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The Journals of Gerontology Series B: Psychological Sciences and Social Sciences logoLink to The Journals of Gerontology Series B: Psychological Sciences and Social Sciences
. 2021 Sep 2;77(7):1269–1279. doi: 10.1093/geronb/gbab160

Family Matters: Cross-Cultural Differences in Familism and Caregiving Outcomes

Francesca Falzarano 1,✉, Jerad Moxley 2, Karl Pillemer 3, Sara J Czaja 4
Editor: Jessica Kelley
PMCID: PMC9255933  PMID: 34473247

Abstract

Objectives

The increasing number of minority older adults, and the subsequent increase in family members providing care to these individuals, highlights the need to understand how cultural values contribute to differential caregiving outcomes. Using the sociocultural stress and coping model as a guiding framework, the current study examined cross-cultural relationships among familism, social support, self-efficacy, and caregiving outcomes and examines how these relationships vary as a function of caregiver background characteristics.

Methods

Baseline data were collected from 243 participants in the Caring for the Caregiver Network randomized controlled intervention trial. Participants completed measures assessing familism, social support, self-efficacy, positive aspects of caregiving, depression, and burden.

Results

African American and Hispanic participants exhibited higher levels of familism compared to Whites. Compared to White participants, African Americans’ endorsement of familism predicted more positive caregiving appraisals. African Americans also reported greater levels of social support, which in turn predicted lower burden and depressive symptoms when compared with Whites. Exploratory analyses demonstrated significant associations between familism and self-efficacy. In the Hispanic subgroup, familism varied as a function of acculturation.

Discussion

Results indicate that greater levels of familism and social support may exert a protective influence against adverse psychosocial caregiving outcomes. These findings can be used to inform intervention efforts targeting culturally congruent, family-centered approaches.

Keywords: Caregiver burden, Cultural values, Depression, Ethnicity, Social support

As older adults live longer with chronic illnesses and disabilities, family members are increasingly relied upon to assume responsibility for their loved one’s care. Over the past several decades, researchers have focused on understanding the potential consequences of family caregiving and its impact on mental and physical health (Capistrant et al., 2016; Joling et al., 2010; Pillemer et al., 2020), as well as the beneficial and rewarding features of caregiving that may buffer care-related burden (Doris et al., 2018). These studies underscore that the perceived impact of caregiving and its associated stress vary across caregivers (Schulz et al., 2020), and the heterogeneity in the relationship between caregiving stressors and outcomes can be influenced by intervening variables, including social support and cultural beliefs (McAullife et al., 2020; Rozario & DeRienzis, 2008). Cultural diversity in the United States reflects a demographic shift, with increasing numbers of minority older adults, including individuals from Hispanic and African American backgrounds (Epps et al., 2014). The increase in minority older adults, and subsequent increase in minority family caregivers, highlights the need to better understand how cultural values contribute to differential caregiving outcomes.

Older African American and Hispanic individuals are disproportionately at higher risk than older White Americans to have Alzheimer’s disease or other related dementias (ADRD; Alzheimer’s Association, 2021). ADRD caregiving is generally more demanding compared to other types of caregiving due to the chronic, progressive nature of ADRD. ADRD caregivers generally experience greater levels of burden compared to other types of caregivers (Riffin et al., 2017), and the role involves more intensive levels of care, including management of problematic behaviors in addition to assisting with activities of daily living and instrumental activities of daily living, as well as care coordination tasks and in some cases medical/nursing tasks. Given the increasing number of minority older adults at risk for ADRD, and the fact that ADRD caregiving is generally associated with higher levels of burden, a better understanding of how culture influences the caregiving process is needed.

The construct of familism has been examined as a driving mechanism of cross-cultural differences in caregiving outcomes. Familism is a cultural value that centers around a sense of collectivism and family attachment, consisting of three factors: familial obligations (obligation to provide care), perceived support (perception of support received from family), and family as referents (using relatives’ views as behavioral/attitudinal references; Knight & Sayegh, 2010). It has been proposed that caregivers who strongly endorse familistic values may be less vulnerable to the negative psychosocial effects of caregiving because caregiving is naturally integrated within a family’s belief system (Dilworth-Anderson et al., 2004). Research suggests that familism can buffer the negative effects of care-related stress, and that African Americans and Hispanics are more likely to be guided by cultural values in their caregiving role compared to Whites (Coon et al., 2004; Depp et al., 2005; McCallum et al., 2007).

Familism, Caregiving, and Psychosocial Outcomes

Existing work investigating racial/ethnic differences in caregiving outcomes has produced mixed results. Some literature has shown that African American caregivers tend to report lower stress appraisals, burden, and depression compared to Whites (Janevic & McConnel, 2001; Kim et al., 2007). Knight et al. (2002) found that familism was high in African Americans, but unrelated to distress, whereas Epps (2014) found that familial obligation predicted higher positive caregiving appraisals. Although no differences in familial obligation were identified, African Americans reported significantly higher positive caregiving appraisals compared to Whites, but not to Hispanics. Furthermore, Pinquart and Sörenson (2005) found that ethnic minorities have worse physical health but better psychological health outcomes, with African Americans reporting lower levels of burden and depressive symptoms. Alternatively, Hispanics exhibited more depression and lower levels of relational quality compared to Whites. According to Pinquart and Sörenson (2005), the finding with regard to better outcomes in African Americans could be attributed to greater familism, higher intrinsic motivation to provide care, greater social support, and use of cognitive coping strategies to assist in deriving meaning from the caregiving role.

In a longitudinal study of African Americans, Dilworth-Anderson et al. (2004) found that those who had either weak or very strong cultural justifications for caregiving had worse psychosocial outcomes, compared to those with moderate levels of cultural justification. Among Hispanics, the cultural emphasis on familism may lead caregivers to neglect their own well-being and self-care to prioritize the needs of their family member, which may contribute to adverse caregiving outcomes (Losada et al., 2010; Sayegh & Knight, 2011).

The influence of culture in caregiving is reflected in Knight and Sayegh’s (2010) sociocultural stress and coping model, which highlights that the negative effects of stress may be mediated by contextual variables including coping, burden, and social support. Furthermore, this model proposes that racial, ethnic, and cultural factors can affect the perception and appraisal of contextual factors, which in turn exerts differential influences on the stress and coping process and subsequent caregiver outcomes. This framework suggests that familism may indirectly affect caregiving outcomes, such that cultural values influence coping strategies, subjective appraisals of caregiver burden, and perceived social support. In an extension of this model, Montoro-Rodriguez and Gallagher-Thompson (2009) examined self-efficacy as a mediator in the relationship between ethnicity and burden and found that Hispanic caregivers reported greater self-efficacy and lower burden compared to Whites. This is consistent with other research demonstrating higher self-efficacy among Hispanic (Depp et al., 2005) and African American caregivers (Easom et al., 2018). Montoro-Rodriguez and Gallagher-Thompson (2009) suggest that self-efficacy can be conceptualized as a cultural value stemming from internalized cultural expectations/beliefs that may affect the perceived caregiving experience. What remains unclear, however, is whether cultural beliefs serve as risk or protective factors for ADRD caregivers, and how familism and self-efficacy vary as a function of race/ethnicity and acculturation.

An important consideration when examining cross-cultural values is the heterogeneity of cultural beliefs within ethnic groups. In a study comparing two Hispanic samples from the United States and Spain, Losada et al. (2006) found that familism was only associated with lower burden in the U.S. sample, which may reflect a number of within-group differences, including acculturation. Although familism was initially proposed as a straightforward construct to explain the diversity in caregiving outcomes, such that persons with strong familial values would perceive the caregiving experience as less stressful, research assessing familism in caregiving has been inconsistent.

Explanations for Mixed Findings

Numerous explanations have been proposed to ascertain the mixed evidence regarding the influence of familism in caregivers. Familism may be protective in individuals with extended social networks to rely upon for instrumental and/or emotional support (Epps et al., 2019; Losada et al., 2006). It has been posited that minority caregivers endorsing familism beliefs—many of whom have experienced socioeconomic adversity and have limited resource access—depend on the support of extended family networks to help with caregiving (Epps et al., 2019; Samson et al., 2016), which in turn makes familism a powerful adaptive resource (Losada et al., 2006). In contrast, high familism with little support can heighten distress (Gelman, 2014). Research (Knight & Sayegh, 2010; McCleary & Blain, 2013; Rozario & DeRienzis, 2008) has shown that individuals with more traditional beliefs may assume their role out of obligation, which can exacerbate feelings of role captivity and distress (Dilworth-Anderson et al., 2004). When a discrepancy exists between the demands of caregiving and available resources, a greater sense of obligation may reinforce feelings of shame, guilt, and frustration in failing to meet familial norms, further contributing to poor mental health (Losada et al., 2010).

Thus, incongruity may exist between a person’s ideal caregiving beliefs and the actual caregiving experience (Knight et al., 2002; Losada et al., 2010; Rosenthal-Gelman, 2010). Research has shown that caregivers who endorse high levels of familial obligation and family as referents may be at greater risk for depression through the activation of maladaptive coping strategies (Kim et al., 2007; Knight et al., 2002; Losada et al., 2010). However, some have also argued that cross-cultural differences may be more related to socioeconomic status than culture (Dilworth-Anderson et al., 2005; Kim et al., 2007), and barriers in obtaining formal services may reinforce expectations that care should be provided by family members.

Another underexplored element when considering cross-cultural differences is how cultural beliefs may operate as a function of the caregiver’s relationship to the care recipient. Prior research examining these associations has been mixed, with some evidence indicating that spousal caregivers may hold more traditional familial beliefs, with a higher perceived obligation to provide care (del-pino-Casado et al., 2011), while Parveen and Morrison (2009) argue that familism would be highest in young adults, as the obligation to provide care is based on a sense of needing to “repay” aging relatives. As previously mentioned, research has demonstrated that higher familism is associated with poor mental health (Knight et al., 2002; Losada et al., 2010), while others have shown that spousal caregivers may experience less anxiety and depression (Parveen et al., 2013) compared to nonspousal caregivers. The contradictory findings regarding the influence of familism on outcomes, including burden and depression, warrant further investigation into how familism varies based on the caregiver’s relationship to the care recipient, and its impact on psychosocial functioning.

The Current Study

The current study examines the impact of familism and social support on positive aspects of caregiving, burden, and depressive symptoms in a diverse sample of caregivers. We examine how the relationships between familism, social support, self-efficacy, and caregiver outcomes vary as a function of background characteristics including race/ethnicity, age, relationship to the care recipient, and acculturation. Using the sociocultural stress and coping model as a theoretical framework, we hypothesize that African Americans and Hispanics will exhibit higher familism, social support, and self-efficacy compared to Whites. Furthermore, we expect that greater familism will predict more positive caregiving outcomes (more positive appraisals, lower burden, and depressive symptoms). Among Hispanics, we hypothesize that familism will vary based on acculturation, such that a greater degree of acculturation will be associated with lower familism.

Method

Participants

The sample includes 243 caregivers who participated in the Caring for the Caregiver Network study, a randomized controlled trial examining a culturally tailored technology-based psychosocial intervention. Participants were recruited from the greater Miami area using a multipronged sampling approach including presentations and lectures given at community centers and support groups, distribution of flyers in health care clinics, radio and newspaper advertisements, professional networks, and participant referrals. One participant who reported their race as “other” was excluded. Inclusion criteria included (a) English or Spanish speaking, (b) ≥18 years of age, (c) provides care to a friend/family member with Alzheimer’s disease for a minimum of 15 h a week over 6 months, (d) has contact with the care recipient at least 5 times a week, (e) resides with or in close proximity to the care recipient, (f) noncognitively impaired based on age/education adjusted scores on the Telephone Interview for Cognitive Status (Brandt et al., 1988), and (g) reported at least two stressors related to caregiving.

Procedure

Caring for the Caregiver Network is a 6-month multicomponent, technology-based psychosocial intervention, delivered in both Spanish and English, designed to provide education, skills training, support, and reduce stress in racial/ethnically diverse ADRD caregivers. The present study uses baseline data, due to the likelihood that the intervention affected variables of interest, collected by a trained assessor in the participant’s home.

Measures

In addition to background characteristics (gender, race/ethnicity, relationship to care recipient, acculturation), measures included in the analyses were burden, depression, positive aspects of caregiving, familism, social support, and caregiver self-efficacy. For full measurement items for each scale, see Supplementary Table 1. Cronbach’s alpha for each measure is reported below. Consistent with Ursachi et al. (2015), Cronbach’s alpha values ranging from 0.6 to 0.7 are considered acceptable, and values greater than 0.8 are considered very good.

Burden

Burden was assessed using the 12-item version of the Zarit Burden Interview (Bédard et al., 2001). Each item began with the stem “Do you feel:” followed by questions such as “stressed between caring for your care recipient and trying to meet other responsibilities?” Participants responded on a Likert scale ranging from 0 (never) to 4 (nearly always). Reponses are summed, with higher scores indicating a higher burden. Cronbach’s alpha in the current sample was α = 0.84, indicating very good reliability.

Positive aspects of caregiving

Participants completed an 11-item instrument assessing positive feelings and experiences derived from the caregiving role (Tarlow et al., 2004). Each item began with the stem “Providing help to my care-recipient …” followed by items including “made me feel more useful.” The response scale ranges from 1 (disagree a lot) to 5 (agree a lot). Scores are summed, with higher scores reflecting more positive caregiving appraisals. Internal consistency in the current sample yielded a Cronbach’s alpha of 0.89, indicating very good reliability.

Familism

A 14-item measure (Sabogal et al., 1987) was administered asking participants to rate how much they agree with each statement on a scale from 1 (very much in disagreement) to 5 (very much in agreement). The measure includes three subscales: familial obligations (six items; “aging parents should live with their children”), familial support (four items; “one can count on the help from relatives to solve most problems”), and family as referents (five items; “much of what a son or daughter does should be done to please parents”). Reliability estimates in the current sample show a Cronbach’s alpha of 0.78, indicating acceptable reliability.

Social support

Social support was measured using 15 items assessing received support, social interaction, satisfaction with support, and negative interactions. Received support included four items measuring tangible, emotional, and informational support derived from a modified version of the Inventory of Socially Supportive Behaviors (Barrera et al., 1981; Krause, 1995). Participants rate the frequency of received support on a 4-point Likert scale ranging from 0 (never) to 3 (very often). Satisfaction with support (Krause, 1995) was assessed with four items: three items measured satisfaction with emotional, tangible, and informational support, and one item assessed global satisfaction with received support. Responses were based on a 4-point Likert scale ranging from 0 (not at all satisfied) to 3 (very satisfied). Social network was derived from the Lubben Social Network Index (Lubben, 1988), which included three items measuring the overall size of participants’ social network (family, friends, and neighbors). Response options consisted of a 5-point Likert scale rating the number of members in the participants’ social network. Negative interactions included four items (Krause, 1995) assessing the frequency of negative social interactions over the past month (“In the past month, how often have others been critical of you?”), with response options ranging from 0 (never) to 3 (very often). Cronbach’s alpha in the current sample was 0.73, indicating acceptable reliability.

Depression

Depression was measured using the 10-item version of the Center for Epidemiological Studies—Depression scale (Andresen et al., 1994). This scale asks participants to rate the presence of depressive symptoms over the previous week, with response options ranging from 0 (rare or none of the time) to 3 (most or all of the time). Scores are summed, with a range of 0–30. Cronbach’s alpha in the current sample was 0.61, indicating acceptable reliability.

Self-efficacy

Self-efficacy was assessed using the Revised Scale for Caregiver Self-Efficacy (Steffen et al., 2002), a 15-item measure comprising three subscales: obtaining respite care (“How confident are you that you can ask a friend/family member to do errands for you?”), responding to disruptive patient behaviors (“When you get angry because the care-recipient repeats the same question over”), and controlling upsetting thoughts about caregiving (“How confident are you that you can control thinking about what you are missing or giving up because of the care-recipient?”). Items are rated from 0 (cannot do at all) to 100 (certainly can do). Scores are summed, with higher scores indicating greater self-efficacy. Cronbach’s alpha in the current sample was 0.85, indicating very good reliability.

Acculturation

In Hispanics, years living in the United States were selected as an indicator of acculturation, with a longer length of time residing in the United States being indicative of greater acculturation. Additionally, the Hispanic sample was divided into two subgroups: U.S. natives versus nonnatives: Participants who immigrated to the United States before the age of 10 years were coded as U.S. natives, while those who immigrated after age 10 were considered non-U.S. natives.

Analysis

Descriptive statistics (means, standard deviations) were calculated for all measures, and mean group comparisons among White, Hispanic, and African Americans were examined. Structural equation modeling was used to examine the relationships among familism, social support, and caregiving outcomes (positive aspects of caregiving, burden, and depression). Latent variables were created for the social support and familism constructs. The social support latent construct included received support, satisfaction with support, and social network. The negative interactions subscale was not included because it was not highly intercorrelated with the other subscales. The familism latent construct included three subscales: familial obligation, support from family, and family as referents. Latent variables were used to predict the observed dependent variables of positive aspects of caregiving, depression, and caregiver burden in separate models. In all models, race is effects coded, with Hispanics used as a reference group. Several model fit indices were examined: the χ 2 test statistic, comparative fit index (CFI; a relative fit measure comparing the proposed model to a null model), root mean square error of approximation (RMSEA; an absolute fit index that adjusts for sample size), and standardized root mean square residual (SRMR; an absolute fit index comparing observed and predicted correlations).

We first report the model fit for the model examining racial differences via direct paths on our dependent variable. The second model examines the indirect effects of race on caregiving outcomes to test, using Δχ 2, if adding the direct path improves model fit. Race is examined as a variable whose impact on the outcome variables of burden, positive aspects of caregiving, and depression is mediated by social support and familism. We examine mediation by computing indirect effects using bootstrapping to estimate confidence intervals (CIs). Racial differences are expressed as differences in the grand mean of all participants. Because the largest group in this study was Hispanics, therefore contributing the most to the grand mean, the results are expressed in terms of African Americans compared to the grand mean and Whites compared to the grand mean. Finally, we examine familism in relation to age, relationship to the care recipient, self-efficacy, and acculturation in a series of exploratory analyses to better ascertain the relationships among these variables.

Results

The sample consisted of 243 participants ranging in age from 20 to 95 years and was comprised of 55 African Americans (Mage = 57.04, SD = 10.56), 79 Whites (Mage = 66.13, SD = 10.81), and 109 Hispanics (Mage = 59.75, SD = 14.35; Table 1). Overall, 28%, 58%, and 35% of African American, White, and Hispanic participants, respectively, were spousal caregivers. White participants were significantly older compared to African Americans and Hispanics. Furthermore, African Americans reported significantly higher positive aspects of caregiving (M = 26.18, SD = 7.74) compared to Whites (M = 22.06, SD = 8.60). African Americans (M = 50.56, SD = 5.89) and Hispanics (M = 49.73, SD = 6.05) also reported higher familism compared to Whites (M = 44.88, SD = 6.08).

Table 1.

Descriptive Statistics, f-Test, and Hedges g for Baseline Measures by Race of Variables Used in This Study

African American Whites Hispanic Americans
Variable n Mean (SD) n Mean (SD) n Mean (SD) f g A–W g A–H g W–H
CG age 55 57.04 (10.56) 79 66.13 (10.81) 109 59.75(14.35) 9.95** −0.84** −0.20 0.49**
Spouse % 54 27.78 (45.21) 78 57.69 (49.72) 108 35.19 (47.98) a a a a
Burden 55 17.49 (7.8) 79 20.59 (7.97) 109 18.59 (8.37) 2.61 −0.39* −0.13 0.24
Positive aspects of CG 55 26.18 (7.74) 78 22.06 (8.6) 109 23.87 (8.92) 3.74* 0.50** 0.27 −0.21
CES-D 55 9.53 (5.85) 79 11.5 (6.41) 109 11.57 (6.58) 2.12 −0.32 −0.32 −0.01
Received support 55 7.42 (2.71) 78 6.04 (2.39) 109 5.85 (2.83) 6.71** 0.54** 0.56* 0.07
Satisfaction with support 53 8.71 (2.66) 76 7.25 (3.51) 107 7.74 (3.74) 2.85 0.46* 0.28 −0.13
Social network 55 9.76 (2.53) 79 8.23 (3.37) 109 7.83 (3.31) 6.92** 0.50** 0.63** 0.12
Negative interactions 55 3.78 (2.64) 79 2.99 (2.64) 109 3.65 (2.77) 1.85 0.30 0.05 −0.24
Overall social support 53 34.26 (7.39) 76 30.43 (8.09) 107 30.03 (8.5) 5.18 0.49** 0.52** −0.05
CG self-efficacy 51 995.56 (213.93) 75 877.1 (243.1) 101 941.67 (255.74) 3.75* 0.51** 0.22 −0.26
Familial obligation 55 4.12 (0.51) 78 3.66 (0.56) 109 4 (0.47) 16.07** 0.85** 0.25 −0.66**
Support from the family 55 3.6 (0.73) 78 3.35 (0.7) 109 3.61 (0.72) 3.43 0.35 −0.01 −0.36
Family as referents 55 3.01 (0.6) 78 2.58 (0.56) 109 2.98 (0.6) 13.04** 0.74** 0.05 −0.69**
Total familism 55 50.56 (5.89) 78 44.88 (6.08) 109 49.73 (6.05) 19.50** 0.94** 0.14 −0.80**
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Notes: A = African Americans; W = Whites; H = Hispanic Americans; CG = caregiver; CES-D = Center for Epidemiologic Studies—Depression scale; a = Due to nonparametric nature, spouse percentage is not calculated as an effect size. For this measure χ 2 = 14.14**, odds ratios A–W = 0.48**, odds ratios A–H = 0.78, odds ratios W–H = 1.62**.

*p < .05, **p < .01.

Positive Aspects of Caregiving

In the model examining the influence of race on positive aspects of caregiving, the fit for the direct model was χ 2 (20) = 29.17, p = .08 and the fit for the indirect model was χ 2 (22) = 29.71, p = .13, indicating that the models did not significantly differ (Δχ 2 (2) = 0.54, p = .76). Inspection of fit indices demonstrate a well-fitting model: RMSEA = 0.04, 90% CI [0.00, 0.07], CFI = 0.97, SRMR = 0.04. African Americans reported greater social support and familism compared to the rest of the sample, and both social support and familism positively predicted positive aspects of caregiving (Figure 1). A significant positive indirect effect was shown for African Americans on positive aspects of caregiving (B = 0.17, 95% CI [0.08, 0.26]), which operated through familism (B = 0.11, 95% CI [0.03, 0.18]), while the path through social support was not significant. A significant negative indirect effect was also identified for Whites on positive aspects of caregiving (B = −0.21, 95% CI [−0.32, −0.11]), which operated through familism (B = −0.18, 95% CI [−0.29, −0.08]), although the path through social support was not significant. These results indicate that African Americans exhibited greater social support and familism, and individuals with higher familism showed higher positive aspects of caregiving compared to other caregivers, while White participants exhibited lower levels.

Figure 1.

Figure 1.

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Structural equation model examining the effects of race predicting social support and familism, and social support and familism predicting positive aspects of caregiving. Note: Model fit statistics for direct model are χ 2 (20) = 29.17, p = .08 and indirect model is χ 2 (22) = 29.71, p = .76. Indirect and direct models did not significantly differ Δχ 2 (2) = 0.54, p = .76. RMSEA = 0.04; 90% CI = [0.00, 0.07]; CFI = 0.97; SRMR = 0.04. RMSEA = root mean square error of approximation; CI = confidence interval; CFI = comparative fit index; SRMR = standardized root mean square residual; *p < .05, **p < .01.

Caregiver Burden

Analyzing burden as an outcome, the direct (χ 2 (20) = 54.32, p < .001) and indirect models (χ 2 (22) = 55.09, p < .001) did not significantly differ (Δχ 2 (2) = 0.60, p = .68). Inspection of fit indices indicates a well-fitting model: RMSEA = 0.07, 90% CI [0.05, 0.10], CFI = 0.91, SRMR = 0.05. Results (Figure 2) showed that familism did not significantly predict burden. However, greater social support was associated with less burden. A significant negative indirect effect was identified for African Americans on burden (B = −0.15, 95% CI [−0.23, −0.06]) through social support (B = −0.09, 95% CI [−0.16, −0.02]). There was a significant indirect effect for Whites on burden, reflecting higher burden in White participants B = 0.14, 95% CI [0.04, 0.25], though for Whites neither the social support nor familism paths were statistically significant. Overall, African Americans reported greater social support, which in turn, predicted lower levels of caregiver burden compared to other caregivers.

Figure 2.

Figure 2.

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Structural equation model examining the effects of race predicting social support and familism, and social support and familism predicting burden. Note: Model fit statistics for direct model are χ 2 (20) = 54.32, p < .001 and indirect model is χ 2 (22) = 55.09, p < .001. Indirect and direct models did not significantly differ Δχ 2 (2) = 0.60, p = .68. RMSEA = 0.07; 90% CI = [0.05, 0.10]; CFI = 0.91; SRMR = 0.05. RMSEA = root mean square error of approximation; CI = confidence interval; CFI = comparative fit index; SRMR = standardized root mean square residual; *p < .05, **p < .01.

Depression

Examining depression as an outcome, the fit for the direct model was χ 2 (20) = 35.23, p = .02, while for the indirect model it was χ 2 (22) = 35.46, p = .04. Both models did not significantly differ (Δχ 2 (2) = 0.23, p = .89). Fit indices indicated adequate fit for the indirect model: RMSEA = 0.05, 90% CI [0.00, 0.08], CFI = 0.96, SRMR = 0.04. Familism did not significantly predict depression, while social support was associated with lower depressive symptoms (Figure 3). There was a significant negative indirect effect for African Americans on depression (B = −0.14, 95% CI [−0.24, −0.05]). Only the path through social support was significant (B = −0.15, 95% CI [−0.23, −0.06]). No significant indirect effects were identified for White participants. Results indicate that being African American was significantly associated with lower depression, and this relationship operated as a function of social support.

Figure 3.

Figure 3.

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Structural equation model examining the effects of race predicting social support and familism, and social support and familism predicting depression. Note: Model fit statistics for direct model are χ 2 (20) = 35.23, p = .002 and indirect model is χ 2 (22) = 35.46, p = .04. Indirect and direct models did not significantly differ Δχ 2 (2) = 0.23, p = .89. RMSEA = 0.05; 90% CI = [0.00, 0.05]; CFI = 0.96; SRMR = 0.04. RMSEA = root mean square error of approximation; CI = confidence interval; CFI = comparative fit index; SRMR = standardized root mean square residual; *p < .05, **p < .01.

Social Support and Caregiver Burden as Mediators

An omnibus model was examined based on the relationships identified in the previous analyses (Supplementary Figure 1). Only the indirect model was tested (χ 2 (37) = 81.87, p < .001, RMSEA = 0.071, 90% CI [0.05, 0.09], CFI = 0.91, SRMR = 0.06) and yielded adequate fit. Social support significantly predicted reduced burden and depression, whereas greater levels of familism significantly predicted positive aspects of caregiving. Given the number of indirect paths, we will focus on depression as our outcome with burden and social support as mediators. A statistically significant negative total indirect path was identified for African Americans on depression (B = −0.15, 95% CI [−0.24, −0.07]). The paths through social support (B = −0.09, 95% CI [−0.15, −0.04]) and social support through burden (B = −0.05, 95% CI [−0.09, −0.01]) accounted for this path. Alternatively, there was a significant positive indirect path for White participants (B = 0.09, 95% CI [0.01, 0.16]) on depression. However, none of the individual paths were statistically significant. In summary, results indicate that being African American was indirectly associated with positive aspects of caregiving through higher levels of familism; positive aspects of caregiving, however, were not significantly associated with depression. Alternatively, being African American was indirectly associated with lower depressive symptoms through greater levels of social support and reduced feelings of burden.

Age, Spousal Status, and Acculturation

Age and being a spousal caregiver were significantly correlated with race and our outcomes of interest (see Table 2 for pairwise correlations). Therefore, a multiple regression analysis was conducted to examine race, familism, age, and spousal status on positive aspects of caregiving. In this model, neither age (t (233) = 0.19, p = .85) nor spousal status (t (233) = −1.54, p = .12) predicted positive aspects of caregiving. Familism, however, significantly predicted positive aspects of caregiving (t (233) = 3.66, p < .01).

Table 2.

Pairwise Intercorrelations of Variables Used in the Study

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1. Age 1.00
2. African American −0.17** 1.00
3. White 0.26** −0.38** 1.00
4. Spouse 0.64** −0.14* 0.24** 1.00
5. Familial obligations −0.23** 0.20** −0.33** −0.15* 1.00
6. Support from the family −0.10 0.06 −0.17** −0.06 0.38** 1.00
7. Family as referents 0.03 0.14* −0.31** −0.02 0.40** 0.29** 1.00
8. Familism score −0.14* 0.19** −0.37** −0.11 0.82** 0.66** 0.77** 1.00
9. Received support −0.09 0.23** −0.06 −0.16* 0.03 0.17** 0.06 0.10 1.00
10. Satisfaction with support 0.02 0.14* −0.11 −0.03 0.00 0.15* 0.02 0.06 0.41** 1.00
11. Social network 0.06 0.23** −0.04 0.07 0.03 0.09 −0.03 0.03 0.45** 0.42** 1.00
12. Negative interactions −0.29** 0.06 −0.12 −0.14* 0.12 −0.06 0.05 0.06 0.02 −0.26** −0.16* 1.00
13. Social support 0.08 0.17* −0.09 −0.02 −0.01 0.15 0.03 0.06 0.71** 0.83** 0.78** −0.52** 1.00
14. Burden −0.11 −0.10 0.14* −0.08 −0.05 −0.09 −0.20** −0.15* 0.01 −0.30** −0.19** 0.26** −0.27** 1.00
15. Positive aspects of CG −0.10 0.15* −0.14* −0.15* 0.15* 0.18** 0.28** 0.27** 0.14* 0.12 0.10 −0.04 0.21** −0.33** 1.00
16. CES-D score 0.02 −0.13* 0.04 0.04 −0.01 −0.08 0.02 −0.02 −0.10 −0.30** −0.30** 0.30** −0.35** 0.62** −0.27** 1.00
17. CG self-efficacy −0.15* 0.14* −0.16* −0.20** 0.21** 0.23** 0.17** 0.27** 0.22** 0.27** 0.33** −0.08 0.34** −0.40** 0.27** −0.43** 1.00
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Note: CG = caregiving; CES-D = Center for Epidemiological Studies—Depression scale.

*p < .05, **p < .001.

We also examined associations among race, familism, and caregiving self-efficacy and found that self-efficacy is positively associated with familism (r = 0.27) and each familism subscale: familial obligations (r = 0.21), familial support (r = 0.23), and family as referents (r = 0.17). Furthermore, caregiving self-efficacy was significantly positively associated with being African American (r = 0.14) and negatively associated with being White (r = −0.16). These preliminary results suggest that cross-cultural differences in familism may positively influence caregiving outcomes through increased social support and self-efficacy.

Finally, we examined the association between acculturation, operationalized as a number of years living in the United States, and familism. Greater years spent in the United States were negatively associated with familism (r = −0.22, p < .05). When controlling for age, the strength of the association between acculturation and familism increased (r = −0.28, p < .01). In a follow-up analysis, we divided our sample into U.S. natives versus nonnatives. An independent samples t-test revealed significant differences in familism between native and nonnative participants, t (51.27) = −2.80, p < .01, with nonnatives (M = 50.60, SD = 6.00) reporting higher familism compared to natives (M = 47.21, SD = 5.43). These results suggest that familism varies within racial/ethnic groups as a function of acculturation, with greater acculturation associated with lower familism.

Discussion

Considerable research has been conducted on potential mechanisms affecting the relationship between caregiving stressors and psychosocial outcomes. This study provides additional insight into the influence of care-related stress on positive aspects of caregiving, burden, and depression in a sample of diverse ADRD caregivers, and how these relationships may be influenced by racial/ethnic differences in cultural values and social support. Prior work examining the role of cultural beliefs in caregiving has yielded mixed results (Dilworth-Anderson et al., 2004; Rozario & DeRienzis, 2008). Rather than solely relying on racial/ethnic group membership as a proxy for culture, we examined racial/ethnic differences in familism and social support to better ascertain cross-cultural differences in caregiving outcomes.

Consistent with prior research (Epps et al., 2019; Liu et al., 2021), we found that African Americans reported greater familism, which in turn predicted higher positive aspects of caregiving. These findings are consistent with research indicating that African American caregivers report greater psychological well-being compared to Whites and that strong cultural justifications for providing care may be protective against adverse caregiving outcomes (Dilworth-Anderson et al., 2004; Liu et al., 2021). In fact, in our data, being African American was positively associated with perceived family obligation, whereas the reverse was true for Whites. The tendency for African Americans to exhibit better well-being and mental health compared to Whites has been described as an “epidemiological paradox” (Katira Perez & Cruess, 2014; Rhoades, 2021). Epps (2014) and Parveen et al. (2014) posit that African Americans’ prior experiences with adversity may allow them to cognitively reframe the caregiving role into an experience that is perceived more positively.

A recent review (Quinn & Toms, 2019) demonstrated that positive caregiving appraisals are associated with better mental health, quality of life, self-efficacy, and reduced burden and suggest that positive caregiving appraisals may be adaptive in helping to build cognitive resources to adequately cope with stressors. We also found that positive aspects of caregiving were associated with lower depressive symptoms and higher self-efficacy. Our findings indicate that the racial/ethnic differences in caregiving appraisals may operate as a function of cultural values, specifically familism, which may influence one’s subjective evaluation of the caregiving role and contribute to more optimal outcomes.

Furthermore, early research highlighted cross-cultural differences in burden and depression, such that African Americans are more likely than Whites to perceive caregiving as less burdensome (Haley et al., 1996). Our findings confirm that African Americans report greater social support, which in turn, predicted reduced burden and depression. This pattern of findings is consistent with Epps et al. (2019) and Samson et al. (2016), who note that African Americans tend to rely on extended kin and non-kin social networks, highlighting the importance of social connections and availability of support while caring for an aging relative.

We also identified a link between acculturation and familism. The results demonstrate that among Hispanics, a greater length of time in the United States was associated with lower familism. Hispanic subgroup analyses revealed that familism was significantly higher in nonnative compared to native participants, consistent with Bacallao and Smokowski (2007) who reported that immersion into the individualistic realms of U.S. culture can lead to a decrease in familism. Interestingly, research has shown that rates of psychiatric disorders, although relatively low in Hispanic immigrants, increase as a function of years living in the United States, reaching prevalence comparable to White populations (Katiria-Perez & Cruess, 2014). These findings point to the possibility that acculturation may lead to the dissipation of strong familial beliefs due to a mismatch between cultural values and the current societal context and norms (Gelman, 2014). As proposed by Losada et al. (2006), examining cultural values in caregiving should be considered within one’s sociocultural context to determine whether this larger context facilitates or impedes familistic values and influences the caregiving stress process.

Our findings are consistent with Knight and Sayegh’s (2010) sociocultural stress and coping model, indicating that cultural values and social support can affect caregiving appraisals and increase self-efficacy, which can lead to more favorable outcomes when caring for an individual with ADRD. It is possible that persons with high familistic beliefs have a stronger commitment to the caregiving role, which can mitigate negative outcomes (Gelman, 2014). Among Latinos, Gelman (2014) found that caregivers who strongly endorsed familism were raised to believe they have an obligation to care for their aging parents and chose to provide care even when formal services were available. Thus, individuals who were raised in a context that heavily emphasizes familistic values may perceive caregiving as a natural part of life, whereas those in more individualistic cultures may instead view caregiving as a disruption of their life and goals.

Three limitations in this study point the way for future investigations. First, researchers should longitudinally examine racial/ethnic differences in familism, social support, and acculturation to determine how these constructs may change across the caregiving trajectory. Second, prior literature (Dilworth-Anderson et al., 2004) suggests that familism may exhibit a curvilinear relationship, with those who endorse either very strong or weak familial beliefs having worse outcomes. Given the heterogeneity of Hispanics in the United States, further investigation into individual differences among Hispanic immigrants is warranted to ascertain the differential influence of familism and social support on caregiving based on country of origin. Third, our study is limited to the racial and ethnic minority groups included in the sample and is specific to ADRD caregiving. Future research should thus seek to examine the influence of cultural values on caregiving outcomes in other minority groups, as well as among different types of caregivers beyond ADRD.

Overall, our results provide novel insights into the relationship between race/ethnicity and caregiving outcomes, and how these relationships vary based on cultural values and social support. The findings suggest that interventions aimed at buffering the negative effects of care-related stress should target and reinforce the importance of social connections, both to kin and non-kin, which may help alleviate burden and depression and increase the rewarding aspects of caregiving.

Family-based therapy, targeting individual cultural beliefs and involvement of other family members, is one promising approach encompassing a family-centered perspective (Eisdorfer et al., 2003; Mitrani & Czaja, 2000). A study examining a combined family therapy and technology intervention among White and Cuban caregivers found that overall, the intervention resulted in decreases in depression among caregivers. The technology enabled family telephone conferences and telephone-based support groups, which may have provided additional opportunities for interaction and support.

Given the heterogeneity among caregivers and the differential relationships that exist between care-related stressors and psychosocial outcomes, it is important to consider the influence of contextual characteristics such as sex, race/ethnicity, cultural values, and acculturation on caregiving outcomes. Future research should focus on the development of culturally congruent family-centered interventions, to promote beneficial family interactions, increase social support, and bolster positive caregiving appraisals, as well as assess the efficacy of such interventions across racial/ethnic groups.

Supplementary Material

gbab160_suppl_Supplementary_Figure
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gbab160_suppl_Supplementary_Table
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Contributor Information

Francesca Falzarano, Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA.

Jerad Moxley, Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA.

Karl Pillemer, College of Human Ecology, Cornell University, Ithaca, New York, USA.

Sara J Czaja, Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA.

Funding

Support for this project came from National Institute of Nursing Research (NINR) (5R01NR014434-05). F. Falzarano acknowledges support from a National Institute on Aging (NIA)-funded T32 training program grant (AG049666). K. Pillemer acknowledges support from an Edward R. Roybal Center Grant from the NIA (P30AG022845).

Conflict of Interest

None declared.

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