Skip to main content
NCBI home page
Wiley Open Access Collection logoLink to Wiley Open Access Collection
. 2025 Jun 3;82(3):2257–2270. doi: 10.1111/jan.17083

Model Predicting Positive Aspects of Caregiving Among Family Cares of Persons With Dementia: A Longitudinal Cohort Study

Doris Sau Fung Yu 1,✉, Sheung‐Tak Cheng 2, Kevin Shuang Zhou Chen 3
PMCID: PMC12907620  PMID: 40459071

ABSTRACT

Aim

Positive aspects of caregiving among family carers of persons living with dementia not only benefit the carers' health, but also enhance the quality and sustainability of invaluable informal care resources. To better inform the development of carer support intervention to optimise positive aspects of caregiving, this paper tested the integrative theoretical model based on stress coping and meaning‐making paradigms.

Design

Longitudinal exploratory study.

Methods

From January 2018 to August 2021, 390 Chinese family carers of persons living with dementia were recruited from the geriatric clinics in Hong Kong. The criterion variable was measured by the Positive Aspect of Caregiving Scale at baseline and 6 months thereafter. The predictors were measured using the Dementia Management Strategies Scale, the Caregiving Self‐Efficacy Scale, the Meaning‐Focused Coping Scale, the Medical Outcome Study Social Support Survey, the Duke University Religion Index, the Positive Affect Index and the Intrinsic Motivations to Care. Path analysis tested the hypothesised model.

Results

The carers aged 56.2 (SD = 12.2); about two‐thirds being female and adult‐child caregivers. The hypothesised model showed an unsatisfactory model fit. The model was optimised by modification index with consideration of the theoretical plausibility in making the changes (CFI = 0.971, RMSEA = 0.057, SRMR = 0.027). After adjusting the baseline PAC, the 6‐month PAC was predicted by self‐efficacy in controlling upsetting thoughts and obtaining respite as well as meaning‐focused coping. Various contextual factors strengthened the self‐efficacy and meaning‐focused coping, indirectly increasing PAC. Whereas carers' intrinsic motivation towards care and good dyadic relationships increased the carer's self‐efficacy in emotional regulation, social support and religiosity played indispensable roles to facilitate meaning‐focused coping.

Conclusion

PAC in dementia context is evolved from an integration of stress coping and existential meaning‐making paradigms. Enhancing emotion and role regulation as well as meaning‐focused coping are crucial to enhance the positive experience of the family carers.

Implications for the Profession and/or Patient Care

This project has generated a theory‐driven and evidence‐based predictive model to explain the manifestation of positive aspects of caregiving in dementia caregiving. The findings provide precise directions on how to empower family caregivers to create a fulfilling and meaningful caregiving adventure.

Impact

Substantial evidence indicates the role of positive aspects of caregiving in enhancing the carers' health outcomes in the context of dementia. However, inadequate theorization of this phenomenon delimits the momentum to develop proactive strategies to optimise such a positive caregiving experience. This longitudinal study indicated that positive aspects of caregiving are evolved from an integrative stress coping and existential meaning‐making paradigm. More specifically, a sense of self‐efficacy in emotional and role regulation as well as the use of meaning‐making coping predict a higher level of positive aspects of caregiving. A context, which is characterised by high religiosity, good intrinsic motivation of care and a good dyadic relationship, also favours the cultivation of this positive experience during life adversity. This study facilitates a paradigm shift in supporting family carers in a dementia context and advances the theorization of positive human experience in facing life adversity.

Reporting Method

The reporting method complies with the STROBE, stands for observational study.

Patient or Public Contribution

Family carers of persons with dementia actively shared their experience in family caregiving.

Keywords: dementia, existentialism, family caregiving, nursing care, positive aspects of caregiving, stress‐coping

Summary.

  • What does this paper contribute to the wider global clinical community
    • ○
      This paper demonstrated that positive aspects of caregiving are evolved from the integration of stress coping and existential paradigms.
    • ○
      The generated evidence indicates that enhancing emotional and role regulation and empowering meaning making are important strategies to promote positive aspects of caregiving in a dementia care context.
    • ○
      The context which is featured by high levels of social support, good dyadic relationships, high religiosity, and motivation to care favours the cultivation of positive caregiving experiences in a dementia caregiving context.

1. Introduction

Global prevalence of dementia casts not only economic and social burdens but also overwhelming demands on family carers of persons living with dementia (PLwD). To ameliorate the dementia caregiving burden, previous efforts in increasing coping resources and dealing with negative experiences demonstrated time‐limited effectiveness (Cheng and Zhang 2020). Positive aspects of caregiving (PAC), on the other hand, is found to positively influence the carers' health and their role fulfilment (Yu et al. 2018). Yet, proactive strategies to promote PAC have gained much less momentum in both theoretical and empirical development. One of the major reasons may be related to the inadequate conceptualization and theorization of this phenomenon. To address this research gap, an integrative theoretical model to predict the evolvement of PAC is imperative to guide the intervention development.

2. Background

Dementia is a progressively degenerating syndrome characterised by multiple functional deficits, leading to daily activity dependence of persons living with this condition (PLwD). Although family caregiving in a dementia context is physically and emotionally burdensome, ample studies have documented the coexistence of positive experience among family carers. The pervasive recognition of PAC reinforces the individual variations in responding to dementia caregiving demands (Cho et al. 2016; Lloyd et al. 2016; Quinn and Toms 2018). Efforts have been made to understand the emergence of PAC, yet they have failed to reach a consensus on the underlying mediating mechanism. Lawton et al. (1991) hypothesised a two‐factor model of caregiving appraisal to predict PAC in dementia caregiving, in which the two primary factors, including the objective characteristics of the caregiving situation and the caregiver's subjective appraisal, interact to shape the caregiving experience. Yet, the empirical testing showed that neither the actual stressors nor appraisal of coping resources predicted its evolvement. While other studies suggested that PAC can be accounted for by various factors relating to stress coping and cognitive psychology, the overall explanatory power was still limited (Cheng et al. 2012; Hodge and Sun 2012; Pendergrass et al. 2019). Further empirical investigation to address the existing fragmented understanding of the evolvement of PAC awaits adequate theoretical conceptualization.

Based on scoping reviews, which identified PAC as comprising four key domains including sense of accomplishment and gratification, attainment of mutuality in a dyadic relationship, enhanced family dynamic and relationship, and attainment of personal growth and purpose in life (Lloyd et al. 2016; Yu et al. 2018), Yu et al. (2021) developed an integrative theoretical model based on the stress coping and the existential meaning‐making paradigm to predict the evolvement of this positive psychological construct. Whereas the stress coping paradigm serves to explain the first domain of PAC, the meaning‐making paradigm rationalises the other three domains in a dementia caregiving context (Figure 1).

FIGURE 1.

FIGURE 1

Open in a new tab

The hypothesized model predicting positive aspects of caregiving (PAC) at 6 months.

2.1. Evolvement of PAC From the Stress Coping Paradigm

For the stress coping paradigm, the Transactional Model of Stress, which describes the relationship between stress coping and emotional response (Lazarus and Folkman 1984), explains the evolvement of the sense of accomplishment and gratification in PAC (Lazarus and Folkman 1984). Specifically, the Transactional Model posits that the perceived caregiving stressors trigger a cognitive process to firstly appraise the threats (i.e., primary appraisal) and then the sufficiency of one's resources to cope (i.e., secondary appraisal). PAC concerning personal accomplishment and gratification are understood as the positive emotions generated from caregivers' subjective appraisal of a successful caregiving role fulfilment (Peacock et al. 2010). As such, active dementia management strategies are postulated to play a fundamental part in leading to PAC via inducing a sense of role fulfilment among the carers. Previous studies, indeed, found that a higher level of PAC among the carers of PLwD might be attributed to proactive strategies to manage symptoms and prevent cognitive declines of the care recipients (Kramer 1997; Lim et al. 2011; Liu et al. 2012; Netto et al. 2009). It should be noted that, however, such effects of proactive disease management should not be given equivalent weight as coping's ‘familiar’ role in carers' burden alleviation. Rather, it is more likely the perceived performance success and self‐affirmation arising from active dementia management strategies that contribute to PAC. Previous studies which identified the lack of association between PAC and objective stressors lend support to this argument (Cheng et al. 2013; Lawton et al. 1991; Lim et al. 2011; Liu et al. 2012). On the other hand, these studies consistently identified the positive association between self‐efficacy and PAC (Cheng et al. 2013; Lawton et al. 1991; Lim et al. 2011; Liu et al. 2012). Self‐efficacy is a psychological construct that reflects people's perception of their own abilities to successfully manage a given situation (Bandura 1977). It is thus hypothesized that carers' self‐efficacy might mediate the positive relationship between active dementia management strategies and PAC. Apart from self‐affirmation, self‐efficacy beliefs derived from successful coping, in fact, vary by contextual factors (Bandura 1997). Social support, featuring mutual encouragement, continuous inspiration and peer affirmation, is consistently found to relate to an improved PAC (Butcher and Buckwalter 2002; Kramer 1997; Peacock et al. 2010; Quinn et al. 2012b). It is possible that such emotional and social interactional support potentially moderates the relationship between active dementia management strategies and self‐efficacy, which thereby intensifies PAC. To sum up, under the stress coping paradigm, PAC would result from the process in which the carers develop a sense of self‐efficacy from using active strategies to manage dementia, and a context, which is characterised by a high level of emotional and social interactional support, would further enhance the evolvement of PAC from active disease coping (Figure 1).

2.2. Evolvement of PAC From the Existential Meaning‐Making Paradigm

The existential meaning‐making paradigm is postulated to explain the evolvement of the other three domains of PAC, including attaining a sense of mutuality in a dyadic relationship with the PLwD, increasing family cohesiveness and functionality, and developing a sense of personal growth. The evolvement of these PAC domains shares the common characteristics that require family caregivers to reframe the situation using a new perspective.

For a sense of mutuality, the progressive increase in cognitive and neuro‐psychiatric symptoms of PLwD would continuously deprive the reciprocal and engaging interactions within the care dyad. This domain of PAC, therefore, can only be achieved if the family cares direct the attention to the subtle positive changes in the functional or health condition of PwD and interpret such changes as an expression of love, appreciation and affection from the care recipients (Narayan et al. 2001; Netto et al. 2009; Peacock et al. 2010). Similarly, another PAC domain about increasing family cohesiveness and functionality requires carers to redefine the challenging caregiving experiences as an opportunity for family members to support each other and work towards a common goal. As for the PAC domain of enhancing personal growth and achieving purpose in life, such experience emerges when carers revisit one's life philosophies and priorities during the stressful encounter. They may anchor more meanings to human relationships rather than material possessions (Cheng et al. 2016; Narayan et al. 2001; Netto et al. 2009; Peacock et al. 2010), reframing dementia caregiving with a more altruistic value system (Netto et al. 2009), or regarding the stressful encounter as offering a platform to strengthen the faith and spiritual growth (Netto et al. 2009; Sanders 2005).

The evolvement of these three domains of PAC, in fact, shares the same feature that requires the carers to adopt new perspectives in interpreting the challenging caregiving situation. In other words, the carers attempt to assign new meanings to the caregiving hardship in a way to generate positive feelings. Such ‘reframing’ efforts can be well explained by the existential meaning‐making paradigm. The meaning‐making model is a psychological approach that deals with existential concerns by identifying two levels of meaning: one is the global meaning which refers to one's general beliefs towards the world and the other is the situational meaning assigned to specific events (George and Park 2016; Park 2013). Any discrepancy between global meaning and the initially appraised situational meaning would give rise to existential distress, which may be resolved by meaning‐making (Park 2013). Meaning‐making is a dynamic process which involves appraisal and reappraisal of a given situation using different perspectives. This may also involve revisiting one's global meaning to better align with the situational meaning. Despite little evidence supporting the contribution of meaning‐focused coping to PAC, a few qualitative studies suggested that similar appraised‐based coping strategies cast impacts on PAC (Duggleby et al. 2009; Lindauer and Harvath 2015; Lloyd et al. 2016; Shim et al. 2012). Among these strategies, accepting the diagnosis of dementia and the resultant caregiving situations has been identified as a prerequisite for promoting PAC (Cheng et al. 2016; Duggleby et al. 2009; Lindauer and Harvath 2015; Shim et al. 2012). Achieving such a psycho‐cognitive state increased the likelihood that the carers adopt positive refocusing techniques to direct the attention to pleasant aspects of their encounters in the caregiving process. The carers also reported adopting new perspectives to reinterpret how dementia caregiving shaped their relationship with others (PwD and family) as well as contributed to personal and spiritual growth. All these findings support the relevance of the existential meaning‐making paradigm in explaining the evolvement of PAC in a dementia caregiving context.

Substantial research has identified important contextual factors that shaped the use of meaning‐focused coping in the stressful context of caregiving. First, a systematic review shows that the motivation of the caregivers in providing care was a significant predictor for their greater use of meaning‐focused coping (Quinn et al. 2010). It is further specified that it was the intrinsic motivation, as opposed to extrinsic motivation (i.e., externally imposed obligation), that made the difference (Quinn et al. 2012b). Second, the relationship quality within the care dyads is another crucial factor. This relationship spans from the premorbid period to the time after the onset of dementia (Motenko 1989; Quinn et al. 2012b; Shim et al. 2013; Walker et al. 1990), and is explained by the strong emotional attachment in the dyadic relationship. Such attachment renders family carers more inclined to view caregiving as a ‘soul‐searching’ experience, and thus increases the chance that they will reframe it in a positive schema (Motenko 1989; Quinn et al. 2012b; Shim et al. 2013; Walker et al. 1990). Lastly, reframing the challenges in caregiving as spiritual experiences also positively influences the use of meaning‐focused coping. This stems from the fact that persons with higher religiosity are more likely to believe that life is praiseworthy of commitment and full of purposes and contentment (Flint et al. 1983; Tomer and Eliason 2000). Other studies complemented that positive appraisals of caregiving were more profound among family carers who believed in religion than those who do not (Heo 2014).

In conclusion, referring to the nature of PAC and the current state‐of‐art, PAC was hypothesized to have evolved from an integration of the stress coping paradigm and the existential meaning‐making paradigm.

3. The Study

The overall aim of this paper was to test this integrative theoretical model (Figure 1) which involved the following hypothesized relationships while controlling for the baseline PAC level:

  1. Increased carers' self‐efficacy mediated the positive effects of active dementia management strategies on the 6‐month PAC.

  2. The relationship between active dementia management strategies and self‐efficacy was stronger with a higher level of social support.

  3. The indirect effect of active dementia management strategies on the 6‐month PAC (at 6 months) via self‐efficacy is moderated by social support.

  4. Meaning‐focused coping is positively associated with the 6‐month PAC (at 6 months).

  5. Higher levels of religiosity, positive dyadic relationships and intrinsic motivation are positively associated with better meaning‐focused coping.

4. Methods

4.1. Design

This longitudinal exploratory study was reported in a study protocol (Yu et al. 2021) and was approved by the relevant Clinical Ethics Research Committee in Hong Kong (UW‐19852).

4.2. Study Setting and Sample

Family carers of PLwD were recruited from the geriatric clinics operated by a regional hospital in Hong Kong. The inclusion criteria were: (i) family caregiver who took care of a Chinese PLwD for at least 6 months; (ii) living in the same household as the PLwD, with caregiving time greater than 4 h a day; (iii) able to speak Chinese and (iv) consent to participate. Primary carers of persons with other chronic diseases were excluded. Power analysis was used to estimate the sample size based on the Root Mean Square Error of Approximation (RMSEA) approach (MacCallum et al. 1996) to test the hypothesised path model (see Figure 1). The method took into consideration the total number of endogenous (n = 5) and exogenous (n = 7; included the multiplicative interaction effect of social support, and active dementia management strategies on self‐efficacy) variables as well as the parameters (n = 40) to be estimated. Using SAS syntax, a sample size of 370 was required to reject the null hypothesis of a good data‐model fit at 80% power and 5% level of significance with a 10% attrition rate (MacCallum et al. 1996; Schermelleh‐Engel et al. 2003).

4.3. Data Collection Procedure and Study Instruments

After obtaining the informed consent of the eligible family carers, the research assistant collected the carers' demographic details and caregiving history. The clinical history of dementia of their care recipient was collected by hospital record review. The research assistant interviewed the carer participants using the following validated questionnaires to capture the model constructs in the geriatric clinics through face‐to‐face interview. The 6‐month evaluation on PAC was measured by telephone interview.

4.3.1. Positive Aspects of Caregiving Instrument (PAC; Chinese Version)

The 11‐item PAC, which measured the subconstructs of self‐affirmation and outlook in life, was used to measure the positive aspect of caregiving (Lou et al. 2015). By using a 5‐point Likert scale for each item, a higher total score indicated better PAC. Cronbach's alpha was 0.89 among Chinese family carers of PLwD, with good criterion and structural validity (Lou et al. 2015).

4.3.2. Dementia Management Strategies Scale—Active Management Subscale (DMSS; Chinese Version)

This 12‐item DMSS subscale measured the extent family carers used engaging, stimulating, and adaptive strategies to manage dementia (Chien 2015). By using a 5‐point Likert scale for each item to measure the frequency of using these strategies, a higher score indicated more active disease management. The Cronbach's alpha of DMSS was 0.88 when used in Chinese dementia carers, with good convergent validity when compared with the dementia symptom severity (Chien 2015).

4.3.3. Caregiving Self‐Efficacy Scale (CSES; Chinese Version)

The 15‐item CSES measured the carers' self‐efficacy with three sub‐scales each particularly focused on (1) managing disturbing behaviour, (2) controlling upsetting thoughts, and (3) obtaining respite in caring for PLwD. These three sub‐scales were independently used in the path analysis. Each item was measured on a 0–100 rating scale, with a higher average score representing higher caregiving self‐efficacy. Cronbach's alphas were 0.89–0.91 for the various subscales, and good factorial validity was identified (Au et al. 2009).

4.3.4. Medical Outcomes Study Social Support Survey (MOS‐SSS‐C; Chinese Version)

The 8‐item emotional subscale and 4‐item social interaction subscale were used to measure the perceived availability of emotional and social interactional support, respectively (Yu et al. 2004). By using a 5‐point Likert scale for each item, a higher score represented better perceived social support. Cronbach's alphas for these subscales were 0.95, with good criterion‐related and construct validity in the Chinese population (Yu et al. 2004).

4.3.5. Meaning‐Focused Coping Scale (MFCS; Chinese Version)

The 26‐item MFCS was used to measure meaning‐focused coping, covering changes in situational and global beliefs, redefining the goal, acceptance, reappraisal strategies including meaning‐making and heuristic thinking, positive coping including long‐term prevention strategies and rational use of resources. By using a 7‐point Likert scale, a higher total score indicated more meaning‐focused coping. Cronbach's alpha was 0.89 in the Chinese population, and the MFCS was construct valid when compared with various psychological constructs (Gan et al. 2013).

4.3.6. Positive Affect Index (PAI; Chinese Version)

The 10‐item PAI was used to measure the relationship quality of the family carers of persons with dementia from the pre‐morbid to current situation (Bengtson et al. 1982). By rating the feelings of understanding, trust, respect, fairness and affection with the care recipient on a 6‐point Likert scale, a higher score indicated a better quality of relationship. Cronbach's alpha ranged from 0.76 to 0.88, with good convergent validity when compared with motivation and burden of the caregiving (Quinn et al. 2012a, 2012b).

4.3.7. Duke University Religion Index (DURI; Chinese Version)

The 5‐item DURI assessed organizational and non‐organizational religious activity and intrinsic religiosity. Measured on a 5‐point Likert scale, a higher score indicated a higher level of religiosity. Cronbach's alpha was 0.90. The scale converged with measures of well‐being (Chen et al. 2014).

4.3.8. Intrinsic Motivations to Care Scale (INMECS; Chinese Version)

The 7‐item INMECS measured the intrinsic motivations of family carers to care for the PLwD (Lyonette and Yardley 2003). Rated on a 5‐point Likert scale, a higher score represented greater intrinsic motivation to care (Lyonette and Yardley 2003). Cronbach's alpha was 0.81, and the validity of the INMECS was evident by its convergency with measures of role maladjustment and caregiving competence. The Chinese version was developed by the research team using the Brislin's method of translation (Jones et al. 2001). A panel of six experts in dementia and family caregiving, including nurse practitioners, geriatricians and academicians in nursing and social science, were invited to comment on its content validity (content validity index: 0.90). The Cronbach's alpha of the Chinese version in this study is 0.92.

4.4. Statistical Analysis

Data were summarised using appropriate descriptive statistics. Normality of the data was examined for skewness, kurtosis, and abnormal probability. Little's Missing Completely at Random Test (MCAR) was used for the missing values analysis (Little 1988). Regression methods were used to impute missing data.

Statistical analyses were performed using Stata Release 17 (StataCorp LLC, College Station, TX) in conjunction with R (version 4.2.1). We computed Pearson's correlations among all variables included in the theoretical model. Only variables that were significantly associated with PAC were included in the final analyses.

The hypothesized model predicting PAC in 6 months was examined by means of path analysis, using the ‘lavaan’ package in R (Rosseel 2012). Path analysis modelling was computed using maximum likelihood (ML) as the estimator. The moderating role of social support was indicated by the significance of the path coefficient that links the multiplicative interaction terms to self‐efficacy subscales. The moderated mediation effects of self‐efficacy were assessed by the significance and strength of the conditional indirect effect of active dementia management strategies on PAC at 6 months. Such indirect effects were dependent on the levels of social support, which was also known as the conditional indirect effect, if the moderated mediation effect holds. The goodness of fit of the models was evaluated using the following criteria: comparative fit index (CFI) ≥ 0.90, root mean square error of approximation (RMSEA) ≤ 0.08, and standardised root mean square residual (SRMR) ≤ 0.06 (Hu and Bentler 1998; Kline 2023; Schermelleh‐Engel et al. 2003). Model refinement was realised by adding or eliminating paths based on the modification indices together with theoretical consideration. In addition, we conducted a bootstrapping method using 5000 bootstrap samples (Preacher and Hayes 2008) to estimate the indirect effects of mediations in the hypothesized model. Since we used bootstrap estimates, 95% confidence intervals and attribute results were reported as significant when the interval did not overlap with zero. The statistical significance of all analyses was established at a two‐sided p < 0.05.

5. Results

From January 2018 to August 2021, a total of 498 family carers of PLwD were screened for eligibility and 390 were recruited. Demographic characteristics of the carers and their care recipients were shown in Table 1. The mean age of carers was 56.2 (SD = 12.2). The majority of them were female (75%) and adult child carers (74%). The care recipients aged 84.5 (SD = 7.3), and about 60% of them were diagnosed with moderate or severe dementia. The data meet the assumption of normality. Results on bivariate correlations (Table 2) indicated that, as hypothesized, PAC at 6 months was positively correlated with all other model constructs, including self‐efficacy in the three sub‐domains (i.e., SE‐DB, SE‐CU and SE‐OR), active dementia management strategies (DMSS), social support (MOS‐SSS‐C), meaning‐focused coping (MFCS), religiosity (DURI), intrinsic motivation to care (INMECS) and a good dyadic relationship (PAI). In addition, family carers with higher intrinsic motivation to care, better dyadic relationships, and stronger religiosity were significantly correlated with more frequent use of meaning‐focused coping. However, while intrinsic motivation was significantly correlated with a good dyadic relationship, there were no such relationships with that of religiosity.

TABLE 1.

Socio‐demographics profile of caregivers and PwD (n = 390).

Characteristics of caregivers Mean (SD) a /n (%) b
Caregiver's age a 56.2 (12.2)
Caregiver's gender b
Male 91 (22.6)
Female 312 (77.4)
Caregiver's relationship with PWD b
Spouse 56 (13.9)
Children 298 (73.9)
Grandchildren 14 (3.5)
Son‐in law or daughter‐in‐law 24 (6.0)
Others 11 (2.7)
Years of caregiving b
1–3 163 (40.4)
3–6 104 (25.8)
6–9 44 (10.9)
> 9 92 (22.8)
Hours spent with PWD daily a 9.0 (7.3), (1–24) h
Marital status b
Single 129 (32.1)
Married 240 (59.7)
Divorced 25 (6.2)
Widowed 8 (2.0)
Education b
Primary education or below 64 (15.9)
Secondary education 184 (45.7)
Tertiary education or above 155 (38.5)
Type of employment b
Full‐time employment 152 (37.8)
Part‐time employment 47 (11.7)
Unemployed 21 (5.2)
Housework 60 (14.9)
Retired 113 (28.1)
Student or others 9 (2.2)
Religious belief b
Christianity 93 (23.2)
Catholicism 20 (5.0)
Buddhism 45 (11.2)
Taoism or others 19 (4.7)
Atheism 224 (55.6)
Characteristics or PWD
PWD's age a 84.5 (7.3), 61–104 years
PWD's gender b
Male 104 (25.8)
Female 299 (74.2)
Stages of Alzheimer's disease b
Early stage 92 (22.8)
Middle stage 170 (42.2)
Late stage 75 (18.6)
Unknown stage 66 (16.4)
Years of diagnosis a 4.3 (3.3), 0.5–20 years
Type of service utilization b
Day centre 67 (16.7)
Day care centre 26 (6.5)
Integrated home care 19 (4.7)
Care support 5 (1.2)
Others 41 (10.2)
None 243 (60.6)
Open in a new tab
a

Mean (SD).

b

Frequency (%).

TABLE 2.

Correlational matrix (highlighted with significant p values).

1. PAC T0 2. PAC T1 3. Self‐efficacy (controlling disturbing behaviours) 4. Self‐efficacy (controlling upsetting thoughts) 5. Self‐efficacy (obtaining respite) 6. Active dementia management strategies 7. Social Support 8. Meaning‐focused coping 9. Dyadic relationships 10. Intrinsic motivation to care
1. PAC T0 1.000
2. PAC T1 0.541*** 1.000
3. SE_DB 0.280*** 0.254*** 1.000
4. SE_CU 0.259*** 0.311*** 0.613*** 1.000
5. SE_OR 0.124* 0.262*** 0.211*** 0.318*** 1.000
6. DMSS 0.327*** 0.262*** 0.248*** 0.170*** 0.073 1.000
7. MOS 0.332*** 0.307*** 0.205*** 0.248*** 0.441*** 0.184*** 1.000
8. MFCS 0.523*** 0.366*** 0.164*** 0.073 0.005 0.286*** 0.378*** 1.000
9. PAI 0.405*** 0.315*** 0.427*** 0.398*** 0.223*** 0.276*** 0.395*** 0.280*** 1.000
10. INMECS 0.410*** 0.319*** 0.376*** 0.297*** 0.114* 0.242*** 0.262*** 0.224*** 0.456*** 1.000
11. DURI 0.103* 0.203*** 0.098* 0.106* 0.033 0.105* 0.135** 0.297*** 0.032 0.075
Open in a new tab

Abbreviations: DMSS, active dementia management strategies; DURI, religiosity; INMECS, intrinsic motivation; MFCS, meaning‐focused coping; MOS, social support; PAC, positive aspects of caregiving at T1 (6 months); PAC_T0, positive aspects of caregiving at baseline; PAI, good dyadic relationships; SE‐CU, self‐efficacy in controlling upsetting thoughts; SE‐DB, self‐efficacy in managing disturbing behaviour; SE‐OR, self‐efficacy in obtaining respite.

*

p < 0.05.

**

p < 0.01.

***

p < 0.001.

The hypothesized theoretical model showed an unsatisfactory model fit (CFI = 0.725, RMSEA = 0.147 and SRMR = 0.091). The model was, therefore, optimised with reference to the modification indices with a threshold value of 10 or above, and the theoretical plausibility of all the suggested paths was considered (Figure 2). The CFI is 0.971, RMSEA is 0.057 and SRMR is 0.027 after adjusting for PAC at baseline, indicating data‐model fit. Table 3 showed the bootstrap parameter estimates of the model pathways.

FIGURE 2.

FIGURE 2

Open in a new tab

The optimised model predicting 6‐month positive aspect of caregiving based on path analysis. Fit statistics: Comparative Fit Index = 0.971, root mean square error of approximation = 0.058, standardised root mean square residual = 0.028; standardised beta coefficient. *p < 0.05; **p < 0.01; ***p < 0.00; T0 = baseline; T1 = 6‐month post‐test. The coefficient of the moderated mediation was shown in the parenthesis.

TABLE 3.

Bootstrap parameter estimates of model pathways predicting PAC (N = 390).

Model pathway Standardised coefficient, β (SE) Bias‐correlated 95% CI
Stress coping paradigm
Direct effect

  1. Self‐efficacy‐controlling disturbing behaviour ➝ PAC_T1

 0.006 (0.022) −0.037, 0.048
  • ii

    Self‐efficacy‐controlling upsetting thought ➝ PAC_T1

 0.046* (0.021) 0.008, 0.095
  • iii

    Self‐efficacy‐ obtaining respite ➝ PAC_T1

 0.047** (0.014) 0.016, 0.078
Indirect effect

  1. Active dementia management strategies ➝ self‐efficacy controlling upsetting thoughts

 −1.234 (0.793) −2.77, 0.337
Active dementia management strategies ➝ self‐efficacy controlling upsetting thoughts ➝ PAC_T1 −0.053 (0.045) −0.151, 0.038
  • ii

    Active dementia management strategies ➝ self‐efficacy in obtaining respite

 −0.689 (1.059) −2.75, 1.401
Active dementia management strategies ➝ self‐efficacy in obtaining respite ➝ PAC_T1 −0.022 (0.051) −0.122, 0.081
  • iii

    Intrinsic motivation to care ➝ self‐efficacy controlling upsetting thoughts

 0.955* (0.355) 0.395, 1.802
Intrinsic motivation to care ➝ self‐efficacy controlling upsetting thoughts ➝ PAC_T1 0.439*** (0.027) 0.387, 0.491
  • iv

    Dyadic relationship ➝ self‐efficacy controlling upsetting thoughts

 0.510** (0.174) 0.205, 0.897
Dyadic relationship ➝ self‐efficacy control upsetting thoughts ➝ PAC_T1 0.023* (0.014) 0.010, 0.037
  • v

    Active dementia management strategies × Social Support ➝ self‐efficacy control upsetting thought

 0.021 (0.011) −0.001, 0.041
Active dementia management strategies × Social Support ➝ self‐efficacy control upsetting thought ➝ PAC_T1 0.001 (0.001) −0.001, 0.003
  • vi

    Active dementia management strategies × Social Support ➝ self‐efficacy in obtaining respite

 0.009 (0.014) −0.019, 0.036
Active dementia management strategies × Social Support ➝ self‐efficacy in obtaining respite ➝ PAC_T1 0.001 (0.001) −0.001, 0.002
Other parameters

  1. Intrinsic motivation to care ➝ Self‐efficacy control disturbing behaviours

 1.723*** (0.362) 0.975, 2.485
  • ii

    Dyadic relationship ➝ Self‐efficacy control disturbing behaviours

 0.584** (0.19) 0.211, 0.945
  • iii

    Active dementia management strategies ➝ Self‐efficacy in control disturbing behaviours

 −1.387 (0.718) −2.782, 0.034
  • iv

    Social support ➝ Self‐efficacy in control disturbing behaviours

 −0.851 (0.357) −1.547, −0.145
  • v

    Active dementia management strategies × Social support ➝ Self‐efficacy in controlling disturbing behaviour

 0.027** (0.010) 0.008, 0.046
Existential meaning‐making paradigm
Direct effect

  1. Meaning‐focused coping ➝ PAC_T1

 0.025* (0.015) 0.009, 0.064
  • ii

    PAC_T0 ➝ PAC_T1

 0.368*** (0.061) 0.232, 0.495
Indirect effect

  1. PAC_T0 ➝ Meaning‐focused coping

 1.493*** (0.183) 1.135, 1.841
PAC_T0 ➝ Meaning‐focused coping ➝ PAC_T1 0.037* (0.023) 0.015, 0.059
  • ii

    Religiosity ➝ Meaning‐focused coping

 0.843*** (0.179) 0.516, 1.167
Religiosity ➝ Meaning‐focused coping ➝PAC_T1 0.021* (0.014) 0.008, 0.034
  • iii

    Social Support ➝ Meaning‐focused coping

 0.340*** (0.096) 0.157, 0.53
Social support ➝ Meaning‐focused coping ➝ PAC_T1 0.009* (0.006) 0.003, 0.014
Other parameters

  1. Intrinsic motivation to care ➝ meaning‐focused coping

 −0.296 (0.483) −1.239, 0.683
  • ii

    Dyadic relationship ➝ meaning‐focused coping

 0.072 (0.183) −0.344, 0.473
Open in a new tab

Note: 95% CIs for bootstrap distributions are defined using the values that mark the upper and lower 2.5% of each distribution.

Abbreviations: CI, confidence interval; PAC_T0, positive aspects of caregiving at baseline; PAC_T1, positive aspects of caregiving at 6 months; SE, standard error.

*

p < 0.05.

**

p < 0.01.

***

p < 0.001.

For the stress coping paradigm, self‐efficacy in controlling upsetting thoughts (β = 0.046, SE = 0.021, 95% CI 0.008–0.095) and obtaining respite (β = 0.047, SE = 0.014, 95% CI = 0.016–0.078), but not controlling disturbing behaviours, were found to significantly predict PAC at 6 months. However, these self‐efficacy subconstructs did not mediate the effects of active dementia management strategies (DMSS) to PAC. Social support did not have any significant moderated mediating effect to influence PAC either.

As for the existential paradigm, meaning‐focus coping significantly predicted more PAC at 6 months (β = 0.025, SE = 0.015, 95% CI 0.009–0.064). Among the other three proposed factors in this paradigm, only higher religiosity (DURI) was strongly related to a higher level of meaning‐focus coping (β = 0.843, SE = 0.179, 95% CI =0.516–1.167), but its indirect effect on PAC was statistically significant (β = 0.021, SE = 0.014, 95% CI = −0.008 to 0.034). The dyadic relationship quality (PAI) and intrinsic motivation to care (INMECS) were not related to meaning‐focused coping. Instead, these two contextual factors were found to be related to a higher level of self‐efficacy in controlling upsetting thoughts (β PAI = 0.510, SE = 0.174, 95% CI 0.205–0.897; β INMECS = 0.955, SE = 0.355, 95% CI 0.395–1.802) in the stress coping paradigm, and their effects were mediated through SE‐CUT to positively predict PAC (β PAI = 0.023, SE = 0.014, 95% CI 0.010–0.037; β INMECS = 0.439, SE = 0.027, 95% CI 0.387–0.491). On the other hand, social support also displays its role in the existential paradigm by positively relating to meaning‐focused coping (β = 0.340, SE = 0.096, 95% CI 0.157–0.53) with a significant indirect effect on PAC (β = 0.009, SE = 0.006, 95% CI = −0.003 to 0.014). Religiosity, social support, intrinsic motivation to care and relationship quality with PLwD are the contextual factors which strengthen the conditions (i.e., self‐efficacy in emotional and role regulation as well as meaning‐focused coping) required to increase PAC in a dementia care context. By the way, attention has to be given to the role of baseline PAC which significantly predicted meaning‐focused coping and has a significant indirect effect on PAC at 6 months. This implies that PAC would keep on evolving through increasing the carer's meaning‐focused coping.

6. Discussion

The role demand of dementia caregiving on family carers is progressively demanding, stressful, and frustrating along the disease course. Optimising their commitment and enthusiasm in providing the informal care to PLwD requires a care support model with sustainable effects. Over the past decade, the longer‐term benefits of PAC on caregiving effectiveness have received growing attention. Elucidating the underlying theoretical mechanism to explain the evolvement of PAC in a dementia context would provide important insights to inform the development of the corresponding carer's support intervention. This is the first longitudinal study to identify an integrated theoretical paradigm comprising stress coping and existential meaning‐making in explaining the evolvement of PAC. The findings point to the role of self‐efficacy in emotional and role regulation, as well as meaning‐focused coping, in predicting a higher level of PAC. As these predictive conditions could be strengthened in a context characterised by stronger religiosity and intrinsic motivation to care, as well as good dyadic relationship and social support, carers not having such personal or dyadic features may deserve additional attention when PAC comes to concern.

For the constructs in the stress coping paradigm, our findings echo with an integrative review of 21 studies which indicated PAC was positively associated with active dementia management strategies, social support, and self‐efficacy (Yu et al. 2018). However, when the existential meaning‐making paradigm was integrated to predict PAC, only self‐efficacy in controlling upsetting thoughts and obtaining respite significantly predicted PAC. The effect of self‐efficacy in controlling disturbing behaviours, however, was not significant. The findings may imply PAC may be more concerned with the social dynamic within the dyad rather than the skillful dementia coping. Cheng et al. (2013), indeed, found that carers with stronger self‐efficacy in controlling upsetting thoughts reported a higher level of PAC when they were confronted with neuro‐psychiatric symptoms. This may imply better emotional regulation would be associated with more perceived performance success in caregiving and thereby contribute to a higher level of self‐affirmation or gratification. By the way, emotional regulation involves proactive use of cognitive reappraisal to reframe an emotion‐eliciting situation into a more positive scenario (Gross 2015). Previous studies found such an adaptive strategy would result in better interpersonal functioning and psychological well‐being (Cutuli 2014; Denson et al. 2012) which, in turn, creates a more favourable internal and external context for PAC to emerge. As for self‐efficacy in obtaining respite, a belief that support can be secured to buffer their caregiving role demand whenever necessary may encourage the carers to continue with their personal pursuit and prevent burnout, thereby leading to a stronger sense of role‐fulfilment and status quo (Brandão et al. 2023). As emotional and role regulation in caregiving is conceptualised in the dyadic process which captures the interaction and relationship attachment between the carers and the PLwD (Brandão et al. 2023; Monin 2016), an interpersonal context characterised by good relationship quality and stronger motivation to care is therefore more relevant than disease management skills and social support to favour the evolvement of PAC. This indeed converges to the phenomenon where caregivers who reported better relationship quality and greater motivation experienced higher levels of caregiving satisfaction (Lloyd et al. 2016).

This study showed that the existential meaning‐making paradigm makes a significant contribution to PAC. This finding addresses an important research gap in the literature. Referring to the recent scope review (He et al. 2022), the stress coping theory was the most typical framework to explain PAC. However, it provides no explanation of how positive experiences, especially those requiring the carers to use a different perspective to interpret the challenging encounter, can be generated. A positive psychology framework has been increasingly adopted to address this limitation. However, the most commonly used self‐efficacy and resilience theories only expanded the coping research to inner strengths to promote positive adaptation (Baluszek et al. 2023; Jin et al. 2023). By integrating the existential paradigm into the model, the current study findings showed that meaning‐making plays an independent role in promoting the evolvement of PAC. The finding echoes the cross‐sectional study that identifies the independent relationship between better meaning‐making and less role captivity, greater personal growth, and competence (Dieker and Qualls 2022; Tretteteig et al. 2017). In fact, the significant predictive effect of meaning‐making on PAC can be best understood in its nature of using appraised‐based strategies which draw on one's values, beliefs and existential goals to enable positive adaptation to a challenging and even overwhelming situation. Instead of alleviating the stressors associated with caregiving, such strategies tend to change the perspectives carers use to interpret their life encounters, which might therefore be more relevant to explain the evolvement of PAC, particularly in the domains relating to mutuality of dyadic relationships, personal growth, and family cohesiveness (Yu et al. 2018).

Another striking finding is that the baseline PAC significantly predicted a higher level of PAC at 6 months through meaning‐making. This implies that PAC would have a scaffolding effect through meaning‐making among the cares in a dementia context. Such effect may be related to the fact that PAC is associated with more positive affect which might favour the use of meaning‐making in interpretating the caregiving encounter (Folkman and Moskowitz 2007). Another possibility is that meaning‐making is concerned with reducing discrepancies between the situation and global meaning. Once the adjustment has been made to generate the initiate PAC, the carers may continue to make sense of the evolving caregiving experience in the more congruent value‐laden schemata, and attributed to stronger PAC. Such evolving effect of PAC may also explain why care interventions to promote PAC always associated with more sustainable effects (He et al. 2022). PAC may act like an ‘inner strength to strengthen the carers’ role adaptation.

Among the three hypothesized contextual factors in the existential meaning‐making paradigm, only religiosity significantly predicted a higher level of meaning‐focused coping. This finding converges with a few studies that address the importance of spirituality in one's meaning‐making process during stressful encounters (Das et al. 2023; Park 2013). Religiosity with significant contextual effect shapes one's global meaning system, in which connotation and purpose are entitled to difficult encounters and suffering for personal and spiritual growth (Park 2013). Additionally, dyadic relationship quality and intrinsic motivation for caregiving are indeed helpful in one's meaning‐making practices if we considered their significant bivariate relationships with meaning‐focus coping in the existential paradigm only. Yet, the integrated paradigms downplay such positive effects when the self‐efficacy in role and emotional regulation were considered. To explain this finding, it is possible that the ability to regulate emotional arousal and manage role strain is crucial in determining the development on PAC. Self‐efficacy in finding respite and controlling upsetting thoughts are psychological resources that directly influence caregivers' perceived ability in their role and emotional regulation, and therefore, they may have a direct impact on PAC. In contrast, intrinsic motivation to care and a good dyadic relationship reflect caregivers' internalised value and relational resources to care, may be more relevant in shaping their commitment to caregiving rather than increasing PAC. While intrinsic motivation to care and good dyadic relationship are important, their effects on PAC may be encompassed within self‐efficacy. On the other hand, social support was helpful in enhancing one's meaning‐making process, indicating its role in increasing one's ability to adopt new perspectives when facing adversity. Chen et al. (2024) identified the meaning‐making process from qualitative evidence, and found that inadequate social support is an imperative barrier to hinder the caregiver from assimilating the meaning created for the caregiving situation to global meaning. This step of assimilation is crucial to catalyse constructive meaning‐making for a challenging dementia situation. Together with the positive influence of social support on self‐affirmation and gratification, it is concluded that a context which is contented with social support is crucial to promote PAC in the integrated paradigm.

This study contributes to existing scholarship by extending the scope of research on PAC to its theoretical conceptualization. According to the latest scoping review on PAC, there is no empirically tested theoretical model to explain its evolvement, and such a research gap has hindered the advancement of carer support intervention to promote the adaptivity of carers through building their PAC. By focusing on the multi‐dimensionality of PAC, this study found that its evolvement is based on an integrated stress coping and existential meaning‐making paradigm. Whereas the perceived performance success in emotional and role regulation is the key coping result attributing to PAC, its evolvement also relies on effective meaning‐making for the challenging encounter. The findings add specificity to the conceptual model proposed by Carbonneau et al. (2010) that carers' sense of self‐efficacy and enrichment events in daily life attribute to PAC. The model also supplements the substantial body of literature which investigated PAC based on the theory of the negative stress process (Wang et al. 2022).

Against this backdrop, the present study joins the existing studies by structuring the evolving process of PAC in an integrated paradigm of stress coping and existential meaning making. When securitizing the mechanism across these two paradigms, there is a possibility that the increased self‐affirmation on emotional and role regulation which resulted from the stress coping paradigm increases the caregivers' acceptance to the challenging situation. This psycho‐cognitive state of acceptance is, indeed, the pre‐requisite to enable an individual to use various adaptive cognitive strategies such as ‘refocusing’ and ‘reframing’ in the existential paradigm to attain PAC (Wright et al. 2023).

6.1. Implications to Research and Practice

This project has generated a theory‐driven and evidence‐based predictive model to explain the manifestation of PAC in dementia caregiving. It enriches the conceptualization of the adaptation process of family caregivers by adding the manifestation of positive experience to the journey of coping with the stressors in challenging caregiving endeavours. The findings call for a paradigm shift from ‘directing attention to reducing caregivers' stressful experience’ to ‘empowering family caregivers to create a meaningful, positive and fulfilling caregiving adventure’. Over the recent years, there has an increasing attention on interventional studies to improve PAC (He et al. 2022). However, the majority of the proposed interventions only focus on collecting the coping resources for stress‐buffering, whereas only a few studies used cognitive‐behavioural strategies to support reframing and refocusing (He et al. 2022). Based on the current findings, it is recommended that promoting PAC requires multimodal interventions that emphasise emotional and role regulation and proactive meaning‐making. In comparison to cognitive‐behavioural strategies that promote cognitive reframing, the self‐distancing meaning‐making technique underpinned by the Construal Level Theory may be an option to facilitate the family caregivers to only focus on the essential feature, rather than the emotionally aroused details, of the caregiving endeavours (Lau and Tov 2023). Narrative strategies can be used to guide constructive self‐reflection and the linkage of challenging encounters to meaningful life domains (Kropf and Tandy 1998; Taves et al. 2018). Peer support and mutual sharing are important to promote social affirmation and optimise the perspectives for understanding personalised encounters.

6.2. Study Limitations

This study is not without limitations. Although the caregivers were recruited from the dementia clinic, the sample was over‐represented by female and adult‐child caregivers, which may hamper the external validity of the study. Second, the study only predicted the evolvement of PAC in the 6‐month period. Given PAC may evolve in a different pattern when the carers become more fully integrate the caregiving with other life roles in a longer term (Gaugler et al. 2000), future study may need to adopt a longer‐term follow‐up period to examine the evolvement of PAC over time. Finally, the study was conducted during the pandemic of COVID‐19 during which dementia caregiving was found to be more vulnerable due to the social distancing policy and the interruption of normal service. The validity of our findings may be subject to a potential history threat.

7. Conclusion

The positive aspect of caregiving plays an important role in promoting the longer‐term role adaptation of family caregivers in the dementia context. By using integrated stress coping and existential paradigms, enhanced emotion and role regulation as well as meaning‐focused coping were found to explain the evolvement of PAC. The social context which is characterised by high emotional and social support would favour its development, particularly for caregivers who have high religiosity, higher intrinsic motivation to care and better dyadic relationship quality. This study lays a theoretical foundation to guide the future advancement of caregiver support service development.

Author Contributions

Doris Sau Fung Yu: conceptualization, methodology, validation, formal analysis, investigation; writing – original draft, supervision, funding acquisition, supervision. Sheung‐Tak Cheng: conceptualization; methodology, writing – review and editing. Kevin Shuang Zhou Chen: formal analysis, writing – review and editing.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgements

The authors would like to acknowledge all the family carers who participate in the interviews. Without their participation, this project would not be possible. Our heartfelt gratitude is also conveyed to the staff in the geriatric clinics who supported our logistic arrangements and record reviews for clinical data collection. Last but not least, we would acknowledge the Hong Kong Research Grant Council for the generous funding support for this study.

Funding: This work was supported by Research Grant Council, General Research Fund (14610317).

Data Availability Statement

The data are not available as the author team would need to comply with the guideline from the Clinical Ethics Research Committee.

References

  1. Au, A. , Lai M.‐K., Lau K.‐M., et al. 2009. “Social Support and Well‐Being in Dementia Family Caregivers: The Mediating Role of Self‐Efficacy.” Aging & Mental Health 13, no. 5: 761–768. [DOI] [PubMed] [Google Scholar]
  2. Baluszek, J. B. , Brønnick K. K., and Wiig S.. 2023. “The Relations Between Resilience and Self‐Efficacy Among Healthcare Practitioners in Context of the COVID‐19 Pandemic–a Rapid Review.” International Journal of Health Governance 28, no. 2: 152–164. [Google Scholar]
  3. Bandura, A. 1977. “Self‐Efficacy: Toward a Unifying Theory of Behavioral Change.” Psychological Review 84, no. 2: 191–215. 10.1037/0033-295X.84.2.191. [DOI] [PubMed] [Google Scholar]
  4. Bandura, A. 1997. Self‐Efficacy: The Exercise of Control. W.H. Freeman. [Google Scholar]
  5. Bengtson, V. L. , Schrader S. S., Mangen D., and Peterson W.. 1982. “Parent‐Child Relations.” In Research Instruments in Social Gerontology, edited by Bengtson V. L., Schrader S. S., Mangen D., and Peterson W., 115–185. University of Minneapolis Press. [Google Scholar]
  6. Brandão, T. , Brites R., Hipólito J., Nunes O., and Tomé Pires C.. 2023. “Emotion Regulation in Dementia Caregiving: The Role of Neuropsychiatric Symptoms and Attachment Orientation.” Journal of Geriatric Psychiatry and Neurology 37, no. 2: 08919887231195228. 10.1177/08919887231195228. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Butcher, H. K. , and Buckwalter K. C.. 2002. “Exasperations as Blessings: Meaning‐Making and the Caregiving Experience.” Journal of Aging and Identity 7, no. 2: 2. 10.1023/A:1015439218276. [DOI] [Google Scholar]
  8. Carbonneau, H. , Caron C., and Desrosiers J.. 2010. “Development of a Conceptual Framework of Positive Aspects of Caregiving in Dementia.” Dementia 9, no. 3: 327–353. 10.1177/1471301210375316. [DOI] [Google Scholar]
  9. Chen, H. , Wang Z., Phillips M. R., Sun Y., and Cheng H. G.. 2014. “Internal Consistency and Test‐Retest Reliability of the Chinese Version of the 5‐Item Duke University Religion Index.” Shanghai Archives of Psychiatry 26, no. 5: 300–309. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Chen, S. , Lou V. W. Q., Leung R., and Yu D. S. F.. 2024. “Meaning‐making of dementia caregiving: A systematic review of qualitative studies.” International Journal of Nursing Studies 158: 104848. 10.1016/j.ijnurstu.2024.104848.. [DOI] [PubMed] [Google Scholar]
  11. Cheng, S. T. , Lam L. C. W., Kwok T., Ng N. S. S., and Fung A. W. T.. 2013. “Self‐Efficacy Is Associated With Less Burden and More Gains From Behavioral Problems of Alzheimer's Disease in Hong Kong Chinese Caregivers.” Gerontologist 53, no. 1: 71–80. 10.1093/geront/gns062. [DOI] [PubMed] [Google Scholar]
  12. Cheng, S. T. , Lau R. W., Mak E. P., et al. 2012. “A Benefit‐Finding Intervention for Family Caregivers of Persons With Alzheimer Disease: Study Protocol of a Randomized Controlled Trial.” Trials 13, no. 1: 1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Cheng, S. T. , Mak E. P. M., Lau R. W. L., Ng N. S. S., and Lam L. C. W.. 2016. “Voices of Alzheimer Caregivers on Positive Aspects of Caregiving.” Gerontologist 56, no. 3: 451–460. 10.1093/geront/gnu118. [DOI] [PubMed] [Google Scholar]
  14. Cheng, S. T. , and Zhang F.. 2020. “A Comprehensive Meta‐Review of Systematic Reviews and Meta‐Analyses on Nonpharmacological Interventions for Informal Dementia Caregivers.” BMC Geriatrics 20, no. 1: 137. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Chien, W. T. 2015. “Testing the Psychometric Properties of a Chinese Version of Dementia Management Strategies Scale.” Neuropsychiatric Disease and Treatment 11: 1663–1675. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Cho, J. , Ory M. G., and Stevens A. B.. 2016. “Socioecological Factors and Positive Aspects of Caregiving: Findings From the REACH II Intervention.” Aging and Mental Health 20, no. 11: 1190–1201. 10.1080/13607863.2015.1068739. [DOI] [PubMed] [Google Scholar]
  17. Cutuli, D. 2014. “Cognitive Reappraisal and Expressive Suppression Strategies Role in the Emotion Regulation: An Overview on Their Modulatory Effects and Neural Correlates.” Frontiers in Systems Neuroscience 8: 175. 10.3389/fnsys.2014.00175. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Das, S. , Malathesh B. C., Chatterjee S. S., Mitra S., and Punnoose V. P.. 2023. “Spiritual‐Religious Coping in Patients With Schizophrenia: A Qualitative Analysis.” Journal of Psychiatry Spectrum 2, no. 2: 74–79. [Google Scholar]
  19. Denson, T. F. , Moulds M. L., and Grisham J. R.. 2012. “The Effects of Analytical Rumination, Reappraisal, and Distraction on Anger Experience.” Behavior Therapy 43, no. 2: 355–364. 10.1016/j.beth.2011.08.001. [DOI] [PubMed] [Google Scholar]
  20. Dieker, J. , and Qualls S.. 2022. “Meaning Focused Coping: Implications for Family Caregiver Burden and Positive Aspects of Care.” Innovation in Aging 6, no. Supplement_1: 696–697. 10.1093/geroni/igac059.2551. [DOI] [Google Scholar]
  21. Duggleby, W. , Williams A., Wright K., and Bollinger S.. 2009. “Renewing Everyday Hope: The Hope Experience of Family Caregivers of Persons With Dementia.” Issues in Mental Health Nursing 30, no. 8: 514–521. 10.1080/01612840802641727. [DOI] [PubMed] [Google Scholar]
  22. Flint, G. A. , Gayton W. F., and Ozmon K. L.. 1983. “Relationship Between Life Satisfaction and Acceptance of Death by Elderly Persons.” Psychological Reports 53: 290. [DOI] [PubMed] [Google Scholar]
  23. Folkman, S. , and Moskowitz J. T.. 2007. “Positive Affect and Meaning‐Focused Coping During Significant Psychological Stress.” Scope of Social Psychology: Theory and Applications 10: 193–208. [Google Scholar]
  24. Gan, Y. , Guo M., and Tong J.. 2013. “Scale Development of Meaning‐Focused Coping.” Journal of Loss and Trauma 18, no. 1: 10–26. [DOI] [PubMed] [Google Scholar]
  25. Gaugler, J. E. , Davey A., Pearlin L. I., and Zarit S. H.. 2000. “Modeling Caregiver Adaptation Over Time: The Longitudinal Impact of Behavior Problems.” Psychology and Aging 15, no. 3: 437–450. [DOI] [PubMed] [Google Scholar]
  26. George, L. S. , and Park C. L.. 2016. “Meaning in Life as Comprehension, Purpose, and Mattering: Toward Integration and New Research Questions.” Review of General Psychology 20, no. 3: 205–220. 10.1037/gpr0000077. [DOI] [Google Scholar]
  27. Gross, J. J. 2015. “Emotion Regulation: Current Status and Future Prospects.” Psychological Inquiry 26, no. 1: 1–26. [Google Scholar]
  28. He, J. , Wang J., Zhong H., and Guan C.. 2022. “The Effectiveness of Multi‐Component Interventions on the Positive and Negative Aspects of Well‐Being Among Informal Caregivers of People With Dementia: A Systematic Review and Meta‐Analysis.” International Journal of Environmental Research and Public Health 19, no. 12: 6973. 10.3390/ijerph19126973. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Heo, G. J. 2014. “Religious Coping, Positive Aspects of Caregiving, and Social Support Among Alzheimer's Disease Caregivers.” Clinical Gerontologist 37, no. 4: 368–385. [Google Scholar]
  30. Hodge, D. R. , and Sun F.. 2012. “Positive Feelings of Caregiving Among Latino Alzheimer's Family Caregivers: Understanding the Role of Spirituality.” Aging & Mental Health 16, no. 6: 689–698. 10.1080/13607863.2012.678481. [DOI] [PubMed] [Google Scholar]
  31. Hu, L. , and Bentler P. M.. 1998. “Fit Indices in Covariance Structure Modeling: Sensitivity to Underparameterized Model Misspecification.” Psychological Methods 3, no. 4: 424–453. [Google Scholar]
  32. Jin, Y. , Bhattarai M., Kuo W., and Bratzke L. C.. 2023. “Relationship Between Resilience and Self‐Care in People With Chronic Conditions: A Systematic Review and Meta‐Analysis.” Journal of Clinical Nursing 32, no. 9–10: 2041–2055. [DOI] [PubMed] [Google Scholar]
  33. Jones, P. S. , Lee J. W., Phillips L. R., Zhang X. E., and Jaceldo K. B.. 2001. “An Adaptation of Brislin's Translation Model for Cross‐Cultural Research.” Nursing Research 50, no. 5: 300–304. [DOI] [PubMed] [Google Scholar]
  34. Kline, R. B. 2023. Principles and Practice of Structural Equation Modeling. Guilford publications. [Google Scholar]
  35. Kramer, B. J. 1997. “Gain in the Caregiving Experience: Where Are We? What Next?” Gerontologist 37, no. 2: 2. [DOI] [PubMed] [Google Scholar]
  36. Kropf, N. P. , and Tandy C.. 1998. “Narrative Therapy With Older Clients: The Use of a “Meaning‐Making” Approach.” Clinical Gerontologist 18, no. 4: 3–16. 10.1300/J018v18n04_02. [DOI] [Google Scholar]
  37. Lau, C. Y. H. , and Tov W.. 2023. “Effects of Positive Reappraisal and Self‐Distancing on the Meaningfulness of Everyday Negative Events.” Frontiers in Psychology 14: 1093412. 10.3389/fpsyg.2023.1093412. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Lawton, M. P. , Moss M., Kleban M. H., Glicksman A., and Rovine M.. 1991. “A Two‐Factor Model of Caregiving Appraisal and Psychological Well‐Being.” Journal of Gerontology 46, no. 4: 181–189. [DOI] [PubMed] [Google Scholar]
  39. Lazarus, R. S. , and Folkman S.. 1984. Stress, Appraisal, and Coping. Springer. [Google Scholar]
  40. Lim, J. , Griva K., Goh J., Chionh H. L., and Yap P.. 2011. “Coping Strategies Influence Caregiver Outcomes Among Asian Family Caregivers of Persons With Dementia in Singapore.” Alzheimer Disease & Associated Disorders 25, no. 1: 34–41. 10.1097/WAD.0b013e3181ec18ae. [DOI] [PubMed] [Google Scholar]
  41. Lindauer, A. , and Harvath T. A.. 2015. “The Meanings Caregivers Ascribe to Dementia‐Related Changes in Care Recipients: A Meta‐Ethnography.” Research in Gerontological Nursing 8, no. 1: 39–48. 10.3928/19404921-20141121-01. [DOI] [PubMed] [Google Scholar]
  42. Little, R. J. 1988. “A Test of Missing Completely at Random for Multivariate Data With Missing Values.” Journal of the American Statistical Association 83, no. 404: 1198–1202. [Google Scholar]
  43. Liu, Y. , Insel K. C., Reed P. G., and Crist J. D.. 2012. “Family Caregiving of Older Chinese People With Dementia: Testing a Model.” Nursing Research 61, no. 1: 39–50. 10.1097/NNR.0b013e31823bc451. [DOI] [PubMed] [Google Scholar]
  44. Lloyd, J. , Patterson T., and Muers J.. 2016. “The Positive Aspects of Caregiving in Dementia: A Critical Review of the Qualitative Literature.” Dementia 15, no. 6: 1534–1561. 10.1177/1471301214564792. [DOI] [PubMed] [Google Scholar]
  45. Lou, V. W. Q. , Lau B. H. P., and Cheung K. S. L.. 2015. “Positive Aspects of Caregiving (PAC): Scale Validation Among Chinese Dementia Caregivers (CG).” Archives of Gerontology and Geriatrics 60, no. 2: 299–306. 10.1016/j.archger.2014.10.019. [DOI] [PubMed] [Google Scholar]
  46. Lyonette, C. , and Yardley L.. 2003. “The Influence on Carer Wellbeing of Motivations to Care for Older People and the Relationship With the Care Recipient.” Ageing and Society 23, no. 4: 487–506. 10.1017/S0144686X03001284. [DOI] [Google Scholar]
  47. MacCallum, R. C. , Browne M. W., and Sugawara H. M.. 1996. “Power Analysis and Determination of Sample Size for Covariance Structure Modeling.” Psychological Methods 1, no. 2: 130–149. [Google Scholar]
  48. Monin, J. K. 2016. “Emotion Regulation in the Context of Spousal Caregiving: Intrapersonal and Interpersonal Strategies.” In Couple Relationships in the Middle and Later Years: Their Nature, Complexity, and Role in Health and Illness, edited by Bookwala J., 281–301. American Psychological Association. 10.1037/14897-015. [DOI] [Google Scholar]
  49. Motenko, A. K. 1989. “The Frustrations, Gratifications, and Well‐Being of Dementia Caregivers.” Gerontologist 29, no. 2: 166–172. [DOI] [PubMed] [Google Scholar]
  50. Narayan, S. , Lewis M., Tornatore J., Hepburn K., and Corcoran‐Perry S.. 2001. “Subjective Responses to Caregiving for a Spouse With Dementia.” Journal of Gerontological Nursing 27, no. 3: 19–28. 10.3928/0098-9134-20010301-05. [DOI] [PubMed] [Google Scholar]
  51. Netto, R. N. , Goh Yen J., and Philip Y. L. K.. 2009. “Growing and Gaining Through Caring for a Loved One With Dementia.” Dementia 8, no. 2: 245–261. 10.1177/1471301209103269. [DOI] [Google Scholar]
  52. Park, C. L. 2013. “The Meaning Making Model: A Framework for Understanding Meaning, Spirituality, and Stress‐Related Growth in Health Psychology.” European Health Psychologist 15, no. 2: 42–47. [Google Scholar]
  53. Peacock, S. , Forbes D., Markle‐Reid M., et al. 2010. “The Positive Aspects of the Caregiving Journey With Dementia: Using a Strengths‐Based Perspective to Reveal Opportunities.” Journal of Applied Gerontology 29, no. 5: 640–659. 10.1177/0733464809341471. [DOI] [Google Scholar]
  54. Pendergrass, A. , Mittelman M., Graessel E., Özbe D., and Karg N.. 2019. “Predictors of the Personal Benefits and Positive Aspects of Informal Caregiving.” Aging & Mental Health 23, no. 11: 1533–1538. [DOI] [PubMed] [Google Scholar]
  55. Preacher, K. J. , and Hayes A. F.. 2008. “Asymptotic and Resampling Strategies for Assessing and Comparing Indirect Effects in Multiple Mediator Models.” Behavior Research Methods 40, no. 3: 879–891. 10.3758/BRM.40.3.879. [DOI] [PubMed] [Google Scholar]
  56. Quinn, C. , Clare L., McGuinness T., and Woods R. T.. 2012a. “The Impact of Relationships, Motivations, and Meanings on Dementia Caregiving Outcomes.” International Psychogeriatrics 24, no. 11: 1816–1826. 10.1017/S1041610212000889. [DOI] [PubMed] [Google Scholar]
  57. Quinn, C. , Clare L., and Woods R. T.. 2010. “The Impact of Motivations and Meanings on the Wellbeing of Caregivers of People With Dementia: A Systematic Review.” International Psychogeriatrics 22, no. 1: 43–55. 10.1017/S1041610209990810. [DOI] [PubMed] [Google Scholar]
  58. Quinn, C. , Clare L., and Woods R. T.. 2012b. “What Predicts Whether Caregivers of People With Dementia Find Meaning in Their Role?” International Journal of Geriatric Psychiatry 27, no. 11: 1195–1202. 10.1002/gps.3773. [DOI] [PubMed] [Google Scholar]
  59. Quinn, C. , and Toms G.. 2018. “Influence of Positive Aspects of Dementia Caregiving on Caregivers' Well‐Being: A Systematic Review.” Gerontologist 59: e584–e596. 10.1093/geront/gny168. [DOI] [PubMed] [Google Scholar]
  60. Rosseel, Y. 2012. “Lavaan: An R Package for Structural Equation Modeling and More. Version 0.5–12 (BETA).” Journal of Statistical Software 48, no. 2: 1–36. [Google Scholar]
  61. Sanders, C. E. 2005. Wicca's Charm: Understanding the Spiritual Hunger Behind the Rise of Modern Witchcraft Andpagan Spirituality. Shaw Books. [Google Scholar]
  62. Schermelleh‐Engel, K. , Moosbrugger H., and Müller H.. 2003. “Evaluating the Fit of Structural Equation Models: Tests of Significance and Descriptive Goodness‐Of‐Fit Measures.” Methods of Psychological Research Online 8, no. 2: 23–74. [Google Scholar]
  63. Shim, B. , Barroso J., and Davis L. L.. 2012. “A Comparative Qualitative Analysis of Stories of Spousal Caregivers of People With Dementia: Negative, Ambivalent, and Positive Experiences.” International Journal of Nursing Studies 49, no. 2: 220–229. 10.1016/j.ijnurstu.2011.09.003. [DOI] [PubMed] [Google Scholar]
  64. Shim, B. , Barroso J., Gilliss C. L., and Davis L. L.. 2013. “Finding Meaning in Caring for a Spouse With Dementia.” Applied Nursing Research 26, no. 3: 121–126. [DOI] [PubMed] [Google Scholar]
  65. Taves, A. , Asprem E., and Ihm E.. 2018. “Psychology, Meaning Making, and the Study of Worldviews: Beyond Religion and Non‐Religion.” Psychology of Religion and Spirituality 10, no. 3: 207–217. [Google Scholar]
  66. Tomer, A. , and Eliason G.. 2000. “Beliefs About Self, Life, and Death: Testing Aspects of a Comprehensive Model of Death Anxiety and Death Attitudes.” In Death Attitudes and the Older Adult: Theories, Concepts, and Applications, 137–153. Taylor & Francis Group. [Google Scholar]
  67. Tretteteig, S. , Vatne S., and Rokstad A. M. M.. 2017. “Meaning in Family Caregiving for People With Dementia: A Narrative Study About Relationships, Values, and Motivation, and How Day Care Influences These Factors.” Journal of Multidisciplinary Healthcare 10: 445–455. 10.2147/JMDH.S151507. [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Walker, A. J. , Shin H.‐Y., and Bird D. N.. 1990. “Perceptions of Relationship Change and Caregiver Satisfaction.” Family Relations 39: 147–152. [Google Scholar]
  69. Wang, J. , Li X., Liu W., et al. 2022. “The Positive Aspects of Caregiving in Dementia: A Scoping Review and Bibliometric Analysis.” Frontiers in Public Health 10: 985391. 10.3389/fpubh.2022.985391. [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Wright, S. R. , Graham C. D., Houghton R., Ghiglieri C., and Berry E.. 2023. “Acceptance and Commitment Therapy (ACT) for Caregivers of Children With Chronic Conditions: A Mixed Methods Systematic Review (MMSR) of Efficacy, Process, and Acceptance.” Journal of Contextual Behavioral Science 27: 72–97. 10.1016/j.jcbs.2022.12.003. [DOI] [Google Scholar]
  71. Yu, D. S. F. , Cheng S., and Kwok T.. 2021. “Developing and Testing of an Integrative Theoretical Model to Predict Positive Aspects of Caregiving Among Family Caregivers of Persons With Dementia: A Study Protocol.” Journal of Advanced Nursing 77, no. 1: 401–410. 10.1111/jan.14561. [DOI] [PubMed] [Google Scholar]
  72. Yu, D. S. F. , Cheng S. T., and Wang J.. 2018. “Unravelling Positive Aspects of Caregiving in Dementia: An Integrative Review of Research Literature.” International Journal of Nursing Studies 79, no. October 2017: 1–26. 10.1016/j.ijnurstu.2017.10.008. [DOI] [PubMed] [Google Scholar]
  73. Yu, D. S. F. , Lee D. T. F., and Woo J.. 2004. “Psychometric Testing of the Chinese Version of the Medical Outcomes Study Social Support Survey (MOS‐SSS‐C).” Research in Nursing & Health 27, no. 2: 135–143. 10.1002/nur.20008. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data are not available as the author team would need to comply with the guideline from the Clinical Ethics Research Committee.

Articles from Journal of Advanced Nursing are provided here courtesy of Wiley

RESOURCES