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O R I G I NA L A R T I C L E
A Proposed Theoretical Framework
Addressing the Effects of Informal
Caregivers on Health-Related Outcomes of
Elderly Recipients in Home Health Care
Eunhee Cho*, PhD, MPH, MSN, RN
Post-Doctoral Fellow, Center for Health Outcomes and Policy Research,
School of Nursing, University of Pennsylvania, Philadelphia, USA
Purpose The purpose of this review is to develop a theoretical framework addressing the effects of informal
caregivers on health-related outcomes of elderly recipients in home health care.
Methods The investigator a) reviewed theories and literature related to informal caregiving and healthrelated outcomes of elderly recipients, b) critiqued the strengths and limitations of these theories and literature
for research in this area, and c) developed a new conceptual framework by deductively applying these theories
and literature to the effects of informal caregivers on health-related outcomes of elderly recipients in home
health care.
Results Social network theories, social support theories, and the literature on informal caregiving are useful
in understanding how informal caregivers affect the outcomes of elderly recipients in home health care. This
review synthesizes these theories and literature into a new theoretical framework in order to fully address the
effects of informal caregivers on health-related outcomes of elderly recipients in home health care.
Conclusion The proposed theoretical framework suggests that health-related outcomes of elderly recipients
are the result of interactions among types of informal caregivers, the nature of the caregiving relationship,
caregiving as a function of such relationships, and the internal processes of the care recipient. [Asian Nursing
Research 2007;1(1):23–34]
Key Words
aged, caregiving, home health care, informal caregivers, social support
INTRODUCTION
A number of studies have been conducted to evaluate the outcomes of older adults who receive formal
home health care (HHC). However, the research does
not consider the potential variability in the outcomes
of older adults by informal caregivers. Since a great
deal of in-home care is provided by informal caregivers, the development of knowledge about the
effects of informal caregivers on the outcomes of
elderly recipients is vital.
Informal caregiving is provided to older adults in
a wide variety of relationships (e.g., spouse, son or
daughter, other relatives, or non-relative caregiver)
*Correspondence to: Eunhee Cho, PhD, MPH, MSN, RN, Center for Health Outcomes and Policy Research, School of
Nursing, University of Pennsylvania, 420 Guardian Drive, Philadelphia, PA 19104-6096, USA.
E-mail: [email protected]
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that can differ tremendously in terms of quantity and
quality. Thus, the various informal caregiving relationships may cause differential outcomes in elderly
recipients, but there is limited research in this area.
In spite of the enormous amount of caregiving literature, research regarding informal caregivers has
focused largely on caregiver experiences such as
caregivers’ stress and burden (Bakas, Pressler, Johnson,
Nauser, & Shaneyfelt, 2006; Nijboer et al., 2000; Pinquart & Sorensen, 2006a) and effects of formal HHC
services on informal caregivers (Brodaty, Green, &
Koschera, 2003; Pinquart & Sorensen, 2006b). Only a
few researchers have examined the effects of informal
caregivers on the health-related outcomes of elderly
recipients. If we are to fully understand the outcomes
of elderly recipients in HHC, we need to take into
account the effects of the various types of informal
caregivers on elderly recipients.
Research is limited due to a lack of theoretical
frameworks that may explain how health-related
outcomes among elderly recipients are affected by
informal caregivers and what variables should be
explored. A theoretical understanding is imperative
in systematically understanding and evaluating the
effects of informal caregivers on the outcomes of
elderly recipients. Thus, the purpose of this review is
to develop a theoretical framework addressing the
effects of informal caregivers on health-related outcomes of elderly recipients in HHC.
METHODS
An electronic database search of MEDLINE (1966 to
February 2006), CINAHL (1982 to February 2007),
and PsycINFO (1887 to February 2007) was performed. Key terms used were: older adults, aged, home
care, home health care, home care services, caregivers,
informal caregivers, family caregivers, home nursing,
informal care. The search was limited to articles published in English. The inclusion criteria for the studies
were: a) reported who the caregivers are; b) reported
what health-related outcomes are achieved for the
care recipients; c) care recipients are elderly patients
(≥ 65); and d) received care in the patient’s home.
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The literature was reviewed to identify applicable
theories to evaluate the effects of informal caregivers
on health-related outcomes of elderly recipients in
HHC. Social network theories and social support
theories were selected because these theories are
predominantly used in the literature and they capture important aspects of adapting to the effects of
informal caregivers on the outcomes of the elderly
recipients. Analysis and critique of these theories
were conducted for use in research on the effects of
informal caregivers on the outcomes of the elderly
recipients. Simultaneous analysis and critique of the
literature on informal caregiving provided several
concepts that had the potential to enhance the
understanding of the effects of informal caregivers
on health-related outcomes of elderly recipients in
HHC. These theories and literature were synthesized into a new theoretical framework addressing
the effects of informal caregivers on health-related
outcomes of elderly recipients in HHC.
For the purpose of this analysis, care recipients
were defined as persons ≥ 65 years of age, and who
receive care from informal caregivers. Informal caregivers were defined as non-paid individuals who are
primarily responsible for providing and/or coordinating care in the home, such as a spouse, offspring,
other relative, and non-relative caregivers (friends,
neighbors). This analysis considered HHC as the
delivery of health and social services provided by formal caregivers in the client’s home. Formal caregivers
are paid professionals or paraprofessionals such as
nurses, physicians, HHC aides, dietitians, and therapists who provide assessment, education, support, and
therapeutic care. HHC includes skilled nursing care,
home health aide services, therapeutic treatments
such as physical, occupational, and speech language
therapies, and other medical social services.
Literature review
Older adults face many health problems as they age.
Various kinds of caregiving relationships ensure that
older adults can stay at home while requiring health
care. Researchers have tried to describe the various
types of caregiving relationships. Social network
theories, social support theories, and the literature
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on informal caregiving have described the caregiving
relationships, even though they have conceptualized
this relationship in different ways.
hierarchical-compensatory patterns are rooted in past
relationships and activated when the older adult needs
assistance (Cantor, 1991; Messeri et al.).
Social network theories
A social network is defined as “the number, frequency
and linkages of contacts with other individuals or
groups” (Worcester, 1990, p. 140). Social network
theories propose that social interactions between individuals lead to heterogeneous relationships that have
different levels of supportiveness (Pierce, Sarason, &
Sarason, 1991). There are two main social network
theories: task-specific theory and hierarchicalcompensatory theory.
Task-specific theory categorizes social network
groups as primary, informal, and formal groups
(Litwak, 1985). According to this theory, each social
network has different natures, and because of these
different natures of social networks, each network
group can optimally manage different tasks (Litwak,
1985; Messeri, Silverstein, & Litwak, 1993). This theory also emphasizes that most people have various
needs, and it is necessary for both formal groups and
primary/informal groups to cooperate in most areas
of life (Messeri et al.). In addition, the provision of aid
varies across different relationships even within the
primary groups such as spouses, offspring, relatives,
and non-relatives. For example, spouses typically live
together. Therefore, they continuously have face-toface contact, and can provide social support over a
long period of time. On the other hand, neighbors
live close by and primary contact is face-to-face, but
unlike spouses, they typically do not provide longterm commitments (Messeri et al.).
Hierarchical-compensatory theory focuses on the
importance of recipients’ preferences. According to
this theory, older adults seeking help have an ordered
preference based on “the primacy of the relationship
between the caregiver and elderly recipient” (Messeri
et al., 1993, p. 123). Older adults prefer the assistance
of spouses. When they are not available, they turn first
to children, second to other relatives, third to friends
or neighbors, and last to formal groups (Cantor, 1991;
Messeri et al.). The social network can be categorized in a hierarchical-compensatory manner. These
Social support theories
Uchino conceptualized social support as “the functions that are provided by social relationships”
(Uchino, 2004, p. 16). Social support theories have
linked the social support provided by social relationships to health outcomes, although each model
within social support theory emphasizes different
processes. There are two main theories in social support theories: direct effect theories and stress-related
theories.
Direct effect theories emphasize the benefits of
receiving social support based on social identity, social
control, or loneliness models (Uchino, 2004). First,
according to the social identity model, social support
has positive effects on health when individuals are
embedded in a social network because it gives individuals meaningful roles that provide self-esteem
and increase the meaning of life, which in turn affects
the health of support recipients (Thoits, 1983). Second, according to the social control model, social
support also has positive effects on health when an
individual is embedded in a social network which can
place pressure on people to follow healthier behaviors
by giving individuals meaningful roles that enhance
an obligation to life (Lewis & Rook, 1999). Third,
based on a loneliness model, loneliness is related to
poor health outcomes because loneliness affects selfesteem, meaning of life, and obligation to life (Stroebe
& Stroebe, 1996; Uchino). This, in turn, may result
in negative health behaviors such as smoking and
the intake of alcohol (Stroebe & Stroebe, 1996).
These negative health behaviors consequently affect
overall health outcomes for the individual.
Stress-related theories have received the most
attention in prior research. These theories focus on
the role of social support in stress-related processes.
The buffering model of social support predicts that
social support is healthy because it buffers the negative effects of stress on health (Cohen & Herbert,
1996). This model suggests that stressors such as
bereavement and daily hassles affect health through
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the appraisal process which is a psychological process
that can be adjusted by social support (Uchino, 2004).
Therefore, based on a buffering model, even when
faced with extremely stressful events such as the
death of a spouse, social support can help reduce the
intensity of the stress response and facilitate coping
strategies over the long term (Uchino). On the other
hand, according to the stress-prevention model, social
support is healthy because social support may prevent people from exposure to potential stressors such
as negative life events (Uchino).
Literature on informal caregiving
Informal caregiving has been studied by gerontologists, nurses, sociologists, and social workers in order
to better understand the care provided by informal
caregivers such as family members, friends, or neighbors to older adults or chronically ill individuals.
The conceptualization of informal caregiving: Informal caregiving has been defined in many different
ways. In most of the literature, informal caregiving has
been conceptualized mainly as an activity or a set of
tasks to assist physical needs (Swanson et al., 1997),
although it is assumed to provide more psychosocial
support than the care provided by professionals. Some
researchers have noted the lack of a comprehensive
definition of informal caregiving, and have attempted
to extend the manner in which the concept of informal caregiving is viewed (Archbold, 1982; Bowers,
1987). Bowers’ study reveals five conceptually distinct but overlapping categories of informal caregiving: anticipatory, preventive, supervisory, instrumental
and protective. Out of these five categories of informal caregiving, only instrumental caregiving is what
has been generally conceptualized as informal caregiving, while the other four types are not included
into a conceptualization of informal caregiving. However, informal caregivers believed that the remaining
four types of caregiving are as significant as, or even
more important, than instrumental caregiving in their
caregiving experience.
Caregiver’s reactions to caregiving: Many researchers
have studied the impact of conducting the caregiving
role or tasks on caregivers. Although some researchers
reported the positive experience of informal caregivers
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(Archbold, Stewart, Greenlick, & Harvath, 1990;
Cohen, Colantonio, & Vernich, 2002), most researchers have reported a variety of negative impacts
that caregiving has imposed on informal caregivers
(Robinson, 1997; Schulz & Beach, 1999). These
negative impacts, such as emotional, health, social,
and financial problems, are conceptualized as caregiver burden or strain (Given & Given, 1991).
Informal caregivers are considered to be at risk due
to the health problems of the caregivers themselves.
Caregivers, particularly elderly spouses, reported that
caregiving negatively affects their physical health
(Schulz & Beach, 1999; Vitaliano, Scanlan, Krenz,
Schwartz, & Marcovina, 1996). The caregivers’ physical health problems may also be associated with caregiver burden. Schulz and Beach reported that the
caregivers experiencing burden had mortality risks
63% higher than non-caregiving controls. However,
caregivers who did not experience this burden did
not have increased mortality rates.
The relationships between caregivers and care
recipients have been considered as a related factor
for caregiver burden. Some studies found that spouse
caregivers experience higher levels of burden
(Nagatomo et al., 1999; Zanetti et al., 1998), while
other researchers reported that children or childrenin-law caregivers experience higher levels of burden
than spouse caregivers (Choi-Kwon, Kim, Kwon, &
Kim, 2005; Donaldson, Tarrier, & Burns, 1998; Given
et al., 2004). Chumbler, Grimm, Cody, and Beck
(2003) examined caregiver burden in diverse caregiving relationships. They found that daughters, sons,
wives, and husbands had comparable burden, but
they had greater burden than more distant relatives.
Thus, studies have revealed mixed findings in terms
of levels of burden among family caregivers.
The literature also suggests that caregiver burden
is related to nursing home admission (Aneshensel,
Pearlin, Levy-Storms, & Schuler, 2000; Bradley, 2003;
Lieberman & Kramer, 1991). For example, Lieberman
and Kramer studied patients with dementia and their
caregivers, and found that the patient characteristics,
such as level of cognitive and medical impairment,
did not predict nursing home placement, whereas the
caregivers’ characteristics, such as type of caregiver
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arrangement, number of family problems, and amount
of burden reported by the caregiver, predicted nursing
home placement.
Limitations of theories and the literature
Social network theories suggest that not all types of
caregivers are of equal benefit to the mental and
physical health of care recipients. In addition, the
theories classify the types of informal caregivers and
the key concepts related to the nature of caregiving
relationships such as availability, familiarity, motivation, and preference (Figure 1). However, social network theories do not specify whether these theories
can be applied to both physical and psychosocial
support (Friedman, 1993). The effects of social networks can be different based on types of support.
Friedman, who tested the hierarchical-compensatory
model in older women with heart disease, found
that the model appears to offer an explanation for
the hierarchy of sources selected for only psychosocial support. In order to understand how informal
caregivers affect the outcomes of elderly recipients,
the effects need to be specified based on types of
caregiving (psychosocial aspects vs. physical aspects).
In addition, social network theories do not elucidate
Social Network
Theories
Task-Specific
Theory
Type of social
networks
the possible mechanism for how the social network
affects the outcomes of care recipients (Uchino,
2004). Thus, another theory is needed in order to
address these mechanisms.
Social support theories are useful to understand the
mechanism for how caregiving influences the health
of care recipients. These theories also provide the key
concepts for mechanisms such as self-esteem, meaning of life, obligation to life, loneliness, stress, health
behaviors, and adherence (Figure 1). These theories
also explain mechanisms of how these key concepts
affect health, including psychological and behavioral
processes. However, social support theories focus
exclusively on psychological effects. Although these
theories reported that physical health can be affected
by social support, the physical health is affected
through the psychological process, or both psychological and behavioral processes. There is no explanation for how social support directly affects the
physiological processes or physical health.
The limitation of social support theories might
be related to the conceptualization of social support
which emphasizes psychosocial aspects rather than
physical aspects. It might not be surprising that social
support theories and research on social support show
Literature on Informal
Caregiving
HierarchicalBurden Theory
Compensatory Theory
• Availability
• Familiarity
• Motivation
• Preference
Conceptualization
of Caregiving
Direct Effect
Theories
• Self-esteem
• Meaning of life
• Obligation to life
• Loneliness
• Caregiver’s
burden
Extracted for
this proposed
conceptual
framework as:
Type of
Caregivers
Social Support
Theories
Stress-Related
Theories
• Stress
• Health behavior
• Adherence
Nature of Caregiving
Relationship
Caregiving
Internal Processes
of a Care Recipient
Figure 1. Factors from theories and the literature.
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that social support protects individuals from a multitude of mental health problems, ranging from
mild depression to suicidal tendencies (Cohen,
Underwood, & Gottlieb, 2000). However, it is less
obvious whether and how social support affects physical health. As opposed to social support, caregiving
may have a strong influence on the physical health of
care recipients. For instance, some caregiving such as
administering medications and feeding can directly
influence physiological processes and physical health,
while social support tends to have an indirect influence on physical health via its’ psychological process.
Thus, in order to understand how informal caregivers
affect the outcomes of elderly recipients, the relationship among caregiving for physical needs, physiological process, and physical health must be addressed.
The literature on informal caregiving provides the
foundation for the conceptualization of informal
caregiving and the acknowledgement that caregiver
burden is an important concept within the caregiving
relationship (Figure 1). In addition, the literature on
informal caregiving informs researchers about what
kinds of outcome measures must be included when
the effects of informal caregivers on elderly recipients
are evaluated. Social network theories and social support theories have investigated mental and physical
health. On the other hand, the informal caregiving
literature shows that health service utilization is
another important outcome measure to consider for
understanding the effects of informal caregivers on
elderly recipients. However, there are limitations of
the literature on informal caregiving for understanding the effects of informal caregivers on elderly recipients in HHC. Researchers have investigated only
some types of informal caregivers or have used a proxy
of available informal caregivers such as marital status
or living arrangements.The incorporation of social network theories for understanding the effects of informal
caregivers on the outcomes of elderly recipients will
be helpful in solving this limitation in the literature.
In addition, informal caregiving studies have not stated
the mechanism for the effect of informal caregivers on
the outcomes of elderly recipients. The incorporation
of social support theories for understanding the phenomenon will be helpful to solve this limitation.
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RESULTS
Given that the phenomenon of how informal caregivers affect the health-related outcomes of elderly
recipients in HHC is complicated, social network
theories, social support theories, and the literature
on informal caregiving cannot fully address the phenomenon but partially explain the phenomenon and
its key elements. Thus, these theories and the literature are incorporated into a new theoretical framework which is depicted in Figure 2.
The key concepts in the proposed theoretical
framework include type of informal caregivers, nature
of the caregiving relationship, caregiving as a function
of the relationship, internal processes of a care recipient, and health-related outcomes of elderly recipients. The proposed theoretical framework shows that
the nature of the caregiving relationship is influenced by the type of informal caregiver and affects
the function of such relationships, caregiving. Healthrelated outcomes of elderly recipients are the result
of the interaction among types of informal caregivers, the nature of the caregiving relationship,
caregiving itself, and the internal processes of the
care recipient.
Types of informal caregivers
The types of informal caregivers are conceptualized
and categorized by task-specific theory, which is one
type of social network theory (Figure 1). Based on
this theory, the type of informal caregivers can be
categorized as spouses, offspring, relatives, and nonrelatives such as friends and neighbors. It is hypothesized that each type of caregiver will have a different
nature of the caregiving relationship.
Nature of the caregiving relationship
The nature of the caregiving relationship is determined by several factors from the literature on social
network theories and informal caregiving (Figure
1). The caregiving relationship is established from
past relationships and the history of interactions.
Therefore, it is important to consider the nature
of the caregiving relationships within an historical
context.
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Informal Caregivers
Internal Processes
of a Care Recipient
Type of Informal
Caregivers:
• Spouse
• Offspring
• Relative
• Non-relative
Nature of Caregiving
Relationship
Determined by:
• Availability
• Familiarity
• Motivation
• Care recipient’s
preference
• Burden
Caregiving
• Psychosocial
support
• Direct care related
to illness and aging
Psychological
Process
• Self-esteem
• Meaning of life
• Obligation to life
• Loneliness
• Stress
Behavioral Process
• Health behaviors
• Adherence
Health-Related
Outcomes of
a Care Recipient
• Mental health
• Physical health
• Health service
utilization
Physiological Process
Figure 2. A proposed theoretical framework addressing the effects of informal caregivers on the health-related outcomes of elderly recipients in home health care.
Availability
Task-specific theory provides the theoretical background for the importance of informal caregivers’
availability in the caregiving relationship. Task-specific
theory uses proximity, length of commitment, commonality of lifestyle, and size of the group in order to
specify primary groups and informal groups (Messeri
et al., 1993). This proposed theoretical framework
specifies caregiving rather than social support. In
order to specify the nature of each caregiving relationship, this proposed theoretical framework modifies
task-specific theory. The concepts of proximity, length
of commitment, and size in task-specific theory are
combined into the concept of availability because
the availability of caregivers, which is a very influential element in the caregiving relationship, is decided
based on these factors. Caregivers must be able to
provide adequate availability in terms of both density
and duration.
Familiarity
The concept of commonality of lifestyle in taskspecific theory is included into the concept of familiarity because if caregivers are familiar with care
recipients (e.g., lifestyles, behaviors, and characteristics), the commonality of lifestyle might not be very
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influential on the outcomes of care recipients. In
this proposed theoretical framework, the concept of
familiarity not only means familiar relationships,
but also includes informal caregivers’ knowledge
about care recipients. The knowledge about what
care recipients want and need is a part of the informal
caregivers’ familiarity with care recipients. Informal
caregivers become familiar with care recipients’
needs, characteristics, and preferences over time,
and thereby, this caregiving relationship becomes
more acceptable to care recipients. This familiarity
can form during a long-term relationship, and
several factors, such as commonality of lifestyles,
common culture, and face-to-face contact, can
influence this formation.
Motivation
Task-specific theory provides the theoretical background for the importance of informal caregivers’
motivation in the caregiving relationship. Taskspecific theory uses type of motivation, division of
labor, and level of technical knowledge to specify
formal groups (Messeri et al., 1993). From the concepts specifying formal groups in task-specific theory, the type of motivation is the only criteria
extracted for this proposed theoretical framework
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because different types of informal caregivers may
have different motivations for caregiving.
Care recipients’ preferences
Hierarchical-compensatory theory provides the theoretical background for the importance of care recipients’ preferences. According to this theory, care
recipients have different preferences for specific types
of informal caregivers. Older adults can experience
less psychological damage to their ego systems when
they receive help from someone they prefer (Cantor,
1989). Therefore, the preference of care recipients
may influence health, specifically mental health.
Informal caregiver’s burden
The associations between the type of informal caregivers and informal caregivers’ burden have been
reported. For instance, researchers have reported
that spouse caregivers experience less role strain than
daughter caregivers because daughter caregivers
experience reversed roles, and have more difficulty
in meeting reciprocal expectations (Johnson &
Catalano, 1983; King, Atienza, Castro, & Collins,
2002). These role strains cause daughter caregivers
to take on a greater burden, which might negatively
affect the health of care recipients.
Caregiving
Caregiving is a concept that encompasses a multitude
of domains including physical and psychosocial.
Unfortunately, the psychosocial aspects of caregiving have not been adequately conceptualized in the
current literature. Although physical assistance is an
important aspect in caregiving, the current conceptualization of caregiving, to concentrate only on
physical assistance, is a partial and incomplete view
and risks neglecting those psychosocial aspects
which may be central to care recipients and caregivers. It should be emphasized that informal caregivers provide both psychosocial support and direct
care related to illness and aging. Thus, in this proposed theoretical framework, caregiving is defined
as psychosocial support as well as direct care related
to illness and aging for care recipients provided by
an informal caregiver in the care recipients’ home.
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Internal processes of a care recipient
Social support theories are adapted in order to
explain the mechanism between caregiving and the
outcomes of elderly recipients. Caregiving affects
care recipients’ health through: a) psychological
processes such as a strong sense of self-esteem, greater
meaning of life, more positive obligation to life, less
loneliness, and less stress; b) behavioral processes
such as health behaviors and adherence; and c)
physiological processes such as cardiovascular, neuroendocrine, and immune function (Thoits, 1983;
Uchino, 2004).
Psychosocial support and direct care provided
by informal caregivers will influence care recipients
through different processes. Since these care recipients’ psychological, behavioral, and physiological
processes influence one another, either psychosocial
support or direct care can influence both care recipients’ mental and physical health. However, care
recipients’ psychological processes might directly
influence care recipients’ mental health without
directly influencing care recipients’ behavioral and/
or physiological processes. In addition, care recipients’ physiological processes might directly influence care recipients’ physical health without directly
influencing care recipients’ psychological and/or
behavioral processes. These processes are all interrelated. Psychosocial support will primarily have an
effect on the psychological processes, and then influence a care recipient’s mental health. Likewise, psychosocial support also can affect a care recipient’s
physical health by behavioral processes that are
influenced by psychological processes. On the other
hand, direct care related to illness and aging will
primarily have an effect on physiological processes,
and then influence a care recipient’s physical health
(Figure 2).
The discrepancy between received care and perceived care can occur due to the internal processes
of a care recipient, especially the psychological
process. Namely, received care may be perceived
differently based on self-esteem or level of stress.
Thus, care recipients who are depressed or who
have low self-esteem may have a higher discrepancy
between received care and perceived care.
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Informal Caregivers
Health-related outcomes of care recipients
Social network theories and social support theories
have investigated mental and physical health. However, the informal caregiving literature shows that
health service utilization such as hospitalization and
nursing home admission is another important outcome measure to consider in order to understand
the effects of informal caregivers on the outcomes
of care recipients.
DISCUSSION
The proposed theoretical framework suggests that the
type of informal caregivers influences the nature of
the caregiving relationship which, in turn, affects the
function of such caregiving relationships, caregiving.
The quality of the caregiving relationship can be considered high if the caregiving relationship is characterized as being highly available, exhibiting a familiarity
between caregivers and care recipients, motivated
by affection, having a preferred caregiver, and having
few burdens. Similarly, the quality of caregiving is considered high if the caregiving comprises a high quality
of psychosocial support and direct care related to
illness and aging. Thus, for caregiving to be optimum,
a psychosocial dimension must be incorporated with
the dimension of direct caregiving.
Each key concept in the proposed framework
needs to be measured. For example, the quality of
caregiving can be assessed by the QUALCARE Scale
(Phillips, Morrison, & Chae, 1990a, 1990b), and caregiver burden can be measured by the Caregiver
Burden Inventory (Novak & Guest, 1989). In terms
of health-related outcomes of care recipients, the
Geriatric Depression Scale (GDS) (Yesavage et al.,
1982) can be used for measuring depressive symptoms, and the Katz ADL index (Katz, Ford,
Moskowitz, Jackson, & Jaffe, 1963) can be employed
for measuring the physical health of elderly recipients.
These are examples in which other instruments can be
applicable to the model. With continued research,
many other instruments could be developed. Furthermore, the proposed theoretical framework needs
to be tested by empirical studies. For example, the
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association between the quality of caregiving as
measured by the QUALCARE Scale and the depressive symptoms of elderly recipients as measured by
the GDS can be tested.
The proposed theoretical framework elucidates
the key elements influencing the health-related
outcomes of elderly recipients. This framework shows
that health care providers need to assess both the
nature of the caregiving relationship and the caregiving itself in order to provide effective interventions.
The most suitable intervention must consider whether
the caregiving deficiency is due to the absence of
caregivers, the nature of the caregiving relationship, or
a quality of caregiving. If care recipients do not receive
appropriate care from informal caregivers because of
an inappropriate caregiving relationship, the interventions targeting improvement to the caregiver’s skill
and knowledge will not be effective because the interventions will not change the fundamental problem.
This theoretical framework will be helpful in terms of
assessing these problems and designing appropriate
interventions based on the aforementioned problems.
If the caregiving deficiency is due to the absence
of informal caregivers and the older adult has a potential informal caregiver, health care providers should
consider developing caregiving relationships and testing interventions aimed at maintaining supportive
caregiving relationships throughout the long term.
However, if the care recipient does not have an
available informal caregiver, the interventions may
be to supplement the role of informal caregivers with
formal HHC. A caregiving deficiency due to the
nature of the caregiving relationship would lead to
interventions to increase the quality of the existing
relationship through increasing the caregiver’s availability, familiarity between the caregiver and care
recipient, motivation of affection, or considering the
care recipient’s preference and decreasing the caregiver’s burden. A caregiving deficiency related to the
nature of the caregiving relationship can be addressed
by mobilization of informal and formal support systems such as support groups and respite care services,
respectively.
Even when a caregiver is present and the nature of
the caregiving relationship is optimal, the outcomes of
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care recipients can be affected by the caregiving itself.
This deficiency can be addressed through education
and development of caregiving skills. Deficiency in different educational domains (psychosocial support vs.
direct care) needs to be addressed by different educational interventions. For example, if the caregivers do
not know how they can effectively provide psychosocial support to the patients, the education needs to
be focused on effective psychosocial support.
Researchers have measured caregiving by either
the structures of informal caregivers (e.g., the presence
of caregiver, types of caregivers, or living arrangement) or the function those informal caregivers may
serve (e.g., provision of ADL or IADL). However, it
appears an appropriate strategy to measure both the
caregiving structure and the caregiving function in
order to know the whole picture of caregiving. This
proposed theoretical framework, incorporating these
two perspectives, will increase the understanding of
both the structural and functional aspects of caregiving. Furthermore, this theoretical framework will help
to integrate the existing literature that separates these
domains, and facilitate the development of effective
interventions based on these perspectives.
The proposed conceptual framework is an initial
step in addressing the effects of informal caregivers
on the health-related outcomes of elderly recipients
in HHC. This proposed conceptual framework
assumes that, on average, caregiving positively affects
the health of older adults. The possibility exists for
negative effects of informal caregivers on care recipients, and researchers need to be aware of these negative effects. Taking into account the negative effects
of caregivers can serve to refine this proposed conceptual framework. The social structural environment
should also be considered for addressing the effects
of informal caregivers on health-related outcomes of
elderly recipients. The social structural environment
in which care recipients, caregivers, and caregiving
relationships between them are affected has not been
sufficiently integrated in this proposed conceptual
framework. Culture, race/ethnicity, gender, and socioeconomic status are of particular concern, which can
refine this proposed conceptual framework in the
future. In spite of these limitations, the proposed
32
theoretical framework indicates what variables should
be explored, and provides direction for future studies
of interrelationships among these variables in order
to improve health-related outcomes of care recipients
in HHC. Thus, the framework described here offers
a map for intervention and research on caregiving for
care recipients in HHC.
ACKNOWLEDGMENTS
The author would like to thank Dr Karen L.
Schumacher for intellectual guidance and invaluable support.
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