Social and Cultural Factors, Self-Efficacy, and Health in Latino Cancer Caregivers

Abstract

Background:

Latino cancer caregivers are at risk for physical, mental, and emotional health issues. Sociocultural factors such as informational support, Anglo-orientation, and spiritual practice may compound or protect against these risks.

Objective:

The purpose of this research project was to examine self-efficacy as a mediator between sociocultural factors and health outcomes in Latino cancer caregivers.

Methods:

This is a secondary analysis of baseline caregiver data from an experimental study testing two psychoeducational interventions in Latina individuals with breast cancer and their caregivers. Caregivers (N = 233) completed items assessing self-efficacy, informational support, Anglo orientation, spiritual practice, depression, and global health. Caregiver data were analyzed using hierarchical linear regression and mediation analysis.

Results:

Spiritual well-being was not significantly associated with health outcomes or self-efficacy. In regression analysis, both informational support (b = .32 [.20, .45], P < .001) and Anglo orientation (b = .1.30 [.11, 2.48], P < .05) were significant predictors of global health, but informational support (b = −.43 [−.55, −.30], P < .001) was the only significant predictor of depression. There were indirect relationships through self-efficacy for symptom management for both informational support and Anglo orientation and health outcomes.

Conclusions:

Informational support and Anglo orientation were significantly related to health outcomes directly and indirectly through self-efficacy in Latino cancer caregivers.

Implications for Practice:

Informational support through the health system and community, when provided with attention to culture and Spanish language translation, can increase Latino cancer caregivers’ self-efficacy to care for themselves and improve health outcomes.

Caregivers are foundational to the U.S. health care system, and the care they provide to individuals with cancer physically, mentally, emotionally, spiritually, and financially amounts to significant cost savings.^1–3 The caregiving experience can be mixed, offering both challenges and opportunities for growth and meaning,¹ and family caregivers experience adverse health consequences related to their caregiving, including burden, distress, increased depression rates, poor health, and increased mortality risk.^4,5 For Latino caregivers, family caregiving is more common than among their non-Hispanic White counterparts, and their physical and financial contributions are greater.¹ (Here, Latino will be used as a collective term for someone who self-identifies as Latino or Latina.) From 2015 to 2020, among Latino caregivers specifically, there was a decline in the number of caregivers reporting excellent or very good health (from 51% to 35%).¹ Latino cancer caregivers are more likely to report physical strain, be in high-intensity caregiving situations, and report lower income and educational attainment, which may put them at higher risk for poor physical and mental health outcomes.¹ Latino caregivers may also be at higher risk for poor physical and mental health outcomes owing to social determinants of health affected by health policy and systemic bias.^1,3,6,7 Conversely, Latino caregivers are less likely to report that caregiving has affected their health than are non-Hispanic White caregivers, and they are more likely to report a sense of purpose and meaning due to their caregiving role.¹

Latino caregivers experience an intersection of caregiving, social, and cultural experiences that impact their health outcomes.⁷ In this study, we focus on the factors of informational support (social/cultural), Anglo orientation (cultural), and spiritual practice (cultural), which are part of the social and cultural context of Latino caregivers and contribute to their health in dynamic ways.^6,7 As noted above, Latino caregivers are at higher risk for poor health outcomes, yet also report positive caregiving experiences.^1,3,6,7 Self-efficacy may be a mechanism to explain how social and cultural factors such as informational support, Anglo-orientation, and spiritual practice impact health. Self-efficacy has been proposed as a mechanism for health outcomes because of its influence on behavioral change, and it is fostered through experiences, internal factors, and interactions with others.⁸ As social and cultural factors, informational support, Anglo orientation, and spiritual practice present opportunities for Latino caregivers to develop greater self-efficacy through vicarious and direct experiences, interactions with others, and internal physiologic processes (see Figure 1).^6–8 In this study, we examine whether caregivers’ self-efficacy for symptom management mediates relationships between the factors of informational support, Anglo-orientation, and spiritual practice and health outcomes—global health and depression.

Figure 1:

Social and Cultural Factors and Self-Efficacy

Background

The incidence and mortality rates of breast cancer are lower in Latino individuals than in non-Hispanic White individuals in the U.S., but the rates of caregiving in the Latino population are the highest among U.S. ethnic groups.^1,9,10 Almost 22% of individuals who are Latino identify themselves as caregivers; these caregivers are often women, and they spend more time in caregiving activities than their non-Hispanic White counterparts.¹ Researchers have examined multi-faceted interventions to support the physical and mental health of Latina individuals with breast cancer and their caregivers, but the mechanism of self-efficacy has not been fully explored.^11–13 Understanding the relationships between (1) the social and cultural factors of informational support, Anglo orientation, and spiritual practice and (2) depression and global health, and whether self-efficacy mediates these relationships can provide clarity regarding how nursing care and interventions can promote greater Latino caregiver health.

Informational support

Informational support as a domain of family support is affected by caregivers’ interactions with family, community networks, and members of health care teams.^14–16 Family support is an important facet of Latino culture, which is characterized by familismo and family reliance,¹⁷ although this cultural norm may vary with caregivers’ age and acculturation.¹⁸ Research has demonstrated the positive effect of informational support on physical and mental health in Latina caregivers at the family, community, and health care levels.^14,19,20 In addition to receiving informational support from family and community, Latino caregivers have reported that they want more information and support from nurses and other health care providers for their caregiving role.^16,19 One major challenge to this is a lack of culturally tailored support, including written and verbal information presented in Spanish.^16,19,21 Another barrier for Latino caregivers may be the desire to respect the authority and status of care recipients, while also desiring more information about the caregiving role.²²

Anglo Orientation

Many researchers have noted the influence of Anglo orientation, the Latino individual’s orientation toward non-Hispanic White culture, on health outcomes. There are situation-dependent relationships between degree of Anglo orientation or acculturation and better or worse health.^23–25 Anglo orientation is a dimension of Latino acculturation along with Mexican or Hispanic orientation. Acculturation is not a linear process, nor does someone with high Anglo orientation automatically have low Mexican or Hispanic orientation. The Latino health paradox posits that individuals in the U.S. who are less acculturated to the dominant culture may live longer and have greater health, although how this plays out individually or contextually is nuanced.^23,25 Examples in the Latino population include worsening health with poor diet and increased body mass index in individuals with greater Anglo orientation, but improvements in health with greater exercise frequency and health care access.^7,23 Access to health care, health behaviors, and end-of-life decision making may be affected by the acculturation of both the caregiver and the care recipient, as well as the way in which the health care system is designed to respond to the language, race and ethnicity, and culture of the individual.^9,23,26 For caregivers specifically, cultural norms may contribute to caregiving through values such as familismo and marianismo, emphasizing the role of women in family care.¹⁷ These norms could contribute to whether female caregivers have choices in caregiving and to caregivers’ finding purpose or meaning in their caregiving roles.²²

Spiritual Practice

Spiritual practice, including church attendance and daily spiritual activities, may have nuanced effects on the health of Latino caregivers, much like Anglo orientation. Spiritual practice is a Latino cultural norm that affects the Latino health paradox through the connection between spirituality and community.^17,27 This idea has been noted in a qualitative study, with caregivers describing the connection between their spiritual practice and family.²⁸ Spirituality has also been described as an anchor during the cancer caregiving experience for individuals who are Latino, with both internal and organizational spirituality resulting in lower perceived caregiver burden.^29,30 Latina individuals with breast cancer have described selecting caregivers on the basis of their religious beliefs.³¹ Research has shown an inverse relationship between religious practice and life expectancy, although religious doubts or struggles, congregational criticism, or negative interpersonal religious experiences all may affect health adversely.³²

Self-Efficacy Theoretical Model

Bandura’s theoretical model of self-efficacy⁸ is used in this study to examine relationships among social and cultural factors, self-efficacy, and well-being. Self-efficacy is one’s belief in one’s ability to achieve a desired outcome, and it is fostered through vicarious experiences, prior successes, physiological responses, and verbal feedback from others (see Figure 1).⁸ Perceived self-efficacy is causally central to Bandura’s social cognitive theory, in which behavioral, personal, and environmental influences, including social and cultural factors, reciprocally affect changes in human behavior.³³ Self-efficacy is fundamental to behavioral change because individuals have agency, or the ability to act for themselves, with a belief in their ability to accomplish goals or enact behavioral change.^8,33 In cancer caregivers, self-efficacy is paramount, given their care responsibilities for both themselves and the individual diagnosed with cancer. Self-efficacy as a mechanism for health and behavioral change may mediate the relationship between social and cultural factors (i.e., informational support, Anglo orientation, and spiritual practice) and global health and depression in caregivers of Latina breast cancer survivors.^8,33,34

Latino caregivers are significant contributors to the care of their loved ones while navigating the challenges of being an ethnic minority with cultural and sociopolitical barriers to care.^7,16 Latino caregivers may be more prone to neglect their own needs while taking care of others,^16,17 thus increasing their risk of negative physical, mental, and emotional consequences of their caregiving role. Individuals who are Latino are also more likely to be uninsured, with decreased access to primary care services.⁷ Self-efficacy has been described in the context of resilience, and it may represent a step between social and cultural factors (i.e., informational support, Anglo orientation, and spiritual practice) that increase risk or resilience and physical and mental health outcomes.³⁴ Therefore, in this study we examine self-efficacy for symptom management (caregiver-oriented) as a mediator in the relationship between social and cultural factors (i.e., informational support, Anglo orientation, spiritual practice) and global health (overall health) and depression (mental health) (see Figure 2). Bandura has emphasized the context-specific nature of self-efficacy and the importance of situation-specific measurement.³⁵ The focus of self-efficacy in this study is self-directed symptom management for caregivers, because our outcomes of interest are related to caregivers’ health.

Figure 2:

Proposed Mediation Model

Research Questions

This study is guided by the following research questions:

1. Are caregivers’ social and cultural factors of informational support, Anglo orientation, and spiritual practice associated with health outcomes (depression and global health)?

2. Does self-efficacy for symptom management mediate the relationships between social and cultural factors (informational support, Anglo orientation and spiritual practice) and each of the health outcomes (depression and global health)? (see Figure 2).

Methods

This is a secondary analysis of a primary experimental study testing two psychosocial interventions in Latina breast cancer survivors and their nominated caregivers in the Southwestern United States.³⁶ Secondary analysis is an efficient and low-cost approach for this examination of the relationship among social and cultural factors, self-efficacy, and health outcomes. The primary study is grounded in support of Latina individuals with breast cancer and their caregivers, including language and cultural tailoring.³⁶ This secondary analysis aligns with this approach in examining social and cultural factors, self-efficacy, and health outcomes. Global health provides a holistic overview of health status, and depression is one of the most common negative consequences of caregiving.¹ Baseline caregiver data were used to test the model of self-efficacy and health outcomes.

Participants

In the primary study, purposive sampling of cancer survivors took place through direct contacts at regional cancer centers, community health clinics serving primarily Latina/o residents, survivorship conferences, breast cancer support groups, placement of brochures in oncology and women’s health clinics, and referrals from health care personnel.³⁶ Caregivers were recruited following designation by cancer survivors, and they completed informed consent procedures to participate in the study. Family caregivers were contacted independently of cancer survivors by a bilingual trained data collector for baseline assessment. The caregivers could opt to participate in either English or Spanish. After the baseline assessment was completed, the participants received a thank-you letter and a $20 gift card to a retail merchant.

The sample for the present study included 257 nominated caregivers of Latina breast cancer survivors. Inclusion criteria from the primary study for informal caregivers were as follows: nomination by cancer survivor, 18 years of age or older, ability to speak English or Spanish, access to and ability to speak on the telephone, and no caregiver cancer diagnosis. Twenty-four individuals were excluded for missing all Anglo-orientation items. The focus of this analysis was Latino caregivers, and the absence of the Anglo-orientation measure was a proxy for excluding non-Hispanic/Latino caregivers from the analysis. These caregivers were also more likely to be spousal caregivers and have higher income and education levels. One individual was excluded for missing over 10% of the study variables of interest, resulting in a final sample of 233.

The primary study was approved by the University of Arizona Institutional Review Board, individuals were informed of the risks and benefits of participating in the study, and they completed consent forms.³⁶ This a was secondary analysis, so it was not designated as human subjects research by the University of Arizona Institutional Review Board.

Procedure

Data from the primary study were collected from both Latina individuals diagnosed with breast cancer and caregivers. Following designation by each individual with cancer, caregivers were contacted independently through telephone calls. Data were collected by trained data collectors who were bilingual in English and Spanish. Calls were audiotaped, and data were entered into an encrypted database rather than collected with a paper and pencil questionnaire.³⁶ For this secondary analysis, only baseline caregiver data were used. Caregiver data included in the analysis were demographic, socio-economic, and socio-cultural data in addition to the measures described below.

Measures

General demographics were collected, including age, gender, number of children, number of children living in the home, and race. Additional demographic information addressed social determinants of health such as education level, employment, and annual household income.

Informational support was assessed using the 8-item Patient Reported Outcomes Information System (PROMIS) Informational Support Short Form. This addresses the frequency of informational support from diverse sources, aligning with family and health care providers as a source of support for Latino cancer caregivers. Responses range from 1 = never to 5 = always; higher scores indicating higher levels of informational support.³⁷ The total score is the sum of all item scores and is converted to a T-score. The PROMIS measures were developed using patient interviews and expert review panels; they have been widely studied and have demonstrated adequate psychometric properties.³⁷ Cronbach’s alpha for the present study was .94.

Anglo orientation was measured using the Anglo Orientation Scale (AOS) from the Acculturation Rating Scale for Mexican Americans II (ARSMA-II).³⁸ The AOS was adapted from the original 13-item subscale to a 7-item scale. The mean score was used in the present study. In the primary study, the scale had a Cronbach’s alpha of .86.³⁹ Jimenez et al.⁴⁰ noted internal consistency of the AOS with a Cronbach’s alpha of .93. This scale has been used in older adults and caregiver populations.⁴⁰

Spiritual practice was measured with 2 items from the spiritual well-being subscale of the Quality of Life-Breast Cancer questionnaire developed by Ferrell et al.,⁴¹ in order to assess the influence of breast cancer on spirituality. Reponses range from 1 (not at all) to 10 (a great deal). The 2 items address involvement in religious activities and spiritual practice. Factor loading for the spiritual practice items were .90 and .92, respectively, and Cronbach’s alpha was .87.

Self-efficacy for symptom management was a single question from the General Symptom Distress Scale, developed by Badger and colleagues.⁴² This item assesses how well a participant manages symptoms on a scale from 1 = cannot manage at all to 10 = can manage extremely well. The item was correlated as expected with depression, positive affect, negative affect, and general health.⁴²

Global health was measured with 4 items from the PROMIS Global Health scale, which rates holistic overall health including quality of life, physical health, and mental health. Responses ranged from 1= poor to 5 excellent. The total score is computed as a sum of the scale’s items and then converted to a T-Score, with high scores indicating greater health.³⁷ Cronbach’s alpha for the present study was .84.

Depression was measured using the 8-item PROMIS Emotional Distress-Depression Short Form, which assesses frequency of symptoms of depression on a scale ranging from 1 = never to 5 = always. The total score is then converted to a standardized T-score. Higher scores reflect more frequent occurrence of depressive symptoms.³⁷ Cronbach’s alpha for the present study was .93.

Data Analysis

Data were analyzed using SPSS Version 26 for frequencies and descriptive statistics.⁴³ Bivariate correlations and hierarchical multiple linear regression were also conducted using SPSS to address Research Question 1. Covariates including income, gender, and education were converted into dummy codes to control for income below 200% of the poverty line for 5 persons in a household, female gender, and high school education or less and then entered in Step 1. In Step 2, predictor variables including informational support, Anglo orientation, and spiritual practice were entered. Regression models were calculated for global health and depression. Mediation analysis to address Research Question 2 was completed using the PROCESS module (Model 4) of SPSS, a path modeling utility for moderation and mediation analysis developed by Andrew Hayes.⁴⁴ PROCESS uses bootstrapping to estimate the indirect effect of X on Y through the mediator, which supports inference of the indirect effect. Bootstrapping creates an empirical representation of the sampling distribution of the indirect effect by treating the obtained sample size as a representation of the population and resampling using replacement. With replacement, a new sample size is built by using cases from the original sample, but allowing any case to be redrawn as the resampling is structured. Once a resample is created, the product of a and b path coefficients is recorded. This process is repeated 5,000 times, and a percentile-based bootstrap confidence interval is generated. If the 95% confidence interval does not include zero between the upper and lower bounds, researchers can reject the null hypothesis of the indirect effect being zero.⁴⁴ These analyses were conducted using self-efficacy for symptom management (care of oneself) as the mediator between the predictor and outcome variables. Female gender, low income, and high school or less education were included as covariates.

Results

Study participants (N = 233) were primarily female (n = 164, 70%), married (n = 157, 67%), employed full or part time (n = 131, 56%), with a high school education or less (n = 136, 58%) and an annual income of $39,999 or less (n = 162, 70%). All participants were Latino, with a mean age of 43.1 years (SD, 13.3; range, 21–82). See Table 1 for complete demographic information.

Table 1.

Participants’ Characteristics (N = 233)

Characteristics	n (%)	Min/Max	Mean (SD)
Sex
Female	164 (70.4%)
Male	69 (29.6%)
Race/Ethnicity
Mexican/Mexican American	129 (55.4%)
Hispanic/Latino	90 (38.6%)
South/Central American	14 (6%)
Marital Status
Married	157 (67.4%)
Unmarried	74 (31.8%)
Relationship to Care Recipient
Spouse/Significant other	60 (25.8%)
Mother	47 (20.2%)
Daughter	46 (19.7%)
Sibling	37 (15.9%)
Friend	25 (10.7%)
Other	18 (7.8%)
Annual Income
<$10,000	45 (19.3%)
$10,000–39,999	117 (50.2%)
≥$40,000	61 (27%)
No Answer	10 (4.3%)
Income Needs Met
Not at All	20 (8.6%)
Barely	145 (62.2%)
Met Plus	68 (29.2%)
Education Level
Elementary/Middle School	71(30.5%)
High school	65 (27.9%)
Vocational/Tech/Some College	61 (26.2%)
College	31 (13.3%)
Other	5 (2.2%)
Employment
Full time	102 (43.8%)
Part time	29 (12.4%)
Unemployed, Seeking Employment	37 (15.9%)
Other	65 (27.9%)
Age		21/82	43.1(13.3)

Research Question 1

Spiritual practice was significantly negatively correlated with Anglo orientation (r = −.18, P < .01), meaning that low spiritual practice was associated with high Anglo orientation. Spiritual practice was not associated with any other study variables. Informational support was positively associated with Anglo orientation (r = .23, P < .01), self-efficacy for symptom management (r = .21, P < .01), and global health (r = .39, P < .01); thus there was high informational support with higher Anglo orientation, self-efficacy, and global health. Informational support was significantly negatively correlated with depression (r = −.43, P < .01); individuals with high informational support had lower depression levels. Anglo orientation was significantly positively associated with self-efficacy for symptom management (r = .21, P < .01) and global health (r = .27, P < .01) and significantly negatively correlated with depression (r = −.13, P < .05), with patterns similar to those for informational support. Self-efficacy symptom management was significantly positively correlated with global health and significantly negatively correlated with depression. Those with high self-efficacy had greater global health (r = .27, P < .01) and lower depression levels (r = −.33, P < .01; see Table 2).

Table 2.

Means and Bivariate Correlations (N = 233)

Variables	Mean (SD)	1.	2.	3.	4.	5.	6.
1. Spiritual Well-Being	16.83 (4.38)	1
2. Anglo-Orientation	2.85 (1.19)	−.18b	1
3. Informational Support	50 (10)	.11	.23b	1
4. Depression	50 (10)	−.07	−.13a	−.43b	1
5. Global Health	50 (10)	.08	.27b	.39b	−.48b	1
6. Self-Efficacy for Symptom Management	7.72 (2.54)	−.00	.21b	.21b	−.33b	.27b	1

Significance:

^ap < .05.

^bp < .01

Regression models were run for both depression and global health as outcome variables (see Table 3). When controlling for gender, income, and education, both Anglo orientation (b = .1.30, 95% CI [.11, 2.48], P < .05) and informational support (b = .32, 95% CI [.20, .45], P < .001) were significantly related to global health. In the depression model, only informational support was significantly related to depression (b = −.43, 95% CI [−.55, −.30], P < .001).

Table 3.

Linear Models for Global Health and Depression (N=233)

	Global Health			Depression
	β	95% CI	p-value	β	95% CI	p-value
Step 1
Gender	−.01	(−.19, .85)	.85	.06	(−1.57, 4.10)	.38
Education	−.21	(−6.78, −1.56)	<.01	.11	(−.44, 4.92)	.10
Income	−.11	(−5.64, .59)	.11	−.02	(−3.65, 2.73)	.77
Step 2
Gender	−.05	(−3.71, 1.52)	.41	.09	(−.60, 4.63)	.13
Education	−.11	(−5.00, 0.38)	.09	.04	(−1.83, 3.55)	.53
Income	−.03	(−3.75, 2.25)	.62	−.08	(−4.90, 1.10)	.21
Anglo-Orientation	.15	(.11, 2.48)	<.05	−.05	(−1.64, .73)	.45
Informational Support	.32	(.20, .45)	<.001	−.43	(−.55, −.30)	<.001
Spiritual Practice	.09	(−.08, .49)	.16	−.06	(−.41, .15)	.37

Model for Global Health: R² =.06 for Step 1; ΔR²=.14 for Step 2 (p<.001); Model for Depression: R² =.01 for Step 1; ΔR²=.19 for Step 2 (p<.001)

Dummy Codes: Gender (1:Female, 0:Male); Education (1:High School Education or Less, 0:Greater than High School Education); Income (1:49,999 or below; 0: 50,000 or greater—200% above poverty line for 5 person household⁵³)

Research Question 2

There were no indirect relationships between spiritual practice and depression or global health through self-efficacy for symptom management. Figure 3 provides an overview of the mediating models for both informational support and Anglo orientation. There was an indirect relationship between Anglo orientation and depression through self-efficacy for symptom management (b = −.58, 95% CI [−1.17, −1.4]). Alternatively, for global health, there was a significant indirect relationship with Anglo orientation through self-efficacy for symptom management (b = .42, 95% CI [.09, .85]. Informational support was also significantly indirectly related to both global health (b = .32, P < .01; b = .04, 95% CI [.007, .09]) and depression (b = −.40, P < .01; b = −.05, 95% CI [−.10, −.01] through self-efficacy for symptom management.

Figure 3:

Self-Efficacy Mediation Models

Discussion

In this sample of caregivers of Latina individuals with breast cancer, social and cultural factors, including informational support and Anglo orientation, were significantly associated with global health and depression. There were indirect relationships through self-efficacy for symptom management between these social and cultural variables and health outcomes. These findings are significant, given the focused population in this study—caregivers of Latina individuals with breast cancer—and the social, cultural, and psychological processes that affect the support and care they receive. Specifically, self-efficacy is fostered through prior experience, verbal support from others, learning from the experiences of others, and physiological cues.⁸ In this study, we have examined social and cultural factors including informational support, Anglo orientation, and spiritual practice that may influence self-efficacy through these pathways.

Not surprisingly, there were relationships between informational support and health outcomes, with greater global health and lower depression in the presence of higher informational support in both bivariate and regression analyses. There was also an indirect relationship between informational support and global health and depression through self-efficacy for symptom management. These findings suggest that the provision of informational support contributes to greater self-efficacy, which then influences better health outcomes in caregivers of Latina individuals with breast cancer. Family members, friends, and community members are an important source of informational support for caregivers who identify as Latino.^{15, 17} There is also evidence that individuals who are Latino rely on health care providers, such as nurses, for health information, but that health care delivery needs to be culturally relevant and available in Spanish.^16,19 Provision of informational support may be one of the ways in which nursing interventions can have the greatest impact among Latino caregivers. As the AARP has noted in a needs assessment of Latino caregivers, the delivery of social support should occur on multiple levels—the health care system, community-based organizations, faith-based programs, and family support.¹⁹ The U.S. CARE Act is an example of legislation that may support programs at the health care and community levels for Latino caregivers.⁴⁵ Along with the provisions in this law for identifying caregivers during hospitalization and providing support during care transitions, nurses should consider individual needs, cultural norms and Spanish language translation when needed to further reduce barriers for Latino caregivers.^16,19,45

In bivariate analysis, greater Anglo orientation was significantly associated with greater global health and lower depression. This relationship remained in multivariate regression only for global health when controlling for gender, education, and income. Examining this relationship with self-efficacy as a mediator in caregivers of Latina individuals with breast cancer provides perspective on the dynamics of these relationships. There were significant indirect relationships through self-efficacy for both global health and depression, suggesting that individuals with greater Anglo orientation have greater self-efficacy and fare better with their health. There are barriers to accessing information and support for individuals who are minoritized based on race or ethnicity, including language barriers, health care provider bias, and the mechanics and culture of the health care system.^6,7 Caregivers with greater Anglo orientation may have prior experiences in navigating the health system, with fewer language barriers to receiving support from health care providers, and they may have social interactions that increase their self-efficacy for managing their own health.^{7, 23} To reduce barriers and promote equity in health outcomes for Latino caregivers, nursing care and research interventions should address cultural and language needs with the use of community-based participatory research models and promotoras, and include discussions about patient- and family-centered values and goals.^6,11,12,16

Spiritual practice was included in the model for this study due to the importance of in Latino culture, but it was not related to either depression or global health.¹⁷ There was a significant inverse relationship between Anglo orientation and spiritual practice, with higher spiritual practice and lower Anglo orientation. This highlights an important aspect of culturally relevant care.¹⁷ Nurses and other health care providers need to address spiritual practice intentionally, to prevent distress and to emphasize sources of strength for all caregivers, including Latino caregivers. Spirituality is a key aspect of palliative care provision for patients and caregivers.⁴⁶ Nursing assessments for spiritual distress, as well as the provision of information about chaplain services, support groups, and spiritual practices, should be included in caregiver interactions across the cancer continuum to accommodate spiritual needs in caregivers of Latina breast cancer survivors.⁴⁶

Self-efficacy for symptom management, which is caregiver focused, was a significant mediator for the relationships between the social and cultural factors of informational support and Anglo orientation and the outcomes of global health and depression. These findings highlight the potential for developing caregiver-focused self-efficacy and improved caregiver health. Prior research has noted improved self-efficacy with educational interventions focused on care of the survivor in cancer caregivers, but no corresponding improvement in mental health.⁴⁷ In addition, several studies have focused on informational needs and interventions for cancer caregivers, but only a few have addressed holistic needs of cancer caregivers.⁴⁸ Cancer caregivers need interventions to support their own health, which in turn may impact the health of the individual diagnosed with cancer.⁴⁹ A vital aspect of providing this support is how it is delivered. In one survey of Latino caregivers, health care providers were the primary source of health care information, and technology-based information sources such as texts, emails, and app-based information were not highly utilized.¹⁹ In the Latino population, a telephone and a promotora-delivered intervention in Latino individuals with cancer and caregivers have demonstrated promising results for survivor and caregiver outcomes.^12,13 An intervention using telenovela-based information delivery has shown promise for Latino individuals with chronic illness and their caregivers.⁵⁰ Nurses are an important source of informational support. As part of this support, nurses should assess Latino caregivers for both their supportive care needs and their preferences for care or intervention delivery to foster greater self-efficacy.^12,19,48,50

The relationships between self-efficacy for symptom management and health outcomes align with prior research demonstrating the relationship between greater self-efficacy and lower symptom distress and depression.^51,52 Nursing interventions to promote health in Latino caregivers should focus on self-efficacy for personal symptom management along with caregiver self-efficacy for caring for the survivor. Greater informational support for caregiver self-care and care recipient support, Spanish language translation, and acknowledgment of the cultural context to promote self-efficacy in Latino cancer caregivers are essential for nursing care.

Limitations

Participants in this study were mostly female, with lower socioeconomic status. Any generalizability is therefore limited to this population. In addition, this was a secondary, cross-sectional data analysis, limiting the ability to identify causal relationships. The measures in this study had strong psychometrics and the significant statistical relationships provide a starting point for further examination of social and cultural factors, self-efficacy for symptom management, and health outcomes in caregivers of Latina individuals with breast cancer.

Conclusion

Caregivers of Latina individuals with breast cancer are fundamental to the health care team, and they are at risk for adverse health consequences related to caregiving. In this study, self-efficacy mediated the relationships between social and cultural factors (i.e., informational support and Anglo orientation) and health outcomes, suggesting a pathway for future nursing research and clinical interventions. Reinforcing self-efficacy through informational support and the provision of culturally relevant care has the potential to improve health outcomes for Latino caregivers of Latina individuals with breast cancer.