spirituality and self efficacy.pdf

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International Psychogeriatrics(2012), 24:12, 19431952 C International Psychogeriatric Association 2012doi:10.1017/S1041610212001287

Spirituality and self-efficacy in dementia family caregiving:trust in God and in yourself

.........................................................................................................................................................................................................................................................................................................................................................................

J. Lopez,1 R. Romero-Moreno,2 M. Marquez-Gonzlez3 and A. Losada21Department of Psychology, Universidad San Pablo CEU, Madrid, Spain2Department of Psychology, Universidad Rey Juan Carlos, Madrid, Spain3Department of Biological and Health Psychology, Universidad Autnoma de Madrid, Madrid, Spain

ABSTRACT

Background: Research indicates that spirituality and self-efficacy have been associated with higher levels of

caregivers well-being. However, these two concepts have rarely been examined simultaneously. The aim of

this study was to analyze the combined effect of spirituality and self-efficacy on the caregiving stress process.

Methods:The study design was cross-sectional. Dementia family caregivers (n = 122) were assessed in relation

to the following variables: stressors (time since caregiving began, daily hours caring, frequency of behavioral

problems, patients functional status); appraisal (caregivers appraisal of behavioral problems), caregivers

personal resources (self-efficacy, spiritual meaning, social support), and outcomes (depression and anxiety).

Results:Participants were divided into four groups corresponding to four profiles defined by their scores on

spiritual meaning and self-efficacy: LELS = Low self-efficacy and low spirituality; HELS = High self-efficacy

and low spirituality; LEHS = Low self-efficacy and high spirituality; and HEHS = High self-efficacy and

high spirituality. No differences were found between groups in stressors, appraisal, or personal resources.

Caregivers in the HEHS group had significantly less depression compared to the LEHS group. Regression

analysis showed that being a HEHS caregiver, low appraisal of behavioral problems and high social support

were associated with low caregiver depression. Only high appraisal of behavioral problems was associated with

high levels of anxiety.

Conclusion: The results of this study suggest that spirituality and self-efficacy had an additiveeffect on caregivers

well-being. A high sense of spiritual meaning and a high self-efficacy, in combination, was associated with

lower levels of depression in caregivers.

Key words:dementia caregivers, spiritual meaning, competence, stress process, coping, anxiety, depression

Introduction

Family caregiving is the oldest form of care

system. Nevertheless, relatives who assume the role

of primary caregiver are exposed to a stressful

situation that increases their risk of developing

important emotional problems, especially anxiety

and depression (Pagel et al., 1985; Schulz and

Williamson, 1991; Crespo et al., 2005; Cooper et al.,2007). Dementia caregiving has been considered as

a prototypical chronic stressful situation, and most

of the research in this field has been carried out

from the stress and coping theoretical model (e.g.

Pearlinet al., 1990; Lawtonet al., 1991). According

to this model of stress, the degree to which the

Correspondence should be addressed to: Javier Lopez, Departamento de

Psicologia, Universidad San Pablo CEU, 28668-Boadilla del Monte, Madrid,

Spain. Phone: +34 91 372 47 00; Fax: +34 91 372 40 00. Email: jlopezm@

ceu.es. Received 27 Dec 2011; revision requested 5 Mar 2012; revised version

received 31 May 2012; accepted 27 Jun 2012. First published online 2 August

2012.

difficult situations faced by caregivers over long

periods of time (stressors such as the care recipients

behavioral problems or dependence) influence their

own mental health (e.g. depression or anxiety) will

vary depending on their personal resources (e.g.

coping or social support). This model highlights the

importance of analyzing the influence of personal

resources on caregiving distress. While the number

of studies analyzing caregivers stress process hasgrown exponentially over the last three decades,

there are some relevant personal resources (which

may attenuate or reinforce the impact of stressors

on caregivers mental health) that deserve more

attention than they have received so far. This is

the case of spirituality and self-efficacy, which are

analyzed in the following sections.

Spirituality

Spirituality refers to the individualized and personal

response to matters such as the meaning of life,


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1944 J. Lopezet al.

death, illness, and existential concerns; it is the

personal quest to understand the ultimate questions

about life, meaning, and our relationship to the

sacred or transcendent. It can be seen as comprising

elements of meaning and connection to a higher

power or something greater than the self (Fetzer

Institute and National Institute on Aging Working

Group, 1999).

The influence of spirituality on caregiver stress

process is under-explored, even though it has been

considered to be an important coping resource

for caregivers (Marquez-Gonzlez et al., 2012). A

review of studies analyzing the role of spirituality

in caregivers well-being showed that most of them

reported either no association between spirituality

and well-being (e.g. depression) or a mixed

association (combination of positive, negative, and

non-significant results) (Hebert et al., 2006). It

is likely that the heterogeneity of the measures

used for assessing spirituality partially explains

the inconsistency of the findings in this researchfield. Even though spirituality is a multidimensional

construct (meaning, forgiveness, spiritual coping,

spiritual history, commitment, and so on; Fetzer

Institute and National Institute on Aging Working

Group, 1999), it is usually operationalized with

broad measures, a fact that may contribute to the

finding of cloudy results (Hebert et al., 2006).

In order to avoid ambiguous research results,

it is necessary to be specific about the dimension

of spirituality measured with caregivers. Spiritual

meaning is a specific spiritual dimension related

to the existentialism perspective. Spiritual meaningin the context of caregiving refers to the spiritual

attributions associated with the experience of

caregiving (Farran et al., 1999). Spiritual or ultimate

meaning relates to caregivers deriving a sense of

purpose from beliefs in a greater spiritual power.

A central element of spirituality is the provision

of ultimate meaning. Spirituality allows people

to interpret events and experiences as ultimately

meaningful by linking them to a broader sense of

order (Farranet al., 1999; Quinn et al., 2010).

Self-EfficacyA non-avoidant belief is the construct of perceived

self-efficacy. It is described as the subjective belief

that one can organize and execute courses of action

in order to manage given situations (Bandura,

1997). It refers to individuals judgment of their

ability to perform a behavior successfully. In the

caregiving area, these efficacy beliefs represent

the caregivers assessment of his/her ability to

successfully master relevant caregiving tasks. Rather

than viewing the demands of caregiving as tasks to

be avoided, those with a high sense of caregiving

self-efficacy may view them as challenges to be

overcome (Gilliam and Steffen, 2006). When

individuals face caregiving demands, those with low

self-efficacy beliefs focus on negative aspects of

the situation, including their personal deficiencies

and the difficulties of the task. Focus on negative

cognitions reduces motivation to initiate an activity,

impacts task persistence, and leads to negativeaffective states, which then perpetuate the cycle

(Bandura, 1997). Optimal performance involves

both skills and the efficacy beliefs to use the skills.

The role of self-efficacy in the stress process,

although indicated as one of the variables that may

contribute to a reduction of the impact of caregiving

demands on health, has been under-studied. It

is especially important to consider caregiver self-

efficacy in cases in which care recipients have

dementia, given that, as this illness progresses, the

caregiving role increasingly includes responsibility

for carrying out specific care and care management

behaviors. In fact, higher caregiver self-efficacyexpectations regarding their own ability to handle

caregiving challenges has been significantly related

to lower scores on burden, anger, anxiety, and

depression, even after controlling for objective

stressors (Marquez-Gonzlez et al., 2009).

Relationships between spirituality and

self-efficacy

It seems plausible to consider different com-

binations (or profiles) of spirituality and self-

efficacy beliefs with a view to making betterpredictions about caregivers well-being. In many

respects, spirituality empowers the individual. Being

connected to an all-powerful and sympathetic

Supreme Being gives spiritual people a tool that

can be used to change their situation or acquire

the strength to endure it. This may strengthen

feelings of self-efficacy and increases beliefs in ones

capability to organize and execute the courses of

action required to manage prospective situations. In

this sense, Lim et al. (2011) found that spirituality is

associated with caregivers gain through the use of

the encouragement strategy to manage dementia-

related problems, suggesting that spiritual beliefscould have provided caregivers with a framework to

positively reframe the situation and enabled them

to be more empathetic, which, in turn, promoted

efforts at encouraging the relative.

Nevertheless, one might also expect spirituality

to be positively related to control or influence by

powerful others. Spiritual persons believe that a

higher power possesses and exerts control over the

affairs of the world. Indeed, one could predict that

spiritual involvement is related to a lower sense of

self-efficacy. Such people place all responsibility for


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Caregivers Spirituality and Self-Efficacy 1945

problem-solving on God, while passively waiting to

receive solutions (Holland et al., 1999; Kinney et al.,

2003).

Kinney et al. (2003) identified three styles of

selecting solutions to problems guided by spiritual

beliefs in dementia caregivers. A collaborative

style consists of involving active personal exchange

with God. In this style, caregiver and God are

viewed as active contributors working together to

solve problems (high spirituality and high self-

efficacy). A deferring style, in which the caregiver

waits for solutions from God, seems to be part of

an externally oriented spirituality providing answers

to questions that the caregiver is not able to

resolve by him/herself. This style was associated

with lower levels of competence (high spirituality).

A self-directing style emphasizes the power of the

caregiver to direct his own life. This style appeared

to be an active coping orientation that stressed

personal agency (high self-efficacy). Spirituality

may increase external control, but at the same time areliance on God may actually improve ones sense of

internal control and thereby improve self-efficacy.

In our opinion, Kinney et al. (2003) skip a style

of selecting solutions to problems a lack of

expectations style in which the caregiver does

not wait for solutions from God, but does not

believe that he can organize and execute courses

of action in order to manage given situations (low

spirituality and low self-efficacy). Consistently with

this perspective, the caregiver does not expect that

the solution comes from God but he does not have

a sense of internal control either.The dementia literature findings on the

effect of spirituality and self-efficacy, considered

simultaneously, on the stress process are not robust.

It is possible to consider the global combined

effect of spirituality and self-efficacy. Nevertheless,

this research is interested in the four possible

profiles of combination between spirituality and

self-efficacy: collaborative, deferring, self-directing,

and lack of expectations. The aim of this paper is

to analyze, drawing on the stress and coping model

framework, the combined role of spiritual meaning

and self-efficacy in dementia caregivers well-being

(depression and anxiety). We hypothesized thatcaregivers with high levels of spiritual meaning

and high self-efficacy would also demonstrate fewer

levels of anxiety and depression.

Methods

Sample

Face-to-face interviews were carried out with

122 dementia caregivers. To be eligible for the

study, caregivers had to meet the following

Table 1. Sociodemographic characterist-ics of the sample

n = 122......................................................................................................................

Gender (%)

Female 80.3

Male 19.7

Relationship with care recipient (%)Spouse 36.1

Son/daughter 56.6

Others (parent-in-law) 7.3

Caregivers age

Mean 59.36

SD 13.14

Range 2987

Time since caring began (months)

Mean 52.57

SD 47.11

Range 6312

Hours caring per day

Mean 11.87

SD 8.13Range 124

Care-recipients illness (%)

Alzheimers disease 58.2

Other dementia 41.8

Care-recipients age

Mean 79.01

SD 8.80

Range 4897

Living arrangement of caregiver (%)

Living with care recipient 87.2

Not living with care recipient 12.8

SD = Standard deviation.

criteria: (1) the caregiver was providing care for

a community-dwelling dementia relative diagnosed

with dementia; (2) the caregiver identified

him/herself as the family member primarily

responsible for the patients care; (3) the caregiver

devoted at least one hour per day to caregiving tasks;

(4) the caregiver had been caring for the patient

for at least three consecutive months; and (5) the

caregiver was 18 years old or over.

Sociodemographic characteristics of the sample

(caregivers age, gender, and relationship with

care recipient; care recipients age; time sincecaring began; hours spent caring per day; and

care recipients illnesses and living arrangement of

caregiver) are shown in Table 1.

The majority of caregivers were Christian

(83.6%). About one-sixth identified themselves

as non-religious persons (16.4%). The average

spiritual mean score was 12.39 (range 028).

Measures

In addition to the sociodemographic variables, and

based on the stress and coping model (Pearlin et al.,


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1946 J. Lopezet al.

1990; Lawton et al., 1991), the following variables

were assessed.

S T R E S S O R S

Frequency of behavioral problems: This variable was

assessed with the Frequency subscale from the

Revised Memory and Behavior Problems Checklist

(RMBPC; Teriet al., 1992), which consists of a 24-item scale measuring the frequency of observable

behavioral problems (e.g. Waking you or other

family members up at night). Scores range from

0 (not at all) to 4 (extremely). In this study, the

internal consistency was 0.83 (Cronbachs ).

Functional status: Patients functional status was

measured using the Barthel Index (Mahoney and

Barthel, 1965). Caregivers respond to a ten-item

scale assessing the relatives level of independence

for activities of daily living (ADL; e.g. To what

extent is your relative able to feed her/himself?).

Total score ranges from 0 to 100. Higher scoresare indicative of higher level of independence in the

patient. Cronbachswas 0.94 in the present study.

Daily hours devoted to caregiving and time since

caregiving began were also considered as stressors.

A P P R A I S A L

Caregivers appraisal of behavioral problems: This was

assessed using the Appraisal subscale from the

RMBPC (Teri et al., 1992). The 24-item scale

provided a score for the amount of distress caused

by the problem behavior (e.g. How much has it

bothered or upset you when you or other familymembers have been woken up at night?). Scores

range from 0 (not at all) to 4 (extremely bothered

or upset). Cronbachs was 0.89.

P E R S O N A L R E S O U RC E S

Social support: The Psychosocial Support Ques-

tionnaire (Reig et al., 1991) was used. This

questionnaire has six items (e.g. When I need it,

there is always someone to encourage me and show

affection) for assessing caregivers perceptions of

the frequency of social, emotional, and instrumental

support they receive. Participants were instructed toanswer these items regarding their lives in general.

The answers range from 0 (never) to 3 (very

often). Cronbachs was 0.81.

Spiritual meaning: This was measured through the

Spanish version of the Ultimate Meaning Scale

(Farranet al., 1999; Fernndez-Capo et al., 2002).

This scale is made up of seven items (e.g. The

Lord wont give you more than you can handle,

I believe in the power of prayer; without it

I couldnt do this, I believe that the Lord

will provide), with responses ranging from 0

(strongly disagree) to 4 (strongly agree), that

were used to assess spiritual attributions associated

with the experience of caregiving. Participants were

instructed to answer these items regarding their lives

in general. Cronbachs was 0.89.

Perceived self-efficacy: This was measured using

the Spanish version of the Revised Scale for

Caregiving Self-efficacy (Steffen et al., 2002;Marquez-Gonzlez et al., 2009). This scale is

made up of 15 items (e.g. How confident are

you that, when [. . .] asks you four times in the

first hour after lunch when lunch is, you can

answer without raising your voice) that were

used to assess caregivers perceived self-efficacy for

obtaining respite, responding to disruptive patient

behaviors, and controlling upsetting thoughts. The

answers range from 0 (cannot do at all) to 100

(certainly can do). Cronbachs was 0.84.

O U T C O M E V A R I A BL E SDepression: Depressive symptomatology was as-

sessed with the Center for Epidemiological Studies

Depression Scale (CES-D; Radloff, 1977). It con-

sists of 20 items that assess how much the person ex-

perienced depressive symptoms during the last week

(e.g. I felt that everything I did was an effort).

Answers range from 0 (hardly ever or never) to 3

(all the time). Cronbachs was 0.90.

Anxiety: Anxiety was assessed using the Tension

subscale of the Profile of Mood States (POMS;

McNair et al., 1971), which consists of nine

items that measure caregivers levels of anxiety(e.g. During last week, how often did you feel

nervous?), with answers ranging from 1 (not at

all) to 5 (very much). Cronbachs was 0.91.

Data analysis

Participants were coded as high or low in spirituality

and perceived self-efficacy, respectively, based on

median splits for each variable (Md = 12 on the

spirituality and Md = 79 on the self-efficacy

scale). Four groups, corresponding to four different

profiles, were formed: HEHS=High in self-efficacy

and high in spirituality; LELS=Low in self-efficacyand low in spirituality; HELS = High in self-

efficacy and low in spirituality; and LEHS = Low

in self-efficacy and high in spirituality. With a view

to analyzing differences between types of profiles

in spirituality and self-efficacy for caregiving,

ANOVAs were carried out to permit the analysis

of differences between these groups in the following

variables: (1) stressors (hours caring per day, time

since caregiving began, level of dependency, and

frequency of behavioral problems); (2) appraisal

(caregivers appraisal of behavioral problems); (3)


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caregivers resources (social support); and (4)

outcome variables (depression and anxiety). In

order to test the effect size of between-group

differences in the assessed variables, partial eta-

square (p2) was used with the usual interpretation

(small effect = 0.010.06; medium effect = 0.06

0.14; large effect = 0.14).

Stressor-related variables (hours caring per day,

time since caregiving began, level of dependency,

and frequency of behavioral problems), appraisal

(caregivers appraisal of behavioral problems), and

caregivers resources variables (social support, and

as dummy variables the four groups corresponding

to the different spirituality and self-efficacy profiles)

were introduced in a stepwise regression analysis in

order to determine how much weight these variables

had in the explanation of caregivers anxiety and

depression and how they were related to it.

Results

No univariate (z scores in excess of 3.29; p HEHS

0.0

80

Anxiety:Mean(SD)

14.4

1(9.4

9)

15.8

2(9.7

9)

20.6

1(10.0

5)

16.5

5(6.7

2)

n.s.

LELS=

Lowself-efficacyandlowspirituality;HELS=

Highself-efficacyandlow

spirituality;LEHS=

Lowself-efficacyandhighspirituality;HEHS=

Highself-efficacyandhighspirituality;

n.s=

Notsignificant;SD=

Standarddeviation.


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1948 J. Lopezet al.

Table 3. Stepwise multiple regression equations to predict depressionand anxiety scores

r2 f.......................................................................................................................................................................................................

Dependent variable: Depression (CES-D)

Social support 0.277 0.107 12.590

Caregivers appraisal of behavioral problems 0.295 0.175 11.018

HEHS 0.203 0.215 9.394

Dependent variable: Anxiety (POMS)

Caregivers appraisal of behavioral problems 0.404 0.163 20.666

p< 0.01; p< 0.001.

CES-D = Center for Epidemiological Studies Depression scale; HEHS = High

self-efficacy and high spirituality; POMS = Profile of Mood States.

the HEHS group. The total percentage of explained

variance of the depression outcome measure

accounted for by these three variables was 21.5%.

On the other hand, lower caregivers appraisal

of behavioral problems was correlated with lower

anxiety. This factor explained 16.3% of variance incaregivers anxiety.

Discussion

The present study extends the data on the

relationship between self-efficacy, spirituality, and

caregiver depression, providing evidence in support

of the association between these two under-

explored aspects of caregivers personal resources

(spiritual meaning and self-efficacy), considered

simultaneously, and caregivers well-being. Thisstudy highlights the importance of specifying the

caregivers profile defined by the combination of

the two variables: self-efficacy and spirituality (high

or low levels in each one). Taken together, these

results suggest that considering together the role of

spirituality and self-efficacy as a personal resource

is complex and warrants further study.

ANOVA analysis showed that caregivers with

a strong sense of HEHS feel less depressed than

caregivers who have a strong sense of LEHS. A com-

bination of these two personal resources (spirituality

and self-efficacy) may better explain caregivers

depressive symptomatology than spirituality alone.Depressive symptoms can perhaps be better

changed with the help of both personal resources

(beliefs in ones ability to successfully execute

courses of action and influence the choices of

activity one undertakes) and a search for an ultimate

truth or higher value, than through spirituality

alone. A strong sense of spirituality in addition to

a high sense of self-efficacy may counteract feelings

of helplessness and loss of control.

The finding suggests that HEHS is associated

with a lower level of depression and that

both intrinsic or faith-related elements (spiritual

meaning) and pragmatic ones (self-efficacy) are

relevant aspects for enhancing caregivers ability

to cope with depression. Dementia caregivers are

engaged in a challenging and important role that

often consumes their health. Caregivers with ahigh sense of spirituality and self-efficacy may

be protected from the negative consequences of

caregiving through the experience of a spiritual

and transcendent dimension that protects their

focus on what they are capable of accomplishing,

rather than on their past failures. Spirituality might

protect against depression because feelings of divine

protection can encourage feelings of security and

friendliness, and when a stressor is a life-threatening

disease or disability, the persons perceived support

from God may reduce reaction to the stressor

(Fetzer Institute and National Institute on AgingWorking Group, 1999). Self-efficacy beliefs can

influence depression outcomes by determining

individuals coping responses, degree of effort, and

persistence in the face of obstacles and aversive

experiences in caregiving (Gilliam and Steffen,

2006). It appears from this research that caregivers

may benefit from their spiritual meaning when it

is connected to self-efficacy. Thus, in exploring

spiritual beliefs with caregivers who are so inclined,

health professionals might include the exploration

of how those beliefs foster a greater sense of self-

efficacy, which may include a sense of being loved

by God, and also a belief that they possess thecoping resources necessary to deal with certain

situations (Kinney et al., 2003). It may also be

possible that spiritual coping strategies such as

praying or meditating, or spiritual attitudes such as

self-compassion or self-kindness, may help people

maintain or increase their self-efficacy and feelings

of internal control, as it has been suggested in

previous studies (Aiet al., 2005; Iskender, 2009).

Depressed individuals who have low levels of

caregiving self-efficacy may then experience their

spirituality in a very passive way (It is all up to


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God, God controls all the events and outcomes of

my life). Nevertheless, both resources (spirituality

and self-efficacy) are compatible: one can act

jointly with a Powerful Other God as a

partner to cope with stressors, and thus maintain

a sense of control and efficacy over life events.

Although most religions, if not all, affirm that the

fundamental features of life are beyond our controland a Powerful Other controls the events of our

lives, some studies have documented that many

people (specially older adults) report working with

a Higher Being as partners in the effort to cope

with major problems in their own life (Schieman,

2003). Empirical evidence has also been found

suggesting that greater internal control is positively

related to spiritual coping strategies such as private

prayer (Ai et al., 2005). These findings provided

evidence that a combination of HEHS may be

wellbeing-enhancing. Spiritual caregivers are not

passive in nature. The study supports the view that

our relationship to the sacred or transcendent mayimply an active exchange or interaction with a higher

power or something greater than the self.

When all variables examined in this research

are taken into account in an additive way to

explain caregiver depression (regression analysis),

both spiritual meaning and self-efficacy have been

found to play an important role in caregivers

well-being. Again, caregivers who have a strong

sense of spirituality and who report HEHS showed

fewer depressive symptoms, suggesting that these

caregivers may cope better with stressors than

caregivers who have neither a strong sense ofspirituality or self-efficacy. In sum, this study

supports the hypothesis that self-efficacy and

spirituality may be related to depression outcome

because, together, they provide better coping

strategies in caregiving situations.

Surprisingly, stronger objective stressors of

caregiving (e.g. longer period since caregiving

began, caring longer hours per day, poorer

functional status, or higher frequency of observable

behavioral problems) were not associated with

caregiver depression and anxiety. A possible

explanation for this is that the actual demands of

caregiving may not be directly related to caregiverswell-being. Instead, other personal factors (such

as caregivers appraisal of behavioral problems,

social support, and higher sense of self-efficacy

and spirituality) may be more strongly related to

caregiving outcomes, providing support for the

stress and coping model (Lawton et al., 1991; Quinn

et al., 2010).

Social support is also related to depression,

suggesting that support from the community

might function as a buffering factor, providing

a way to channel or relieve depressive feelings.

Caregivers of relatives with dementia often

live an isolated existence, breaking up their

relation with family members and former friends.

Stressors can proliferate when the caregiver has

difficulty meeting ongoing demands without any

functional or emotional support. Furthermore, the

perception that one is accepted and valued in

ones interpersonal environment bolsters esteem,confidence, and efficacy, which guard against

depression. Feelings of hopelessness, sorrow, or

being alone are emotions commonly associated with

depression; individuals with a healthy social support

network can more easily handle such feelings. Close

relationships increase happiness in individuals,

because they know that they are not alone in the

world. Confidence boosts from others help decrease

sorrow and states of sadness in individuals (Pearlin

et al., 1990; Schulz and Williamson, 1991).

Caregivers appraisal of behavioral problems is

the only variable related to both depression and

anxiety. The stress and coping theoretical modeladapted to caregiving affirms the central role played

by caregivers appraisals in the understanding and

explanation of psychological outcomes. Although

behaviors identified as problematic in dementia

have negative effects on caregiver health, they

may not be experienced in the same way by

different caregivers. Caregivers might appraise a

potentially problematic situation as upsetting

that is, as a situation that could bring distress

to oneself or to a relationship; but they might

also appraise a potentially problematic situation as

challenging, rather than distressing: as a situationto be overcome. The amount of distress caused

by problem behaviors caregivers appraisal of

behavioral problems in persons with dementia

may influence their interactions with that person

in ways that reduce the incidence of behavioral

problems (i.e. by helping caregivers modulate

thoughts and feelings that influence their modes

of interaction). Therefore, it is the perception of

a caregiving situation as stressful, not the mere

presence of a potentially stressful situation, that

determines whether the event is interpreted as

manageable. In other words, how caregivers think

about the situation influences the way they act andemotionally respond, suggesting that appraisal plays

a mediating role between a potential stressor and

coping actions (Lawton et al., 1991).

The results of this study are consistent with

previous findings regarding significant associations

between caregivers well-being (depression and

anxiety) and their appraisals (Crespo et al., 2005).

Furthermore, other studies have found moderator

or mediator effects of social support (Pearlin et al.,

1990; Schulz and Williamson, 1991), self-efficacy

(Gilliam and Steffen, 2006; Romero-Moreno


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1950 J. Lopezet al.

et al., 2011), and spirituality (Thompson et al.,

2002; Marquez-Gonzlez et al., 2012) on caregiver

depression. Nevertheless, Thompson et al. (2002)

found that spirituality was associated with

less depression in Latina caregivers but not

in Caucasians, suggesting the importance of

considering the influence of cultural factors on

analyzing the association between this constructand depression. In fact, according to a review by

Hebert et al. (2006), the effects of spirituality on

depression are unclear. However, the findings of the

present study, in which the combination of HEHS

was significantly related to caregivers depression,

suggest that what is important in relation to

depression outcomes is precisely their combined

effect.

Contrary to our hypotheses, caregivers with

high spiritual meaning and high self-efficacy did

not report less anxiety. There is considerable

literature on burden and depression in caregivers

of people with dementia. Anxiety has been arelatively neglected outcome measure. Anxiety

among dementia caregivers has received far less

attention in the literature than depression, and may

require specific research. Cooper et al. (2007) found

that there is a considerable comorbidity between

anxiety and depression, and most caregivers

with depressive symptomatology also reported

symptoms of anxiety, although the converse is not

clear. Factors associated with depression may not

bear the same relationship to anxiety (Cooper et al.,

2007) and control or efficacy variables would be

more highly related to caregivers depression thanto anxiety (Pagel et al., 1985; Cooper et al., 2007).

Nevertheless, a systematic review found a lack of

evidence regarding determinants of anxiety caseness

or levels in caregivers of people with dementia

(Cooperet al., 2007).

This study has interesting implications for

the design of interventions with caregivers. High

or negative appraisal of behavioral problems

is theoretically and empirically associated with

perceptions of low self-efficacy in coping with

such behaviors (Haley et al., 1996), which, over

time, may contribute along with other factors (e.g.

absence of spiritual meaning, absence of socialsupport) to the development of helplessness and

depression. Increasing self-efficacy in caregivers by

training them to cope better with problem behaviors

(so that they appraise them as less stressful),

reinforcing the social support network, and finding

spiritual meaning within the caregiving experience

may help alleviate their depression level.

There were several limitations to this study that

make it necessary to interpret the study findings

with caution. It should be acknowledged that the

convenience-based nature of the sample (made up

of voluntary caregivers recruited through health

and social centers) limits the generalization of

these findings. Nevertheless, the sample looked

similar to other national samples of dementia

caregivers. Furthermore, the cross-sectional design

of the study precludes any kind of causal inferences

about the directionality of the influences of the

relationships between spirituality, self-efficacy, andcaregivers well-being. It would be interesting

to analyze the directions of the relationships

between these variables with a view to explaining

caregiver depression and identifying the potential

action mechanisms of interventions. In this sense,

there is a need for longitudinal and experimental

studies. Including qualitative inquiry may also help

to further clarify the relationship among these

variables. Further, self-report bias may have been

introduced by participants in responding to sensitive

personal information such as spiritual meaning. A

limitation of the Ultimate Meaning Scale is that

it was grounded in qualitative comments madeby caregivers who reflected a primarily Judeo-

Christian perspective; terms such as Lord and

God may not be appropriate for all caregivers

(Farran et al., 1999). Moreover, the present study

involves primarily Christian caregivers. It would

be useful to compare Christian beliefs with other

belief systems that are somewhat different in focus

(e.g. Buddhism). In spite of these limitations, this

study provides some useful insights about the role of

spirituality and self-efficacy in caregiver depression,

and particularly about the relevance of considering

these two variables jointly in caregiving research.The current study is an important first step in

understanding the combined effect of spirituality

and self-efficacy and its relationship to the

emotional functioning of dementia caregivers.

However, there is still much to be studied in

the area of spirituality and self-efficacy in families

of relatives with dementia. For example, future

research might examine whether men and women,

or parents and siblings, share similar spiritual and

self-efficacy beliefs, and how this congruence or

lack thereof influences family functioning. Also,

different spiritual orientations could be studied,

to determine how they influence self-efficacy.The impact of self-efficacy and spirituality in

dementia caregiver emotional well-being may be

generalized to other situations during which other

chronic role strains arise. Developing a more

comprehensive theory of stress and coping in

caregiving contexts (including relationships with

others in the family or on the job) may be

an additional fruitful line of research. Future

research might also examine more systematically

how emotional states, such as the two assessed

in the present study, depression and anxiety,


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engender or are engendered by specific patterns

of spiritual and self-efficacy beliefs. It would

also be very interesting to analyze the moderator

role of self-efficacy in the relationship between

spirituality and depression. Once these relationships

are better understood, intervention programs could

be specifically tailored to better support dementia

caregivers including, if appropriate, spiritual andself-efficacy, in combination, elements.

Conflict of interest

None.

Description of authors roles

Javier Lpez worked on the data analysis and the

writing of the paper; Rosa Romero-Moreno worked

on the study implementation and helped write the

paper; and Mara Mrquez-Gonzlez and Andrs

Losada designed and carried out the study, and

helped write the paper.

Acknowledgments

This work was funded by the Spanish Ministry of

Education (grant number SEJ2006-02489/PSIC)

and the Spanish Ministry of Science and Innovation

(PSI 2009-081327PSIC).

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