Abstract
Higher levels of spirituality and more positive mental health help-seeking attitudes were correlated with lower levels of self-reported caregiver burden in a survey of Asian-American caregivers.
Caregiving, or the act of caring for the necessary daily tasks of another person, is a responsibility that can affect caregivers socially, financially, physically, and emotionally (Adelman et al., 2014). The extent to which caregivers perceive these adverse effects is referred to as caregiver burden. Caregiver burden has been linked to significant mental health challenges, which can greatly affect caregivers’ daily functioning and their ability to continue providing care. It is estimated that between 26% and 57% of caregivers nationwide experience depressive symptoms and between 21% and 44% of caregivers experience anxiety symptoms (Loh et al., 2017; Parker Oliver et al., 2013; Sallim et al., 2015).
Among caregivers in the United States, Asian-Americans are more likely to provide intergenerational caregiving, or care for a family member who is at least one generation older than them (Lien & Huang, 2017). An AARP (2020) survey found that 52% of Asian-American caregivers provide support for a parent, compared with 43% of White and 33% of African-American caregivers. This same survey found that 61% of Asian-Americans felt obligated to take on their caregiving role, likely because of the Asian culture’s concept of filial piety, or the expectation to care for older family members (Do et al., 2015). Even as many Asians immigrate to the United States and acculturate to more Western cultural values, Asian-Americans still hold strong beliefs about the obligation to care for parents and the importance of filial responsibilities in regard to caregiving (Miyawaki, 2015). For example, third-generation Japanese-American caregivers with high acculturation levels also scored high on filial responsibility levels (Miyawaki, 2017). In addition, Liu et al. (2000) found that language, place of birth, and generation did not have a direct relation to filial piety among Chinese caregivers. This feeling of lack of choice over caregiving has been found to be a significant risk factor for caregiver burden (Adelman et al., 2014).
Although Asian-Americans report several positive outcomes of caregiving, such as bringing the family closer and respecting cultural expectations, they also report negative outcomes related to mental health. Pinquart and Sörensen (2005) found that Asian- American family caregivers showed higher levels of depression than White non-Hispanic caregivers. Moreover, Chinese-American family caregivers reported more feelings of shame and lack of support than European-American family caregivers (Han et al., 2019). In addition, Do et al. (2015) identified that Korean-American daughters and daughters-in-law providing nonprofessional care to parents reported poorer subjective health and higher pain while performing daily activities.
Asian-Americans have a complex history with respect to understanding mental health issues. Although not a homogeneous group, most Asian-Americans are influenced by collectivistic philosophies that emphasize interdependence and social harmony (Markus & Kitayama, 1991). These philosophies influence common Asian-American beliefs such as honoring the family’s name and discouraging the expression of emotion or weakness (Han & Pong, 2015). Any struggle with mental health, subsequently, is believed to be a negative reflection on the family, compromising the family’s status in the community (Han & Pong, 2015). These beliefs can lead Asian-Americans to harbor stigma toward mental health challenges and be reluctant to seek professional help. According to Okazaki et al. (2014), Asian-Americans have the lowest rates of mental health service use among ethnic groups regardless of gender, age, and location; however, this is not because they have lower rates of mental illness (Sue et al., 2012). This suggests that Asian-American caregivers who are experiencing feelings of burden may be less likely to seek out mental health services, thus potentially exacerbating their mental health challenges.
Given the concerning issue of many Asian- Americans experiencing caregiver burden and avoiding mental health services, it is important to identify protective factors against perceived burden and subsequent mental health decline for this unique population. One potential protective factor identified by the literature is spirituality. Spirituality is defined as the way in which people seek meaning and experience connectedness to the present, to others, or to a higher power (Puchalski et al., 2009, as cited in American Occupational Therapy Association [AOTA], 2014). It has been found to be correlated with reduced mental health symptoms and increased psychological well-being across cultures (Kim et al., 2011). In Asian-American communities, engagement in spiritual activity can act as a buffer against mental health issues (Ai et al., 2013). In Ai et al.’s (2013) study, attendance at public religious gatherings significantly predicted decreased negative mental health outcomes among Asian-Americans. This finding shows that spirituality in the form of attendance at religious events can positively affect mental health among Asian-Americans. With regard to caregiving, spirituality has been correlated with a reduction in perceived burden among African-American, White, and Hispanic-American caregivers (Heo & Koeske, 2013). However, more research is needed to confirm whether this relationship can also be generalized to Asian-Americans.
According to the updated sociocultural stress and coping model (Knight & Sayegh, 2010), cultural values of filial piety influence coping resources, such as social support and coping style, that subsequently influence caregivers’ appraisal of burden. Spirituality and mental health help-seeking attitudes are coping resources that are influenced by cultural values in Asian-American communities. This theoretical framework supports the investigation of spirituality and mental health help-seeking attitudes as they relate to perceived burden among Asian-American intergenerational caregivers. We hypothesized that favorable mental health help-seeking attitudes would be negatively correlated with caregiver burden. In addition, we hypothesized that spirituality would be negatively correlated with and a negative predictor of caregiver burden.
Method
This pilot study had a quantitative survey research design and received approval from the California State University Dominguez Hills institutional review board.
Participants
Research participants were Asian-American intergenerational caregivers, defined as those who currently or previously provided care to an Asian family member who is at least one generation older. People caring for a family member in their generation, such as a cousin or sibling, were excluded in order to understand the unique experience of caring for an elderly family member, which is expected of people in Asian culture. Participants must have cared for the elderly family member for at least 1 mo and within the past 3 yr. Caring for family members was operationally defined as providing routine assistance with at least one activity of daily living (ADL) or instrumental activity of daily living (IADL). Participants were recruited through convenience and snowball sampling from personal and social networks.
Measures
Five instruments validated across cultures were added sequentially to an online survey questionnaire to determine the relationship among caregiver burden, mental health help-seeking attitudes, and spirituality. The survey started with demographic questions to gather information, including gender, ethnicity, generation of caregiver, hours per week providing care, and number of domains of care, which consisted of the total number of ADL and IADL domains the participant provided assistance with. The domains of care were adapted from the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014) and included toileting; dressing; feeding or eating, including meal preparation; driving and community mobility; and financial management, among others.
Caregiver Burden Measure
The Burden Scale for Family Caregivers (BSFC) is a 28-item questionnaire used to measure caregiver burden on the basis of the caregiver’s experience of providing care and their ability to cope with the care situation (Gräßel, 2001; Grau et al., 2015). This instrument exhibits high reliability and validity for measuring caregiver burden in many populations, including Japanese caregivers (Fukahori et al., 2010; Grau et al., 2015).
Spirituality Measures
The Spirituality Scale (SS; Delaney, 2005) is a 23-item questionnaire that measures four dimensions of spirituality: self-discovery, relationships with others, eco-awareness, and higher power or universal intelligence. This holistic assessment measures a diverse perspective of human spirituality and has evidence of good to excellent reliability among a sample that included 15 religious denominations (Delaney, 2005).
The Expressions of Spirituality Inventory–Revised (ESI–R) Cognitive Orientation Toward Spirituality subscale (MacDonald, 2000) is a 6-item subscale used to measure beliefs and attitudes about the nature and significance of a person’s spirituality as it relates to their personal functioning. The ESI–R Religiousness subscale is a 6-item assessment that measures religious beliefs, behavior, and practice. Both subscales have demonstrated good reliability across individualistic and collectivist cultures, including Japanese, South Korean, and Indian cultures (MacDonald, 2000; MacDonald et al., 2015).
Attitudes Toward Mental Health Help-Seeking Measures
The Mental Help Seeking Attitudes Scale (MHSAS) is a 9-item semantic differential scale that measures a person’s opinion about seeking counseling from a mental health professional (Hammer, 2020). The MHSAS has strong psychometric properties, including internal consistency, temporal stability, internal validity, and convergent validity, with community-dwelling U.S. adult samples (Hammer et al., 2018).
The Self-Stigma of Seeking Psychological Help (SSOSH) is a 10-item Likert scale that measures people’s negative views toward receiving help from a mental health professional. The SSOSH demonstrates strong psychometric properties and similar univariate structure across American and Taiwanese samples (Vogel et al., 2006, 2013).
Procedure
The study was conducted through an online survey on the Google Form platform that was open to participants from March to June 2020. The survey took participants approximately 15 min to complete.
Data Analysis
IBM SPSS Statistics (Version 26) was used for data analysis. Descriptive statistics and frequency analysis were conducted to summarize participants’ demographic data. Pearson product–moment correlation coefficients with one-tailed significance were used to examine the relationships among perceived caregiver burden and demographic data, help-seeking attitudes, and spirituality. Multiple linear regression with stepwise analysis was performed to identify predictors for caregiver burden scores. An α level of .05 was used to determine significance.
Results
This pilot study included 101 participants. Their demographic and personal characteristics are shown in Table 1. A majority of the participants were female (86.1%), and almost half (46.5%) of all participants were Japanese American.
Demographic Characteristics of the Participants
Note. N = 101.
Through data analysis of demographic data and caregiver burden, various statistically significant correlations were determined. Statistically significant positive correlations were found between the BSFC and number of domains of care, number of elderly family members cared for, and number of hours per week providing care (Table 2).
Correlations of Measures With the BSFC
Note. BSFC = Burden Scale for Family Caregivers; ESI–R C = Expressions of Spirituality Inventory–Revised Cognitive Orientation Toward Spirituality subscale; ESI–R R = Expressions of Spirituality Inventory–Revised Religiousness subscale; HPC = hours per week providing care; MHSAS = Mental Help Seeking Attitudes Scale; ND = number of domains of care; NFM = number of elderly family members cared for; SS = Spirituality Scale; SSOSH = Self-Stigma of Seeking Psychological Help.
p < .05.
p < .01.
Data analysis examining the research hypotheses revealed a statistically significant negative low correlation between the BSFC and the MHSAS, r(99) = −.27, p < .01. Statistically significant negative low correlations were found between the BSFC and the SS, r(99) = −.28, p < .01, and the BSFC and ESI–R Religiousness subscale, r(99) = −.21, p < .05. Analysis also revealed a close to statistically significant correlation between the BSFC and the ESI–R Cognitive Orientation Toward Spirituality subscale, r(99) = −.17, p = .05.
To investigate our second hypothesis, further analysis was done to determine which of the significant correlators of the BSFC, which included spirituality, were in fact predictors of caregiver burden. Multiple linear regression with stepwise analysis revealed that number of domains of care and SS scores were statistically significant predictors of BSFC scores, β
Discussion
Asian-Americans are more likely to take on the role of caregiving for elderly family members (AARP, 2020) and to hold negative attitudes toward seeking mental health services (Han & Pong, 2015). Spirituality has been shown to help mitigate the impact of mental health challenges (Ai et al., 2013) and, more specifically, feelings of caregiver burden (Heo & Koeske, 2013). This pilot survey study investigated the relationship between spirituality and mental health help-seeking attitudes and caregiver burden among Asian-Americans who provide care for elderly family members.
Demographic variables such as number of hours per week providing care, number of elders being cared for, and number of domains of care provided were found to be significantly positively correlated with caregiver burden. The number of domains of care provided was also found to be a significant predictor of caregiver burden. These results confirm the existing literature that reports that higher number of hours spent caregiving and higher care needs of older adults are risk factors for subjective caregiver burden (Adelman et al., 2014).
Confirming our first hypothesis, we found a negative correlation between favorable mental health help-seeking attitudes and caregiver burden. This suggests that Asian-American caregivers with less favorable attitudes toward seeking help with mental health concerns may experience higher levels of perceived caregiver burden. Asian-Americans are among the least likely to use mental health services (Okazaki et al., 2014), and our results show that those with higher caregiver burden hold less favorable attitudes toward seeking mental health services. This is alarming because in addition to the cultural stigma regarding mental health, Asian-Americans experiencing high levels of caregiver burden are also currently less open to seeking mental health help.
Consistent with our second hypothesis, we found a negative correlation between caregiver burden and spirituality. This suggests that caregivers with higher levels of spirituality may experience lower levels of perceived caregiver burden. Moreover, spirituality was in fact found to be a predictor of caregiver burden, such that as spirituality increased, caregiver burden decreased. This supports previous literature that spirituality may provide protective factors for mental health (Ai et al., 2013). A possible explanation for this is that attendance at religious services is a mediator between spirituality and mental health (Heo & Koeske, 2013) because it affords opportunities for social support from people of similar beliefs (Ai et al., 2013).
Another factor that influenced this study was the onset of the global coronavirus disease 2019 (COVID-19) pandemic, which occurred during the process of data collection and introduced potential confounding variables because of its unexpected development and prolonged safety measures. Kent et al. (2020) deciphered the impact of COVID-19 on caregivers, noting increased financial burden, isolation, loneliness, and stress regarding management of older adults’ health while adhering to social distancing. Moreover, one study by Sheth et al. (2020) found an increase in time spent caregiving since the onset of the pandemic, as well as a statistically significant increase in stress and pain among a sample of caregivers in April–June 2020 compared with caregivers in January 2020. However, on the basis of this sample’s average time spent providing care (M = 4.95 yr) and the study design, which allowed participants to reflect on the entirety of their caregiving experience, it is possible that these results reflect pre–COVID-19 experiences.
Implications for Occupational Therapy Practice
These results have the following implications for occupational therapy practice: Occupational therapy practitioners should consider the unique attitudes among Asian-American cultures and the significance of intergenerational caregiving in Asian-American families. Occupational therapy practitioners should be aware of the potential correlation between favorable mental health help-seeking attitudes and lower caregiver burden among Asian-American intergenerational caregivers and offer culturally sensitive mental health resources. Because spirituality may be a protective factor against caregiver burden, occupational therapy practitioners implementing family-centered care can investigate spirituality practices with Asian-American intergenerational caregivers.
Limitations and Future Research
Some limitations of this pilot study exist with the sampling methods used to recruit participants. As a result of the unprecedented circumstance of a worldwide pandemic, community sites abruptly closed during the recruitment process, which resulted in a less rigorous sampling method. Other limitations of this study are that only 14 men were included, and the sample included a greater proportion of Japanese- and Filipino-Americans, which decreases the generalizability of the results to all Asian-Americans. Finally, it was assumed that all participants were equally computer literate and had access to the Internet to complete the survey, which may also have affected the overall generalizability of the results.
Because this was a pilot study, further research with a larger and more diverse sample of Asian-Americans would help determine whether differences exist between groups and could confirm this study’s findings. Future research investigating aspects of spirituality, such as social support or service attendance, that contribute to lower levels of caregiver burden is necessary to better guide interventions. In addition, the scope of this study was focused on mental health help-seeking attitudes; however, further qualitative studies can investigate the relationship between attitudes and mental health service usage to determine whether this mediates the negative correlation with caregiver burden. Moreover, research investigating the effectiveness of various forms of mental health support with Asian-Americans, such as formal support (e.g., mental health professionals) and nonformal support (e.g., community circles, relationships), would help guide occupational therapy practices and expand opportunities for them to access services. Last, future research focusing on caregiver burden among Asian-Americans providing care to family members with a specific condition would offer more tailored information on the unique experiences with that diagnosis.
Conclusion
With more than half of the Asian-American caregiver population providing care to elderly family members and given their vital role as partners in the delivery of health care services, there is an increased need to understand the factors that relate to feelings of caregiver burden. This study found that higher levels of spirituality and more positive mental health help-seeking attitudes were correlated with lower levels of self-reported caregiver burden among Asian-American caregivers. These results provide further evidence that spirituality is, in fact, a negative predictor of caregiver burden. Because Asian-Americans are less likely to seek formal mental health services (Okazaki et al., 2014), a need exists to promote positive mental health help-seeking attitudes and offer alternative methods for mental health promotion, such as spirituality. Thus, occupational therapy practitioners can incorporate these interventions when working with Asian-American older adults and their family caregivers to prevent caregiver burden and promote more holistic, culturally relevant, and family-centered care.