Gil Choi, Ph.D., Terry Tirrito, Ph.D., Frances Mills,
M.S.W. Ph.D. Candidate
Summary/Abstract: This study examined the role that faith-based
organizations play for caregivers in maintaining the elderly
and disabled in their homes. The study explored if persons
who use religious beliefs and practices cope with caregiver
stress better than those who do not use religious beliefs
and practices. The study also explored the role of religious
coping as a factor affecting decisions to institutionalize
and the role that faith-based practices and organizations
play in helping caregivers maintain the elderly and disabled
in their homes.
Gil Choi, PhD is Associate Professor
College of Social Work at the University of South Carolina.
Terry Tirrito, PhD is Associate Dean and Professor in the
College of Social Work at the University of South Carolina.
Frances Mills, MSW, PhD Candidate is a 2006 Hartford Doctoral
Fellow and teaches part-time in the College of Social Work
at the University of South Carolina.
According to recent census data, the fastest growing sector
of the population over the next two decades will be older
adults (U.S. Census Bureau, 2001). Koenig & Lawson (2004)
report that in 2000, there were eight times more people in
the 65-74 age group, sixteen times more people 75-84, and
thirty-four times more people over 85 than there were in 1900
and maintain this trend will continue. As the aging population
increases dramatically in the next two decades, the need for
services to support and maintain optimal quality of life will
also increase for this population. Advances in medicine and
technology now allow people to live longer, but often with
disabilities that require ongoing care (Koenig & Lawson,
The need for caregiving is expected to increase along the
same trajectory, as an aging population will result in numbers
of people whose health prevents them from caring for themselves
(The Canadian Study of Health and Aging Working Group [CSHA],2002
& Navalie-Waliser et al., 2001). According to Koenig (1994),
family members provide 85% of all caregiving to ill or disabled
older adults and are at risk themselves of deteriorating health
and social relationships. Some of the conditions of older
adults that necessitate caregiving include: Alzheimer's Disease
(AD), chronic illness such as diabetes, mental retardation,
and frailty. The number of people with these conditions will
only increase. For example, Morano & King (2005) state
that by the year 2010, the number of people diagnosed with
AD is expected to grow from 4 million to more than 10 million.
With this expected growth, it is important for social work
research to develop an understanding of how caregivers navigate
the strain of caregiving and to identify factors that may
impact caregiver decision making.
Religion and spirituality's positive effects have been identified
as contributing to caregiver's sense of well-being and coping
(Berg-Weger et al., 2001). Religiosity and spirituality have
been found to help mediate the perception of and reaction
to caregiving stress(Morano & King, 2005). Few research
studies have focused on the impact of religiosity and spirituality
on caregiver decisions that involve placing loved ones in
institutional care. Finding out how spirituality and religiosity
impacts caregiving decisions can provide important knowledge
to social workers for development of caregiving interventions.
It has implications for the care recipient, the caregiver,
and for faith-based organizations as well.
After a brief literature review, this study will use adaptations
of the stress and appraisal models of Pearlin et al. (1990)
and Chang (1998) to examine the effects of religion and spirituality
and religious coping on caregiver decision-making.
Caregiver burden and caregiver strain are terms that refer
to the numerous negative outcomes of providing care to or
for another person (Hunt, 2003). Negative outcomes of caregiving
may include social isolation; disruption of leisure/employment
time; depression and anxiety; physical symptoms/illnesses;
and emotional instabilities (Berg-Weger et al., 2001; Dillworth-Anderson
& Gibson, 2002).
There is evidence in the caregiving literature that high levels
of caregiver burden are related to premature institutionalization
of the care recipient. The gerontological literature indicates
that stress, strain, and negative responses to caregiving
are well recognized as issues which influence a caregiver's
decision to institutionalize a family member in a long-term
care facility. Gaugler et al. (2005), maintain that the institutional
process is a complex one. According to them, the emotional,
psychological, and physical tolls associated with caregiving,
subjective appraisals of stress by caregiver, and a sense
of being trapped are associated with institutionalization
because primary caregivers view institutionalization as a
relief. They also maintain that as caregiving requires more
physical assistance, institutionalization is further expedited.
In other words, the desire to institutionalize is greatest
when caregivers experience high level of stress and when the
caregiving is physically burdensome. Aneshensel, Pearlin,
and Schuler (1993) also note that increased levels of caregiving
strain are associated with institutionalization.
In recent years researchers increasingly have directed their
attention to the relationship between caregiver's religious
involvement and its effects on caregiving. Some studies indicate
that family members who practice religio us beliefs to cope
with the task of providing care exhibit less caregiving strain
and positive psychological well-being than others who do not
(Lawton et al, 1989; Fingerman et al., 1996). Koenig (1994)
notes that indices of religious coping have been associated
with lower rates of depression.
Williams & Dilworth-Anderson (2002) report that caregivers
who have more cohesive networks of informal support, such
as those provided by religious congregations are less likely
to use formal supports to provide care.
Crowther et al. (2002) suggest that the concept of positive
spirituality should be a factor in Rowe and Kahn's model of
successful aging. Rowe and Kahn's model defines successful
aging as avoidance of disease and disability, maintenance
of physical and cognitive functioning, and engagement in social
activities. However, Crowther states that spirituality has
positive effects on wellness and he asserts this opens doors
of opportunity for groups who have become reluctant recipients
of traditional interventions.
Religious involvement has been linked positively to physical
and mental health as well as to longevity (Koenig, 2004).
Kraus (2002) points out the positive relationship between
religion and optimism and identifies a substantial number
of studies between optimism and physical health. Kraus states
that people who are optimistic tend to cope more effectively
with stressful life events and concludes that spiritual support
is related to health. Due to a stress-buffering role of religious
involvement, caregivers have a lower incidence of depression
(Morano and King, 2005). Caregiver depression is known as
a factor associated with earlier admission of a loved one
to a nursing home. Chang (1998) reports that caregivers who
use religious or spiritual beliefs to cope have a better relationship
with their care recipients, a factor associated with lower
levels of depression.
Little is known about how religion or spirituality help caregivers
in making decisions that affect their loved ones, such as
the decision to institutionalize or the decision to keep at
home. Finding out how spirituality and religion impact caregivers'
decisions can provide important knowledge for social work
in the development of caregiving interventions. It has implications
for caregivers, care recipients, and for faith-based organizations
Faith-based organizations can fill the gap for social services
that public agencies are unable to provide to older adults.
Faith communities provide numerous advantages for older adults
and their caregivers. Hale and Bennett (2003) state that faith-based
organizations and relationships that develop as a result of
involvement provide a natural means to foster and support
caregiving. They emphasize that faith-based communities have
regular contact with the people who need them and are likely
to reflect the traditions and values of the community residents,
thus lending a sense of familiarity and comfort when seeking
help and support. Barker (2002) notes the strengths of these
relationships, stating that they possibly play a key role,
through social interaction that will reduce anxieties and
stave off institutionalization.
The present analysis was designed to assess the influence
of religiosity and spirituality on caregiver decision-making,
specifically the decision to provide care for a loved one
at home rather than to institutionalize.
Pearlin et al. (1990) offer a conceptual model of caregiving
and the stress process. They maintain that caregiver stress
is not a unitary occurrence but a mix of circumstances, experiences,
responses, and resources that vary considerably among caregivers
and that consequently vary in their impact on caregiver health
and behavior. Their model is based on background and context,
such as socioeconomic status, caregiving history, family and
network composition and program availability; primary stress
indicators, such as cognitive status and problematic behavior
of care recipient and primary stress indicators such as overload
and relational deprivation of caregiver; secondary role strains,
such as family conflict, economic problems, and constriction
of family life; secondary intrapsychic strains, such as self-esteem,
mastery, loss of self, role captivity, competence and gain;
outcomes, such as depression, anxiety, irascibility, cognitive
disturbance, physical health, and yielding of role; mediators
include coping and social support. They note that there are
caregivers who find some inner enrichment and growth even
as they contend with mounting burdens while other caregivers
do not. According to Pearlin et al., mediators include coping
and social support.
Chang (1998) provides a conceptual view of religious coping.
Chang notes an indirect influence of religious and spiritual
coping on caregiver distress. Chang reports that caregivers
who use religion and spirituality to cope with caregiving
have a better relationship with care recipients and have lower
levels of depression. The present study examined the social
service needs of the caregiver and proposed the following
H1: Persons who use religious practices cope with caregiving
stress better than those who do not.
H2: Religious support received from congregations affects
decisions to institutionalize.
A random sample of 941 long-term care participants was obtained
to test the research hypotheses. Participants were caregivers
of Continuing Long Term Care (CLTC) recipients of South Carolina
Department of Health and Human Services. Those who chose to
participate in the study completed the anonymous questionnaire
which took about 30 minutes. After the surveys were entered
into SPSS and cleaned for missing data, a total N of 232 was
Demographic variables. Morano (2005) states that variables
such as caregiver's gender, age, income, and years of education
are frequently reported in the caregiving literature. Race,
employment status, marital status, relationship to care recipient,
place of caregiving, number of hours of caregiving, length
of caregiving were also variables of interest with regard
to the caregiver in this study. The care recipient's gender,
age, and cognitive status were also variables of interest
in this study.
Care burden stressor variables. Care burden stress (Pearlin,
1990) was measured on 3 subscales: role overload was measured
with 3 items; role captivity was measured with 3 items; and
six stressors associated with the consequences of long term
caregiving and overall care burden were measured with one
item. The instrument shows high internal consistency with
Cronbach's coefficient alpha of .88 for role overload, .84
for role captivity, and .81 for stressors associated with
the consequences of long term caregiving.
Quality of life variables. The overall quality of life was
measured on a single item taken from the McGill Quality of
Life (MQOL) Questionnaire (Cohen, 1997). Internal consistency
was examined and found to be good with a Chronbach's alpha
of .83 for the total scale.
Social life. Caregiver's social life (Clipp & George,
1993) was measured on 4 items. It showed a high internal consistency
of .85. Questions were answered on a scale 1 = very dissatisfied,
2 = dissatisfied, 3 = satisfied, and 4 = very satisfied.
Depression. Depression was measured by the CES-D Scale (Radloff,
1977). The instrument consists of 20 items measuring a broad
range of manifestations of depression and has excellent internal
consistency with Cronbach's coefficient alpha of .90.
Religious/spiritual coping. The role of religious and spiritual
coping with caregiving was measured using a single item (Chang,
1998). It measures to what extent religious or spiritual beliefs
help caregivers handle the whole experience of caregiving.
Analyses were conducted using SPSS. Independent sample t
tests were conducted to assess differences between gender
and differences between race on role overload, role captivity,
and other stressors; on quality of life; on social life; on
depression; and on whether religious and spiritual beliefs
helped to cope with caregiving. One way ANOVA was conducted
to assess differences in role overload, role captivity, other
stressors, and overall careburder among different education
and household income categories of caregivers. Correlation
coefficients among study variables in the two groups, gender
and race, were compared.
Descriptive characteristics of sample and study variables
The final sample consisted of 232 caregivers with notable
gender differe nces. Approximately 19% were male and 81% were
female. On average, participants were 57.4 years of age (SD
= 11.9). Approximately 49.8% of caregivers who took this survey
were White and 49.3% of caregivers were black. Educational
attainment by respondents reflected that 83% had a high school
education or greater and 39% worked full or part-time, while
the remaining 61% were retired or unemployed due to health
or caregiving duties. Approximately 66% of participants reported
they had an income under $25,000 and over half (59.4%) were
Over half of caregivers (63%) reported their own home as the
place most frequently used to provide care and on average
the number of hours a day spent providing care by the caregiver
was 17.5 (SD = 8.9). Caregivers reported that they had cared
for the care recipient on average 9.4 years (SD = 9.5). The
length of time for caregiving ranged from nine months to 60
years. Gender of the care recipients was reported as 41% male
and 59% female. The average age of the care recipient was
65.5 (SD = 20.7) and 53% of survey respondents reported that
the care recipient was cognitively impaired. See Table 1.
The results of t-test indicate there was no statistically
significant difference in role overload, role captivity, and
other stressors based on gender (p>.05). However, female
caregivers showed slightly higher stress levels in each of
the three domains. Data analysis indicated that African American
caregivers and white caregivers showed a significant difference
in role overload (t=2.31, df=201, p<.05) and in other stressors
associated with the consequences of long term caregiving (t=2.94,
df=200, p<.01). It is apparent that white caregivers were
more significantly stressed by role overload and other stressors
than were African American caregivers. However, no significant
difference was found in role captivity between African American
caregivers and white caregivers (p>.05).
No significant difference in the subjective quality of life
was found based on gender (t = .072, p> .05) and race (t
= 1.00, p> .05) even though female and African American
caregivers rated slightly higher than male caregivers.
T-tests revealed no significant difference in all domains
of social life based on gender (p>.05). However, a significant
difference between white caregivers and African American caregivers
is apparent. African American caregivers are more satisfied
with contacts with friends and relatives (t=3.20, df=211,
p=.002), worship attendance and involvement in voluntary organizations
and clubs (t=3.50, df=208, p=.001), amount of time spent on
recreation and hobbies (t=3.32, df=208, p=.001), and time
spent relaxing (t=3.77, df=211, p=.000) than are white caregivers.
Data analysis indicated that African American caregivers were
more social than white caregivers under the same circumstances
Independent samples t-test showed that there was no statistically
significant difference in depression between males and females
(t=1.216, df=163, p>.05). Even though female caregivers
(mean=18.90, SD=12.75) were more depressed than males (mean=15.97,
SD=10.78), the difference was not significant. White caregivers
(mean=20.71, SD=13.61) were s ignificantly more depressed
than were African American caregivers (mean=15.99, SD=10.50),(t=2.448,
H1: Persons who use religious practices cope with caregiving
stress better than those who do not.
Religious and spiritual coping was negatively correlated with
role overload (r=-.153, p<.05), role captivity (r=-.169,
p<.05), other stressors (r=-.198, p<.05), caring role
preoccupation (r=-.203, p<.01), and depression (r=-.205,
p<.01). Data analysis indicated that caregivers who used
religious and spiritual coping were able to lower careburden
stresses, thus resulting in lower depression. See Table 2.
H2: Religious support received from congregations affects
decisions to institutionalize.
Caregiver's decision-making is positively correlated with
spiritual help-seeking (r=.266, p=.000), church-based emotional
support (r=.255, p=.000), church-based religious/spiritual
support (r=.226, p=.000), religious practice including worship
attendance, praying, reading the bible, watching televised
programs (r=.337, p=.000), daily spiritual experiences (r=.351,
p=.000), and religious/spiritual coping (r=.222, p=.000).
Data analysis indicated that religious beliefs have a significant
impact on a caregiver's decision of whether to care for the
loved one at home or to place the loved one in a nursing home.
When a caregiver's religious beliefs are strengthened by spiritual
help-seeking, emotional and spiritual/religious support provided
by church, daily spiritual experiences, and active religious
practices, they are likely to decide to care for their loved
ones at home rather than to place their loved ones in a nursing
home. See Table 3.
The present analysis assessed the extent to which religious
and spiritual support of caregivers impacted the caregiver's
decision to care for their loved one at home. The findings
of this study indicate that caregivers who used religious
and spiritual practices to cope with care burden were able
to lower care burden stresses, thus resulting in lower depression.
Church-based emotional support was negatively correlated with
role captivity, care burden stressors, overall care burden
and depression. Church-based emotional support showed a moderating
effect on depression. Accessibility to religious support services
was negatively correlated with role captivity, stressors,
overall care burden and depression. Caregivers who felt they
were able to obtain help from their pastors, ministers, and
people in their congregations in time of need were less stressed
and less depressed.
Data analysis indicated that religious practices had a significant
impact on a caregiver 's decision to care for a family member
at home or to place in a nursing home. When a caregiver's
religious practices were strengthened by spiritual help-seeking,
emotional and spiritual/religious support provided by religious
congregations, daily spiritual practices, and active religious
practices, they were likely to decide to care for their family
member at home rather than to place in a nursing home.
The present analysis is limited by the cross-sectional nature
of the sample, geographic region, and by the higher educational
status of sample participants. Use of a longitudinal research
design and inclusion of a more representative sample may increase
the generalizability of the study findings and the ability
to infer causal effects.
The findings of this study confirm the research hypothesis
that faith-based organizations can have a significant impact
upon long term care services. It is clear from the study findings
that programs and services provided by faith-based organizations
can delay institutionalization.
It is important to share this information with faith-based
organizations in supporting the need for faith-based organizations
to become involved in programs and services for caregivers
and older adults. Current support services should be assessed
to determine the feasibility of faith-based activities for
caregivers. Social workers can provide resource information
to faith-based organizations that can be easily distributed
in places of worship. Social workers can work with clergy
to develop interventions to assist faith-based organizations
in securing Federal funding for programs and services for
the elderly and disabled.
From the results of this study, it is clear that a caregiver's
spirituality influences decision-making on caregiving. With
less stress, burden, and role overload, the caregiver can
maintain the elderly or disabled person in a home environment.
Spiritual support from places of worship play a significant
role in the caregiver's ability to support the older adult
or the person with a diability at home. The question remains,
" How can we mobilize faith organizations to offer support
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