a series of hierarchical regression analyses predicting psychological strain

Predictor

Time-based CIW ΔR2 .48

ΔR2

|t|

**

.48

CG age

−.11

2.56

SE

.06

CR sex

**

.48 .02

0.44

−.11

2.74

1.51

.05

1.23

.02

0.44

.01

0.31

CR age

.02

0.50

.02

T

.01

0.25

T1 CD

−.02

0.42

T1 JD

.00

0.04

T1 PS

.53

9.59

2nd step

.05

T1 AS

−.08

T1 EF

−.01

**

−.11

2.54

.07

1.60

−.01

0.16

0.46

.00

0.09

.01

0.20

.00

0.01

−.04

0.72

−.04

0.72

.01

0.33

.04

0.95

.53

9.54

**

9.53

**

**

4.07

1.68

−.07

0.31

.04 **

.21

4.11

1.47

−.04

0.88

−.02

0.41

−.01

0.30

1.02

−.07

1.55

−.05

1.24

.04

0.85

.02

0.51

.06

1.29

.03

0.72

.02

0.52

.02

0.47

−.12

2.31

−.11

2.16

−.15

2.99

.02

.01

.48

**

.06

**

*

*

**

**

−.04

*

ΔR2

|t| 0.07

.23

ce pt

T1 RC

3rd step

**

ed

T1 IS

β .00

.53

M

4.54

T1 AC

**

.05

.25

T1 FS

*

**

T2 IC

ΔR2

|t|

cr

0.24

Behavior-based CIW

us

.01

β

an

CG sex

**

**

.01

.01

T2 IC × T1 AS

−.10

1.65

−.08

1.23

.02

0.29

T2 IC × T1 EF

.08

1.08

.02

0.26

.02

0.33

T2 IC × T1 IS

.03

0.54

.00

0.04

−.05

0.83

T2 IC × T1 RC

.01

0.29

.07

1.22

.05

1.06

T2 IC × T1 FS

−.08

1.50

−.04

0.70

−.10

1.68

T2 IC × T1 AC

.05

0.93

.03

0.46

.13

2.30

T1 AS × T1 AC

.04

0.82

.03

0.69

.03

0.66

T1 EF × T1 AC

−.02

0.36

−.03

0.60

.00

0.10

T1 IS × T1 AC

.02

0.44

.01

0.18

−.01

0.25

Ac

Downloaded by [JAMES COOK UNIVERSITY] at 07:43 26 August 2017

1st step

β

Strain-based CIW

ip t

Interrole conflict

*

30

T1 RC × T1 AC

−.04

0.82

−.01

0.15

−.05

1.09

T1 FS × T1 AC

.02

0.39

.03

0.70

−.01

0.16

4th step

.01

*

.02

*

.01

−.03

0.49

−.05

0.72

.06

0.80

T2 IC × T1 EF ×T1 AC

.02

0.26

.02

0.30

−.03

0.44

T2 IC × T1 IS ×T1 AC

.00

0.04

−.04

0.76

.07

1.18

T2 IC × T1 RC ×T1 AC

.02

0.43

.01

0.12

.09

1.63

T2 IC × T1 FS ×T1 AC

−.08

1.44

−.12

2.16

−.18

3.01

.55

**

.56

**

*

.55

**

cr

Notes. The value of the standardized partial regression coefficient is represented in the final

us

step.

CIW = caregiving interfering with work, WIC = work interfering with caregiving, WCIP =

an

work and caregiving interfering with personal life, CG = caregiver, SE = state of employment (0 = full-time, 1 = part-time), CR = care recipient, T = time since being caregiver, CD =

M

caregiving demands, JD = job demands, PS = psychological strain, AC = attentional control, AS = adjustment of schedules, EF = emotion-focused coping, IS = informal support seeking,

Ac

ce pt

p < .01, * p < .05.

ed

RC = reducing caregiving load, FS = formal support seeking, IC = interrole conflict. **

**

ip t

T2 IC × T1 AS ×T1 AC

R2 Downloaded by [JAMES COOK UNIVERSITY] at 07:43 26 August 2017

.02

.56

**

ed

ce pt

Ac

ip t

cr

us

an

M

Downloaded by [JAMES COOK UNIVERSITY] at 07:43 26 August 2017

31

Figure 1. Conceptual model of the present study.

32

Figure 2. Simple slope analysis of second order interaction terms between strain-based CIW, formal support seeking, and attention control on psychological strain. AT = attention control,

cr us an M ed ce pt Ac

Downloaded by [JAMES COOK UNIVERSITY] at 07:43 26 August 2017

ip t

CIW = caregiving interfering with work, FS = formal support seeking.

33

Figure 3. Simple slope analysis of second order interaction terms between behavior-based CIW, formal support seeking, and attention control on psychological strain. AT = attention

cr us an M ed ce pt Ac

Downloaded by [JAMES COOK UNIVERSITY] at 07:43 26 August 2017

ip t

control, CIW = caregiving interfering with work, FS = formal support seeking.