Abstract
Background: Researchers have identified important gender differences in the experience of caring for a family member or friend living with advanced disease; however, trends suggest that these differences may be diminishing over time in response to changing gender roles. In addition, while many studies have found caregiving experiences and outcomes to be poorer among female caregivers, noteworthy exceptions exist.
Objective: The primary aim of this exploratory study was to determine how, if at all, current day caregiving at end of life varies by gender.
Methods: We conducted a secondary analysis of data from a multisite randomized controlled trial of a family caregiving intervention performed between 2010 and 2014. We compared female and male hospice family caregivers on baseline variables using χ2 tests for association of categorical variables and t-tests for continuous variables. Our sample included 289 family caregivers of individuals receiving services from one of two hospice agencies located in the northwestern United States. Demographic data and other categorical variables of interest were provided via caregiver self-report using an instrument created specifically for this study. Reaction to caregiving and caregiving burden were measured using the Caregiver Reaction Assessment (CRA).
Results: As it related to caregiving, females had significantly lower self-esteem and more negative impact on their schedule, health, and family support than males. No gender differences were detected with regard to the impact of caregiving on individuals' finances.
Conclusions: Despite changing social expectations, pronounced gender differences persist in caregiving at the end of life.
Introduction
Family members and friends play an essential role in caring for individuals with advanced disease who are nearing the end of their lives.1 As illnesses progress, family caregivers become increasingly responsible for both hands-on care (e.g., assisting with bathing, toileting, and hygiene) and providing support for instrumental activities of daily living such as cooking, cleaning, and paying bills.2 In addition to primary stressors directly related to caregiving tasks, many family caregivers must also cope with secondary stressors, such as financial challenges and the need to manage family communication, that indirectly result from occupying a caregiving role.3 While many family caregivers are able to describe positive aspects of their caregiving experience,4 research suggests that the multiple stressors associated with family caregiving at the end of life can give rise to serious negative outcomes including increased anxiety, poor physical health, and compromised quality of life.5
Hospice teams' work with family caregivers
According to the National Hospice and Palliative Care Organization,6 over 1.5 million U.S. patients and their family members received care from a hospice agency in 2013. To access care under the Medicare Hospice Benefit, the predominant source of payment for hospice services in the Unted States,6 patients must be expected to live six months or less if their disease takes its natural course.7 After choosing hospice, patients and families receive services provided by an interdisciplinary team of health care professionals including nurses, physicians, chaplains, social workers, and others.8
Hospice teams view patients and families as interdependent and, thus, provide services to both as a single unit of care.9 As such, hospice professionals are ideally positioned to support family caregivers of patients with limited life expectancy via interventions such as counseling to ameliorate psychological distress, facilitating advance care planning, and helping family members prepare for the patient's death.9 Recognizing that each patient and family are unique, experts recommend that hospice professionals provide end-of-life care based on individualized assessments of each family's resources, strengths, expectations, and identified needs.10
Reactions to caregiving and caregiving burden
Even when faced with similar responsibilities, no two hospice family caregivers are affected in exactly the same way. Given and colleagues11 identified five dimensions of caregiving burdens and reactions that potentially differ among individual caregivers and caregiving groups. The first dimension, caregiver self-esteem, relates to the ways in which the caregiving experience affects the caregiver's sense of self-worth. Someone whose self-esteem is positively affected by caregiving might report that they find caregiving to be a privilege or that caregiving fulfills them. The second dimension, impact on finances, pertains to the financial consequences of caregiving, which may vary considerably among groups with different assets and/or levels of income. Impact on schedule is the third dimension of caregiving burdens and reactions. It accounts for the various ways in which caregivers' daily activities may be affected by their caregiving responsibilities. For example, caregivers may see friends and family less frequently as a result of caregiving or may stop or reduce work outside of the home to care for a family member. Impact on health, the fourth dimension, takes into consideration the toll caregiving can have on individuals' physical health. Feeling tired all the time or believing one's health has deteriorated as a result of caregiving are negative potential reactions to the caregiving experience. Finally, caregivers may report a lack of family support, which is the fifth dimension of caregiving burdens and reactions. Individuals with a lack of family support may report feeling abandoned or feeling as if caregiving responsibilities have been “dumped” onto them by less involved family members.
Theoretical framework: The Stress Process Model
Differences in reactions to end-of-life caregiving and caregiving burden take on increased importance when viewed through the lens of the Stress Process Model (SPM).12 The SPM posits that caregiving outcomes (e.g., caregiver quality of life, psychological well-being) result from a process in which individuals encounter both primary and secondary stressors. Primary stressors are directly related to the provision of care (e.g., need to administer daily medications), while secondary stressors result from caregiving but do not directly involve the provision of care (e.g., inability to get away to spend time with friends). In addition, the SPM emphasizes the importance of caregivers' backgrounds (including pertinent demographic characteristics) and the context in which they provide care (e.g., their caregiving history, the amount of care they provide). Thus, the SPM suggests that, by better understanding differences in caregivers' characteristics and experiences, members of the hospice interdisciplinary team will be better equipped to identify opportunities to support family caregivers and to help them cope in such a way that negative caregiving outcomes are minimized or avoided entirely.
Gender and family caregiving
One of the caregiver demographic characteristics that has garnered considerable attention in recent years is gender. As has been the case historically, modern-day family caregiving responsibilities fall disproportionately on women; however, a growing number of men are assuming caregiving roles, a trend that is likely to continue as family life is reconstructed alongside ever-changing gender roles and expectations.13 Researchers have identified a number of caregiving outcomes that vary between men and women, with more negative effects generally found among female caregivers. For example, research findings have shown that, when compared with male caregivers, women in family caregiving roles are often more likely to experience psychological distress14–16 and physical health problems.17
There is reason to suspect that these disparities may be on the decline, however. Nearly a decade ago, Pinquart and Sorensen17 noted that gender differences in family caregiver variables tended to be smaller in more recent studies than in older ones, leading them to wonder if such differences were becoming less pronounced in response to changing gender expectations. This underscores the time-sensitive nature of research on gender differences in family caregiving and suggests that research in this important area of inquiry should be ongoing.
In addition, while many studies have identified poorer outcomes for female caregivers than males, a recent research synthesis18 cited gender as a variable that generated “equivocal” results when studied as a predictor of hospice family caregiver outcomes such as grief, burden, depression, and quality of life. It appears that, at least for family members caring for hospice patients, the issue of gender differences in caregiving experiences and outcomes is far from decided.
Study aim
The primary aim of this exploratory analysis was to determine how, if at all, caregiving at end of life varies by gender. We consulted the SPM and the existing body of research on family caregiving to inform our selection of other key variables of interest, ultimately choosing to focus our analysis on gender differences in terms of caregiving background and context in addition to caregiving reactions and burden. Specific variables are defined later in our discussion of study methods.
Methods
We conducted a secondary analysis of data from a multisite randomized controlled trial of a family caregiving intervention conducted between 2010 and 2014 in collaboration with two hospice agencies in one northwestern U.S. state (R01NR012213; principal investigator: Demiris). The institutional review board of the principal investigator's academic institution approved the original study prior to participant recruitment. Inclusion criteria required that participants were English-speaking adult family caregivers of a hospice patient at the time of their participation in the study, that they had no greater than mild cognitive impairment, and that they had functional hearing and access to the Internet and/or a standard phone line. Although study participants completed measures at various points throughout the original study, only baseline measures (i.e., those completed upon study enrollment and before exposure to any treatment conditions) were included in the present analysis. Most baseline measures were administered shortly after hospice services were initiated, as this typically coincided with the caregiver's enrollment in the study.
Study variables and corresponding measures
Demographic questionnaire
Information on caregiver background and context, including gender, age, race, ethnicity, relationship to patient, amount and duration of caregiving, and employment status was provided via self-report using a demographic questionnaire specifically designed for the original study.
Caregiver Reaction Assesssment
Study participants' reaction to caregiving and caregiving burden were measured using the Caregiver Reaction Assessment (CRA).11 Because the CRA focuses on the experiences of individuals actively involved in caregiving, bereaved family caregivers enrolled in the original study (43.8% of the total sample) did not complete the CRA. The CRA contains 24 Likert-type items divided among the following five subscales: caregiver self-esteem (seven items), impact on finances (three items), impact on schedule (five items), impact on health (four items), and lack of family support (five items). Researchers previously concluded that the CRA's psychometric properties are satisfactory, with internal consistencies for individual subscales ranging from 0.62 (lack of family support) to 0.83 (financial problems).19
Statistical analysis
We compared female and male hospice family caregivers on baseline variables using χ2 tests for association of categorical variables and t-tests for continuous variables. All analyses used listwise deletion of missing data, as there was minimal missing data (<3%). The primary analyses were calculated using multiple regression with robust standard errors using Huber-White sandwich estimators. The model contains gender and caregiver age, race/ethnicity, relationship to hospice patient, and amount and duration of caregiving as covariates. To further explore gender influences on caregiving experiences at the end of life, we added interaction terms combining significant covariates with gender to the regression models. All regression assumptions were satisfied, and we detected no evidence of multicollinearity across the independent variables, with a variance inflation factor of 1.53. Statistical analyses were conducted using Stata statistical software version 13.1 (StataCorp, College Station, TX).
Results
The sample consisted of 289 hospice family caregivers (76.1% female) with a mean (SD) age of 61.2 (12.2) years (range, 25–100 years). As previously indicated, this represented 56.2% of the total sample of family caregivers who participated in the original study. Caregivers in our analytic sample were predominantly white (87.9%) adult children (58.8%) or spouses/partners (27.3%) of the hospice patient. Most had been providing care for over one year (72.3%), and more than half (52.3%) provided care for 20 hours or more per week. There were no significant differences between female and male caregivers in terms of race/ethnicity, residing with the hospice patient, employment status, or amount of caregiving provided each week. Female caregivers were younger (mean difference = 4.3, p = 0.01), more likely to be an adult child of the hospice patient (61.8%) than male caregivers (49.3%, p = 0.02), and more likely than male caregivers to have provided care for a duration greater than one year (75.9% compared to 60.9%, p = 0.02). Descriptive statistics for the demographic and caregiving measures for the sample as a whole and for female and male caregivers are shown in Table 1.
Table 1.
Characteristics of Caregivers
| Characteristic | All caregivers (n = 289) n (%)a | Female caregivers (n = 220) n (%)a | Male caregivers (n = 69) n (%)a |
|---|---|---|---|
| Age, mean (SD) | 61.2 (12.2) | 60.1 (11.7) | 64.4 (13.5) |
| Race/ethnicity | |||
| White, non-Hispanic | 254 (87.9) | 194 (88.2) | 60 (87.0) |
| Asian | 12 (4.2) | 8 (3.6) | 4 (5.8) |
| Black, not Hispanic | 8 (2.8) | 6 (2.7) | 2 (2.9) |
| Hispanic or Latino | 6 (2.1) | 5 (2.3) | 1 (1.5) |
| Multiethnic | 9 (3.1) | 7 (3.2) | 2 (2.9) |
| Relationship to patient | |||
| Adult child | 170 (58.8) | 136 (61.8) | 34 (49.3) |
| Spouse or partner | 79 (27.3) | 51 (23.2) | 28 (40.6) |
| Other | 40 (13.8) | 33 (15.0) | 7 (10.1) |
| Resides with patient | 139 (48.1) | 99 (45.0) | 40 (58.0) |
| Employed | 130 (45.0) | 95 (43.2) | 35 (50.7) |
| Amount of caregiving (>20 hr/wk) | 153 (52.9) | 113 (51.4) | 40 (58.0) |
| Duration of caregiving (>1 year) | 209 (72.3) | 167 (75.9) | 42 (60.9) |
| CRA, mean (SD)b | |||
| Self-esteem | 4.0 (0.7) | 4.0 (0.7) | 4.2 (0.6) |
| Finances | 2.2 (1.0) | 2.2 (1.0) | 2.2 (1.2) |
| Schedule | 3.6 (0.9) | 3.6 (0.9) | 3.4 (0.8) |
| Health | 2.6 (0.6) | 2.7 (0.6) | 2.4 (0.6) |
| Family support | 2.2 (1.0) | 2.3 (1.0) | 1.8 (0.9) |
Due to rounding, percentages might not sum to 100.
Range 1–5; higher is greater caregiver burden on all subscales except self-esteem.
CRA, Caregiver Reaction Assessment.
Unadjusted gender differences in reactions to caregiving and caregiving burden were found in three of the five subscales of the CRA. Male caregivers reported greater positive impact on self-esteem (t(277) = 2.79, p = 0.01) and less negative impact on both health (t(277) = −2.16, p = 0.01) and family support (t(274) = −3.86, p < 0.001) than female caregivers. The results of regression analyses concerning gender differences in reaction to caregiving and caregiving burden when controlling for other key predictors are presented in Table 2. Gender differences in reaction to caregiving and caregiving burden were present even after adjusting for caregiver age, race/ethnicity, relationship to hospice patient, and both the amount and duration of caregiving. Specifically, female caregivers had significantly lower self-esteem and more negative impact on their schedule, health, and family support. There was no difference between female and male caregivers in terms of the impact of caregiving on their finances. We found no evidence of interactive effects for gender and age, gender and relationship, or gender and duration of caregiving for any of the dependent variables.
Table 2.
Characteristics Associated with Caregiver Reactions and Burden by Gender
| Subscalea | B (SE)b | 95% CI for B | P value |
|---|---|---|---|
| Self-esteem | |||
| Female | −0.20 (0.09) | −0.37 to −0.30 | 0.02 |
| Age | 0.00 (0.00) | −0.00 to 0.10 | 0.30 |
| White | −0.27 (0.10) | −0.47 to −0.07 | 0.01 |
| Spouse or partner | −0.16 (0.14) | −0.43 to 0.12 | 0.26 |
| Adult child | −0.18 (0.12) | −0.41 to 0.05 | 0.13 |
| Duration of caregiving | −0.17 (0.09) | −0.35 to 0.01 | 0.06 |
| Amount of caregiving | 0.28 (0.08) | 0.11 to 0.44 | 0.001 |
| R2 = 0.12, F7, 268 = 5.21, P < 0.001 | |||
| Finances | |||
| Female | 0.04 (.17) | −0.28 to 0.37 | 0.79 |
| Age | −0.01 (.01) | −0.02 to 0.00 | 0.05 |
| White | −0.44 (.20) | −0.83 to −0.04 | 0.03 |
| Spouse or partner | 0.14 (0.22) | −0.31 to 0.58 | 0.54 |
| Adult child | 0.02 (0.19) | −0.35 to 0.40 | 0.91 |
| Duration of caregiving | 0.01 (0.14) | −0.28 to 0.29 | 0.97 |
| Amount of caregiving | 0.16 (0.14) | −0.10 to 0.43 | 0.23 |
| R2 = 0.04, F7, 268 = 2.02, P = 0.05 | |||
| Schedule | |||
| Female | 0.22 (0.11) | 0.01 to 0.44 | 0.04 |
| Age | −0.02 (0.00) | −0.02 to −0.01 | ≤0.01 |
| White | 0.05 (0.16) | −0.27 to 0.37 | 0.77 |
| Spouse or partner | 0.32 (0.18) | −0.04 to 0.68 | 0.08 |
| Adult child | 0.20 (0.15) | −0.09 to 0.49 | 0.18 |
| Duration of caregiving | 0.02 (0.11) | −0.20 to 0.24 | 0.21 |
| Amount of caregiving | 0.76 (0.11) | 0.55 to 0.98 | ≤0.01 |
| R2 = 0.04, F7, 267 = 13.65, P < 0.001 | |||
| Health | |||
| Female | 0.21 (0.09) | 0.03 to 0.38 | 0.02 |
| Age | −0.00 (0.00) | −0.01 to 0.00 | 0.33 |
| White | 0.13 (0.13) | −0.13 to 0.39 | 0.33 |
| Spouse or partner | 0.22 (0.13) | −0.04 to 0.49 | 0.10 |
| Adult child | 0.15 (0.11) | −0.08 to 0.37 | 0.20 |
| Duration of caregiving | 0.16 (0.08) | 0.01 to 0.31 | 0.04 |
| Amount of caregiving | −0.03 (0.08) | −0.19 to 0.12 | 0.68 |
| R2 = 0.05, F7, 268 = 2.19, P = 0.04 | |||
| Family support | |||
| Female | 0.41 (0.13) | 0.15 to 0.67 | ≤0.01 |
| Age | −0.01 (0.01) | −0.03 to −0.00 | 0.04 |
| White | −0.21 (0.22) | −0.65 to 0.22 | 0.33 |
| Spouse or partner | −0.16 (0.24) | −0.63 to 0.30 | 0.48 |
| Adult child | 0.07 (0.20) | −0.33 to 0.46 | 0.74 |
| Duration of caregiving | 0.19 (0.12) | −0.05 to 0.44 | 0.12 |
| Amount of caregiving | −0.03 (0.13) | −0.29 to 0.22 | 0.80 |
| R2 = 0.11, F7, 265 = 7.53, P < 0.001 | |||
Higher scores on all subscales, except self-esteem, indicate greater caregiver burden.
Robust standard errors.
B, unstandarized regression coefficient; CI, confidence interval; F, F-statistic; R2, R-squared; SE, standard error.
Discussion
In many respects, these results echo the findings of other studies on gender differences in caregiving. In their meta-analysis of over 200 studies of family caregiving, Pinquart and Sorensen17 found solid support for their hypothesis that caregiving women report higher levels of burden than their male counterparts, consistent with our findings. It is noteworthy, however, that these differences persist nearly a decade later, especially given Pinquart and Sorensen's finding that gender differences in caregiver variables appeared less pronounced in later studies.
Other researchers have tried to explain why gender differences in perceived burden exist. Research by Papastavrou and colleagues20 indicates that coping may play a role. In their study of family caregivers of individuals with dementia, they found that women reported using emotional coping strategies more than men did which, at least in part, explained their high levels of burden. This explanation would be consistent with the previously described SPM,12 which features coping as a mediator of relationships among background and context, stressors/strains, and outcomes. Viewing these findings with a different theoretical lens introduces alternate explanations for our findings, however. In their exploration of feminist perspectives on family care, Hooyman and Gonyea21 examined the repercussions of the socially constructed view of women as “natural” caregivers, highlighting the many ways in which fulfilling family care responsibilities is viewed as an expectation for women. Feeling as if caregiving is an assumed or “natural” responsibility rather than a choice could clearly affect one's reaction to caregiving and the degree to which they experience caregiving as burdensome. For example, if caring for a seriously ill family member is merely an extension of a lifelong caregiving career, female caregivers might be less likely to view it as a privilege or something they enjoy. Similarly, if family members view female caregivers as naturally better at caregiving, they might be less likely to perceive support as being needed and, thus, be less likely to offer it.
Implications for hospice teams
Our study findings have a number of implications for hospice teams. Interventions consistent with the SPM are available to support women in caregiving roles by enhancing their ability to cope with their often highly stressful situations. Prior research indicating that problem-focused (versus emotion-focused) coping was associated with lower levels of perceived caregiver burden lends support for specific interventions such as problem-solving therapy, which is supported by a robust evidence base22 and has shown promise in hospice-specific settings.23 Interventions consistent with a feminist perspective on family care may involve helping female caregivers access support from their social network of family members and friends, who may be less likely to perceive women as needing help in their caregiving role than men or who may be more likely to provide unsolicited critiques of caregiving provided by women, who are often assumed to be “natural” caregivers. This may involve structured interventions, such as assertiveness training or communication skills education, but it may also be accomplished through the provision of peer support. For example, caregivers may benefit from hearing how others have secured tangible support by taking advantage of even vague offers of help (e.g., “If there's ever anything I can do…”) from family members and friends. Finally, all caregivers—women and men alike—stand to benefit from interventions at the macro level that create structural changes to support family caregiving and that acknowledge the tremendous social benefit provided by the family members and friends who care for others in their final days of life.
Study limitations
A number of study limitations warrant attention. First, our study conceptualized gender as a binary construct, a practice that is increasingly challenged in favor of approaches that more adequately reflect the complexity of gender and gender expression in U.S. society.24 Second, our study sample was limited to volunteer participants from two hospice agencies of one geographic region in the United States. Therefore, our findings cannot necessarily be generalized to the full hospice caregiver population, to those whose care recipients do not receive services from a hospice agency, or to those who differ from participants in our study in other important respects (e.g., age, relationship to the care recipient). Third, our study examined only baseline data cross-sectionally. Future research would benefit from a longitudinal examination of gender differences in the caregiving experience.
Finally, we strongly caution against interpreting our results as evidence that the male caregiving experience is easy or that male caregivers would not benefit from additional support. On the contrary, research indicates that men often experience a decline in well-being upon entering a caregiving role (e.g., decreased happiness, increased depression among husband caregivers)25 and are often reluctant to share personal feelings or access support services.26 In addition, some speculate that male caregivers participating in research studies may underreport caregiving challenges and symptoms of distress, drawing into question the extent to which identified gender differences accurately reflect caregivers' experiences.27
Future studies including male caregivers would be enhanced by careful consideration of this possibility and by implementing strategies to enhance the validity of caregivers' responses to self-report measures. Potentially helpful strategies include emphasizing the confidential nature of the research and/or asking participants to report on their caregiving strengths as well as the challenges they have faced. On the practice front, hospice professionals should ensure that supports are available for all family caregivers and acknowledge the many ways in which families and communities benefit from their contributions.
Acknowledgment
This study was supported by the National Institute of Nursing (research award number R01NR012213; principal investigator: Demiris), registered as clinical trial record NCT01444027. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health.
Author Disclosure Statement
No competing financial interests exist.
References
- 1.Rabow MW, Hauser JM, Adams J: Supporting family caregivers at the end of life: “They don't know what they don't know.” JAMA 2004;291:483–491 [DOI] [PubMed] [Google Scholar]
- 2.Waldrop DP, Kramer BJ, Skretny JA, et al. : Final transitions: Family caregiving at the end of life. J Palliat Med 2005;8:623–638 [DOI] [PubMed] [Google Scholar]
- 3.Wittenberg-Lyles E, Demiris G, Parker Oliver D, et al. : Stress variances among informal hospice caregivers. Qual Health Res 2012;22:1114–1125 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Hudson P: Positive aspects and challenges associated with caring for a dying relative at home. Int J Palliat Nurs 2004;10:58–65 [DOI] [PubMed] [Google Scholar]
- 5.Stajduhar K, Funk L, Toye C, et al. : Part 1: Home-based family caregiving at the end of life: A comprehensive review of published quantitative research (1998–2008). Palliat Med 2010;24:573–593 [DOI] [PubMed] [Google Scholar]
- 6.National Hospice and Palliative Care Organization: NHPCO Facts and Figures: Hospice Care in America 2014. NHPCO, 2105. www.nhpco.org/sites/default/files/public/Statistics_Research/2014_Facts_Figures.pdf Last accessed September1, 2015 [Google Scholar]
- 7.U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services: Medicare and Medicaid Programs: Hospice Conditions of Participation 2008. U.S. Department of Health and Human Services, 2009. www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R65SOMA.pdf Last accessed September1, 2015 [Google Scholar]
- 8.Parker Oliver D, Peck M: Inside the interdisciplinary team experiences of hospice social workers. J Soc Work End Life Palliat Care 2006;2:7–21 [DOI] [PubMed] [Google Scholar]
- 9.Weisenfluh S: Social work and palliative care in hospice. In: Altman J, Otis-Green S. (eds): Oxford Textbook of Palliative Social Work. New York: Oxford University Press, 2011, pp. 71–78 [Google Scholar]
- 10.Gwyther LP, Altilio T, Blacker S, et al. : Social work competencies in palliative and end-of-life care. J Soc Work End Life Palliat Care 2005;1:87–120 [DOI] [PubMed] [Google Scholar]
- 11.Given CW, Given B, Stommel M, et al. : The caregiver reaction assessment (CRA) for caregivers to persons with chronic physical and mental impairments. Res Nurs Health 1992;15:271–283 [DOI] [PubMed] [Google Scholar]
- 12.Pearlin LI, Mullan JT, Semple SJ, Skaff MM: Caregiving and the stress process: An overview of concepts and their measures. Gerontologist 1990;30:583–594 [DOI] [PubMed] [Google Scholar]
- 13.Kramer BJ, Thompson EH: Men as Caregivers. Amherst, NY: Prometheus Books, 2005 [Google Scholar]
- 14.Parker Oliver D, Albright DL, Washington K, et al. : Hospice caregiver depression: The evidence surrounding the greatest pain of all. J Soc Work End Life Palliat Care 2013;9:256–271 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Washington KT, Demiris G, Pike KC, et al. : Anxiety among informal hospice caregivers: An exploratory study. Palliat Support Care 2014:1–7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Yee JL, Schulz R: Gender differences in psychiatric morbidity among family caregivers: A review and analysis. Gerontologist 2000;40:147–164 [DOI] [PubMed] [Google Scholar]
- 17.Pinquart M, Sorensen S: Gender differences in caregiver stressors, social resources, and health: An updated meta-analysis. J Gerontol B Psychol Sci Soc Sci 2006;61:P33–P45 [DOI] [PubMed] [Google Scholar]
- 18.Pottie CG, Burch KA, Thomas LP, Irwin SA: Informal caregiving of hospice patients. J Palliat Med 2014;17:845–856 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Nijboer C, Triemstra M, Tempelaar R, et al. : Measuring both negative and positive reactions to giving care to cancer patients: Psychometric qualities of the Caregiver Reaction Assessment (CRA). Soc Sci Med 1999;48:1259–1269 [DOI] [PubMed] [Google Scholar]
- 20.Papastavrou E, Kalokerinou A, Papacostas SS, et al. : Caring for a relative with dementia: Family caregiver burden. J Adv Nurs 2007;58:446–457 [DOI] [PubMed] [Google Scholar]
- 21.Hooyman NR, Gonyea JG: Feminist Perspectives on Family Care: Policies and Gender Justice. Thousand Oaks, CA: Sage, 1995 [Google Scholar]
- 22.Nezu AM, Nezu CM, D'Zurilla TJ: Problem-solving therapy: Empirical support and flexibility of applications. In: Problem-Solving Therapy: A Treatment Manual. New York: Springer, 2013 [Google Scholar]
- 23.Parker Oliver D, Washington K, Demiris G, et al. : Problem solving interventions: An opportunity for hospice social workers to better meet caregiver needs. J Soc Work End Life Palliat Care 2012;8:3–9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Markman ER: Gender identity disorder, the gender binary, and transgender oppression: Implications for ethical social work. Smith Coll Stud Soc Work 2011;81:314–327 [Google Scholar]
- 25.Kramer BJ, Lambert JD: Caregiving as a life course transition among older husbands: A prospective study. Gerontologist 1999;39:658–667 [DOI] [PubMed] [Google Scholar]
- 26.Kaye LW: Service utilization and support provision of caregiving men. In: Kramer BJ, Thompson EH. (eds): Men as Caregivers. Amherst, NY: Prometheus Books, 2005, pp. 359–378 [Google Scholar]
- 27.Bookwala J, Newman JL, Schulz R: Methodological issues in research on men caregivers. In: Kramer BJ, Thompson EH. (eds): Men as Caregivers. Amherst, NY: Prometheus Books, 2005, pp. 69–96 [Google Scholar]