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Published in final edited form as: J Nurs Meas. 2003 SPRING-SUMMER;11(1):19–28. doi: 10.1891/jnum.11.1.19.52060

Assessing the Cultural Appropriateness of the Finding Meaning Through Caregiving Scale for Korean Caregivers

Eunice E Lee 1, Carol J Farran 2, Toni Tripp-Reimer 3, Georgia Robins Sadler 4
PMCID: PMC3089433  NIHMSID: NIHMS291859  PMID: 15132009

Abstract

Before psychometric instruments can be used for populations other than those for whom they were originally developed, validation of cultural appropriateness is essential. This article describes the assessment of the cultural appropriateness of the Finding Meaning Through Caregiving Scale (FMTCS) with Korean female family caregivers. The FMTCS measures finding meaning among caregivers from an existential perspective and has three subscales: Loss/Powerlessness, Provisional Meaning, and Ultimate Meaning. The instrument’s cultural appropriateness was examined through semistructured interviews with ten Korean-born female family caregivers, five caregivers living in Korea, and five living in the United States, The interview data are reported according to the three dimensions described by Flaherty and colleagues (1988): content, semantic, and conceptual equivalence. Although the majority of items of the FMTCS appeared applicable to Korean caregivers, items on the Loss/Powerlessness and Provisional Meaning subscales asking caregivers about feelings related to missing their past relationships or communications appeared inappropriate for many Korean daughters-in-law. Of equal importance, a unique source of meaning among Korean caregivers that is not assessed in the FMTCS is an interpersonal context, including the importance caregivers place on teaching children and feeling proud of one’s caregiving accomplishments in the eyes of other relatives. The addition of new items that address the interpersonal context is warranted to improve the instrument’s cultural appropriateness for Korean caregivers.

Validation of the psychometric properties of instruments for use with varied populations is critical to assure the cultural appropriateness of the scales’ items (Okazaki & Sue, 1998). In the United States, in spite of the diverse fabric of the population, instruments are commonly developed and tested primarily with European Americans. On account of the content and meaning of the language used differing when items are translated, a scale’s cross-cultural equivalence must be assessed before use with other cultural groups. Otherwise, the instrument may measure a different construct, resulting in ambiguous findings and preventing meaningful intra- and intercultural group comparisons.

Guyatt (1993) suggested three ways to adapt an instrument developed in one language to compare concepts across cultures:

  1. simply translate the original questionnaire into the second language;

  2. develop a culturally appropriate instrument for each culture; and

  3. revise the original instrument by omitting irrelevant items and adding new culturally appropriate items.

Other methods that have been suggested for examining the cross-cultural equivalence of instruments include factor analysis and item response theory (Behling & Law, 2000). Using factor analysis or item response theory requires large samples and sophisticated training.

Each of Guyatt’s methods has positive and negative aspects. The first method is cost-effective and simple, but offers no assurance that the instrument is culturally appropriate. The second method could be costly and time-consuming, and although the resulting instruments would be culturally sensitive, there would be no assurance that the instruments would be useful for cross-cultural comparisons of the concepts that the original instrument measured.

The third method of revising the original instrument to make it culturally appropriate appears to be the most practical approach in health care in which access to large samples may be limited. It can be accomplished via focus groups or individual interviews that help identify and preserve the scale’s applicable items, allow inappropriate items to be deleted or modified, and add items to address essential, culture-bound concepts that were missing in the original scale. This article illustrates the use of individual interviews to assess the cultural appropriateness of the Finding Meaning Through Caregiving Scale (FMTCS) with Korean-born caregivers living in the U.S. (KA) and their Korean homeland (KK) and then describes the outcomes. The term “Korean caregivers” indicates both groups unless otherwise specified.

SIGNIFICANCE OF THE STUDY

During the next 50 years, the Asian Pacific Islander (API) elderly are projected to grow more than six-fold, from 822,000 to 5,366,000, a growth rate second only to the growth of Latinos (Administration on Aging, 2001). Family members are often called upon to provide care to these aging and often fragile persons, and the period of family caretaking responsibilities continues to lengthen as medical advances permit further extension of life.

In all cultural groups, the transition from adult child to adult child caregiver is challenging. In the API community, women are traditionally expected to be caregivers of their elders (Asahara, Momose, Murashima, Okubo, & Magilvy, 2001; Choi, 1993; Kim, 2001; Shi, 1993; Yamamoto & Wallhagen, 1997), In the U.S., however, there are new social pressures, economic pressures, and expectations of a high standard of living that place new demands on Asian families. These demands often result in two-career households or other external pressures, thereby disrupting the traditional pattern of women staying home to care for elders and children. These women must balance the emotional and physical challenges of combining their traditional familial roles with involvement and employment outside of the home (Kim, Kim, & Hurh, 1991; Yamamoto, Rhee, & Chang, 1994).

Understanding how family members find meaning in caregiving may lead to new interventions to advance the well-being of these caregivers (Kramer, 1997). The few studies that have been done of API caregivers have focused mainly on caregiving satisfaction (Jones, 1996; Ramanathan & Ramanathan, 1994, Son, Zauszniewski, Wykle, & Picot, 2000).

Another way of exploring caregiving is from an existential perspective, in which the individual finds meaning amid suffering (Frankl, 1962, 1997). The Finding Meaning Through Caregiving Scale (FMTCS) was developed from an existential perspective specifically to measure positive, existential aspects of caregiving (Farran, Miller, Kaufman, Donner, & Fogg, 1999). It was developed and tested with groups of predominantly European American caregivers. Intuitively, this existential perspective should be relevant to caregivers from diverse backgrounds. However, the ways in which caregivers find meaning in suffering may be differently influenced by their culture. Hence, before using the instrument wirn diverse cultural groups, it is necessary to evaluate the instrument’s cross-cultural appropriateness.

Description of the Finding Meaning Through Caregiving Scale (FMTCS)

The FMTCS was developed to measure systematically the concept of meaning among caregivers in order to understand better the caregiving process and outcomes (Farran, Miller, Kaufman, Donner, & Fogg, 1999). The FMTCS has been primarily developed based on existential perspectives, a philosophical perspective, that evolved from Victor Frankl’s personal experiences in a concentration camp (Frankl, 1962, 1978). Existentialism addresses issues such as suffering, meaninglessness, hope, and transcendence. The construct of “finding meaning through caregiving” was initially identified by Farran and colleagues from a qualitative study (Farran, Keane-Hagerty, Salloway, Kupferer, & Wilken, 1991) they conducted. From their interviews with 94 family caregivers of persons with dementia, they identified six major themes: loss, powerlessness, personal choices, positive aspects, provisional meaning, and ultimate meaning (Farran et al., 1991). Based on the six themes, an original 135-item FMTCS was developed and revised to the 43-item FMTCS (Farran at al., 1999).

The FMTCS has three subscales: Loss/Powerlessness (LP), Provisional Meaning (PM), and Ultimate Meaning (UM) (Farran et al., 1999). The LP and PM subscales each have 19 items, and the UM subscale has 5 items. The FMTCS is a 5-point Likert-type scale, from 1 “strongly disagree” to 5 “strongly agree.” LP items are reverse-scored when the total FMTCS score is calculated. The possible total FMTCS score ranges 43–215; the LP and PM subscales range 19–95, and the UM subscale ranges 5–25 (Farran et al., 1999).

The LP subscale refers to caregivers’ feelings of loss and powerlessness associated with caregiving for their family members and themselves. The PM subscale refers to what keeps caregivers notivated and what is pleasant about their daily experiences. The UM subscale refers to a “higher power,” a philosophical, religious, or spiritual structure. The internal consistency reliabilities for each subscale and for the total scale are from 0.88 to 0.95 (Farran et al., 1999). The FMTCs’s psychometric properties have been established in two consecutive studies with mainly European American caregivers (Farran et al., 1999). The first study focused on establishing convergent and discriminate validity with measures that were developed based on existential perspectives such as Non-Death Grief Experience Inventory-Form B (GEI-B), Life Attitude Profile-Revised (LAP-R), Ladder of Life Index (LOL1), and Public and Private Religiosity. The second study established convergent and discriminate validity with measures that were developed based on a stress/adaptation model that is commonly used in caregiving research, such as the Frequency of Behavior Problems Scale, Center for Epidemiologic Studies-Depression (CES-D), Global Role Strain, Marital Tension, Marital Satisfaction, Caregiver Satisfaction, and Religiosity (Farran et al., 1999). Construct validity was supported by confirmatory factor analysis demonstrating that the three subscales were theoretically derived (Farran et al., 1999).

METHODS

The study used cross-sectional semistructured interviews to examine the cultural appropriateness of the FMTCS expressly for use with Korean caregivers. Individual interviews were chosen from focus groups for two reasons. First, since the study was narrowly focused on Korean women’s caregiving experiences of family members with dementia, so the size of the available subpopulation would be limited, especially among Korean American caregivers. Second, for women who were already burdened by their caregiving responsibilities, participation in focus groups was a barrier to study participation.

Translation of the FMTCS

A panel of three Korean Americans (KA), a nurse researcher, a pastor, and a social worker who were fluent in Korean and English, translated the FMTCS. The scale was first translated into Korean by the nurse researcher and the pastor. As a first assessment of equivalence, the Korean version of the FMTCS was then back-translated into English by the social worker (Berry, 1992; Marin & Marin, 1991; Van de Vijver & Leung, 1997). The panel then identified and addressed the substantive differences between the original and back-translated versions.

For the item of the Loss/Powerlessness (LP) subscale: “I miss not being able to be spontaneous in my life because of caring for my relative,” an equivalent Korean word for spontaneous could not be found. Two expressions, control of the situation and having freedom from the situation, were discussed by the panel. The Korean word for addressing control of the situation was chosen by the three-member panel as the closest approximation of the meaning of spontaneous because the expression appeared to be more relevant within the caregiving context.

For another item on the same subscale: “I have no hope, I am grasping at straws,” there is no equivalent Korean idiom for grasping at straws. Therefore, the idiom was translated into a Korean idiom: When one is drowning in water, he will try to hold on to anything, even a straw.

Another difficulty concerned the term blessing, which is used three times in the Provisional Meaning (PM) subscale. Even though there is a Korean word for blessing, the translators disagreed about its use. The Korean term for “blessing,” chugbog, is not commonly used and limited to use in church and is related to a spiritual blessing. However, because there was no other appropriate word, the term chugbog was eventually used.

Sample

The Korean caregivers were recruited for this study through social service agencies, churches, and physicians’ offices in Seoul and the Chicago and Los Angeles areas using “snowball” sampling. Informants were the primary caregivers of elderly relatives with dementia, providing care daily. The sample, which included five daughters-in-law, three daughters, and two wives, were aged from 36 to 72. All caregivers spoke, read, and wrote Korean as their primary language, and interviews were conducted in Korean.

Data Collection

Semistructured individual interviews lasting 60 to 90 minutes were conducted in the informants’ homes. Each interview had two parts. First, each caregiver was asked whether each item of the FMTCS was relevant to her caregiving experiences. An explanation was elicited if an item was not relevant. Second, each caregiver was asked if there were other important thoughts or feelings making sense of her caregiving experiences that were not in the FMTCS. Interviews were phonically recorded, translated from Korean to English, and transcribed for analysis.

Analysis of Data

The interview data were coded using standard qualitative content analysis (Miles & Huberman, 1994). Initially, the primary author independently identified and categorized codes for subjects’ responses to each question. Next, the data were divided by caregivers’ relationships to care recipients to identify any relation-specific patterns wimin the data. Then, a qualitative researcher independently assigned subjects’ responses to codes to assess inter-rater reliability. In areas in which the two did not agree, definitions were clarified and discussions were continued until a consensus was reached. In addition, responses to each item were examined separately to determine which items were typically difficult for Korean caregivers to understand.

The interview data were examined from three perspectives to assess the scale’s cross-cultural transferability to Korean caregivers: semantic, content, and conceptual equivalence (Flaherty et al., 1988). Semantic equivalence was examined to determine whether the meaning of each item remained the same after translation into Korean. Items that were typically problematic for Korean caregivers to understand or interpret were examined to determine the comparability of the Korean language to the original language. Content validity was examined item by item to determine whether the items were relevant for Korean caregivers. Conceptual equivalence was examined to evaluate whether an item measured the same construct in different cultures (Flaherty et al., 1988). When caregivers suggested rewording or rephrasing an item, their suggestions were considered potential ways to refine the FMTCS to make it a culturally appropriate and valid measure for finding meaning among Korean caregivers.

RESULTS

Semantic Equivalence

As expected, several respondents questioned the use of chugbog in relation to their caregiving experiences. Thus, items containing the term “blessing” might have produced biased responses from Korean caregivers because they may under-report feelings that are not the religious blessing that chugbog denotes.

For the item “I am a strong person” on the PM subscale, one wife said, “Yes, I’m a strong person. Even though I have a small frame, in fact, I’m strong.” Her response was more physically than emotionally oriented. The word “strong” can connote physical or mental strength. The translation would have been clearer had it been, “I am a mentally strong person.”

Content Equivalence

Loss/Powerlessness Subscale (19 Items).

The LP subscale of the FMTCS includes two areas of concentration: feelings of powerlessness (12 items) and feelings of loss (7 items) (Farran et al., 1999). Korean caregivers suggested that the 12 items measuring feelings of powerlessness, such as “I wish to be free” and “I feel trapped,” were relevant for Korean culture.

In contrast, of the seven items measuring feelings of loss, five were not relevant for some of the Korean caregivers. These items included feelings related to “missing past communications,” “the patient’s ability to love me,” “little things we did together,” “losing the person I once knew,” and “our previous social life.” Caregiving is a culturally bestowed responsibility for Korean daughters-in-law, rather than the outcome of a previous loving relationship, thus, the daughters-in-law often have not developed meaningful relationships wirn their in-laws before becoming their caregivers. They never had a social life together; they did not miss it. They became caregivers because their culture mandated that they do so.

Provisional Meaning Subscale (19 Items).

Seventeen of the 19 items of the PM subscale appeared to be relevant to Korean caregivers. The 17 items focus on how caregivers find day-to-day meaning through caregiving, such as, “Caregiving helps me feel good that 1 am helping,” or “I am glad I am here to care for my relative.” The other two items’ relevance to Korean daughters-in-law was questionable. “Cherishing the past memories” and “the hugs and ‘I love you’ make it worth it all” were troublesome to most Korean daughters-in-law. One daughter-in-law said, “There are no hugs, or ‘I love you.’ Such things don’t exist in Korean culture, especially between a mother-in-law and a daughter-in-law.”

Ultimate Meaning Subscale (5 Items).

As with all cultural groups, many of the items on the 5-item UM subscale did not appear applicable to caregivers who claimed no religion: “The Lord won’t give you more than you can handle,” “1 believe in the power of prayer,” “1 believe that the Lord will provide,” “I have faith that the good Lord has reasons for this,” and “God is good.” One daughter-in-law said, “Because I don’t have any religion, I never thought about this before,” and “1 think that the Lord applies only for someone who has a religion.”

Conceptual Equivalence

When caregivers were asked to share their ways of finding meaning and making sense of their experiences, many themes emerged that were similar to those reported by Farran and colleagues (1991), such as making personal choices about life and caregiving and valuing the positive aspects of caregiving.

In addition, Korean caregivers found meaning in caregiving that was related to an interpersonal context. Many Korean caregivers talked about their appreciation of their family members’ support. Almost all talked about how they were glad to fulfill their responsibilities or obligations. Many caregivers talked about their appreciation of their financial and physical ability to provide care for their relatives. Themes that were new among these caregivers were the importance the caregivers placed on teaching children and feeling proud of themselves before other relatives.

Importance of Teaching Children.

Some Korean caregivers noted how important it was to be role models for their children and to teach their children how to provide care for elders, how to respect elders, how to fulfill their responsibilities, and how to accept a situation. One KK daughter-in-law stated:

I can be a role model to my children, I’m glad … I’m proud of myself in front of my children. I don’t want to hear from my children later, “How good were you to our grand-mother?” That’s why I do my best in providing care for my mother-in-law.

Feeling Proud of Oneself in Relation to Others.

One daughter-in-law described how proud of herself she was in front of her husband’s siblings because of all her husband’s many siblings, she was the one providing care. She stated:

I’m proud of myself in front of my brothers and sisters-in-law. Because I provide tare for her [mother-in-law], they [my brothers and sisters-in-law] treat me nice. At times, I feel I don’t want to do this. But because my relatives-in-law treat me nice, thank me for what I’m doing, and feel sorry for my trouble, how can 1 refuse to take care of her? In that way, I feel rewarded … There are seven siblings in my husband’s family, five brothers and two sisters. Some of them don’t want to provide care for her [my mother-in-law] even though they can afford to. They would provide lip services, but none of them want to live with my mother-in-law … I’m proud of myself that 1 do what I say.

DISCUSSION

Korean women caregivers agreed that the majority of the items on the three FMTCS subscales were relevant and appropriate to their caregiving experiences, except for items measuring feelings of loss. The concept of finding meaning through caregiving appears helpful in understanding why some Korean caregivers have more strength than others in similar caregiving situations, even as the construct is helpful in understanding European American caregivers (Farran et al., 1999).

However, dimensions of finding meaning found relevant for European Americans appear less relevant for Korean caregivers. Several items on the LP and PM subscales that measure unaffectionate relationships between care recipients and caregivers appear irrelevant for the majority of Korean daughter-in-law caregivers. Korean daughters-in-law are likely to become caregivers based on cultural expectations rather than affectionate relationships. In Korean culture, the adult son, especially the eldest son, is responsible for his elderly parents, and the oldest son’s wife is usually responsible for providing daily care for her parents-in-law based on traditional filial expectations (Choi, 1993; Youn, Knight, Jeong, & Benton, 1999). Filial piety is a major motivation tor Koreans who care for their parents (Lee & Sung, 1997, 1998; Sung, 1992, 1994, 1995). Studies of Korean daughter-in-law caregivers consistently report that they express significantly higher filial responsibility and less affection than American caregivers (Lee & Sung, 1997; Sung, 1994). Therefore, caution is warranted when using the FMTCS, especially the LP and PM subscales, with Korean daughter-in-law caregivers.

Further, Korean caregivers’ perceptions of their caregiving experiences appeared affected by their interpersonal context, not simply by the individual context. Asian Americans tend to value harmony and the unity of the family, and they emphasize interpersonal relationships and interdependence (Braun & Browne, 1998). Indeed, filial piety has been summarized as “putting one’s family members in a harmonious order by caring for one’s parents with love, respect, responsibility, and desire to repay” (Sung, 1998). In this sample, daughters and daughters-in-law especially emphasized the importance of teaching their children how to serve their elders.

The interpersonal context is not a part of finding meaning in the FMTCS. However, based on these findings, items could be added to the Korean version of the FMTCS to measure the interpersonal context of finding meaning to make the scale culturally appropriate and valid. For example, an additional item on the LP subscale might be, “I received support/recognition from my family members.” On the PM subscale, an additional item might be, “I am proud in front of other family members because I provide care to my relative” and “My caregiving situation helps me to teach my children.” Clearly, such items may be equally relevant to the European Americans and these items may be worthy of testing within that population as well.

Items on the PM and UM subscales based on Christian beliefs should be revised for caregivers, not just Korean caregivers, but also any caregivers who have a religion other than Christianity or no espoused religion. Items that assess the broader dimensions of spirituality may be better than items that address a specific religion. Semantic inequivalence in translation occurred here because the Korean language lacks a literal translation for the word “blessing” when used in its vernacular context. People who do not hold Christian beliefs or who are not familiar with the word “blessing” may have difficulties responding to the items of these subscales.

LIMITATION OF THE STUDY

This study used a small number of Korean-born caregivers who lived in large urban areas of Korea and the United States. American-born Korean caregivers and those who live in rural areas may have different perspectives on finding meaning through caregiving. The study design of cross-sectional interviews might not have captured changes in found meaning as caregivers’ experiences continued.

CONCLUSION

A Euro-centric bias often underlies instruments used to measure psychosocial phenomena. Instruments developed and normed with majority groups are often used with members of different cultures without critical evaluation. This research project used individual interviews to assess the cultural appropriateness of the Finding Meaning Through Caregiving Scale with Korean caregivers and demonstrated that instruments developed and normed with one group must re-evaluate the appropriateness of their cultural context before they can be used with confidence with other groups. Among Korean and Korean American caregivers, filial expectations appear to influence profoundly their ways of finding meaning, especially among daughter-in-law caregivers.

Adding several items related to finding meaning through the interpersonal context of caregiving can make the FMTCS culturally applicable for Korean caregivers. Furthermore, caution is warranted when the instrument is used with Korean daughter-in-law caregivers because six items on the subscales do not apply equally. Finally, for test takers from all cultural groups who do not align themselves with Christian constructs, the questions related to finding spiritual meaning may not be relevant.

Further research with a larger number of KA subjects is needed to establish the psychometric properties of a revised FMTCS based on this study’s findings. Establishing validity of the revised FMTCS is recommended through examining the relationships between the FMTCS and instruments measuring other constructs, such as caregiving burden and stress of satisfaction. Once the revised scale is tested and validated among Korean caregivers, it can be tested with other Asian-American caregiver groups, who have many commonalities related to family values and interpersonal relationships, as well as other minority groups (Asahara, Momose, Murashima, Okubo, & Magilvy, 2001; Braun & Browne, 1998). Then intra- and inter-cultural group comparisons will be possible for multiple groups of caregivers.

This study demonstrates that using semistructured interviews is an effective preliminary strategy for detecting both acceptable and problematic items on instruments such as the FMTCS. Routine examination of the cross-cultural equivalence of an instrument with a relatively small number of individual interviews is recommended before using the instrument with a new cultural group. The individual interview method indicates a broader applicability for assessing the adequacy of an instrument, and the method should be effective for making a preliminary assessment of the cross-cultural appropriateness of instruments used with a variety of cultural groups.

Acknowledgments.

This study was primarily supported by the Individual National Research Service Award Predoctoral Fellowship from the National Institutes of Health (1F31 NR 07285-01), the Institutional Postdoctoral Fellowships at the University of Iowa College of Nursing (T32 NR07058), the faculty research fund at the University of San Diego, and the Mentored Scientist Development Award (MSDA) from National Institute of Nursing Research (K01 NR 08096) to Dr. Eunice E. Lee. The authors are grateful to Drs. Allen Orsi, Diane Hatton, Linda Robinson, and Jane Geroges at the University of San Diego, and Dr. Vanessa Malcarne at San Diego State University, for their helpful consultation in the preparation of this article.

Contributor Information

Eunice E. Lee, University of Illinois at Chicago College of Nursing

Carol J. Farran, Rush University Chicago, IL

Toni Tripp-Reimer, The University of Iowa College of Nursing, Iowa City, IA.

Georgia Robins Sadler, UCSD School of Medicine, La Jolla, CA.

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