The Multidimensionality of Caregiving Appraisal in Chronic Illnesses

Abstract

Caregiving appraisal refers to how caregivers cognitively and emotionally evaluate their caregiving situation. Caregivers are relatives, partners, friends, or others who provide unpaid, ongoing assistance to individuals with chronic illnesses or disabilities. First introduced by Lawton and colleagues in 1989, the concept has been inconsistently defined in the literature, often conflated with related constructs such as caregiving burden. As caregiving roles rapidly evolve amid changes in healthcare delivery that are tending toward home-based care, there is a pressing need to revisit and refine the caregiving appraisal framework. This dissertation employed a multi-method, multi-phase approach to update the caregiving appraisal theory, clarify its core dimensions, and improve its measurement through conceptual analysis, qualitative exploration, secondary data analysis, and new scale development.Chapter 2 presents a concept analysis using Rodgers’ evolutionary model. The analysis systematically searched six databases, identifying 86 relevant studies that revealed various definitions and dimensions of caregiving appraisal. The concept analysis clarifies that caregiving appraisal involves dynamic, cyclical, subjective cognitive evaluations and assessments by caregivers, encompassing cognitive and affective responses, and the re-evaluation of potential stressors and one’s coping ability. Caregiving appraisal is a multidimensional construct that can be neutral, positive, or negative. Different dimensions of caregiving appraisal can occur simultaneously. Additionally, caregiving appraisal acts as a mediator between caregivers’ objective stress and their reactions to that stress. In this analysis, we defined the action of appraising unspecified stress in a caregiving situation as the general (or broad) definition of caregiving appraisal, and the action of appraising specified stress as the specific (or narrow) definition (e.g., illness severity caregiving appraisal, social support caregiving appraisal). Compared to Lawton’s Caregiving Appraisal model, in our analysis, caregiving appraisal encompasses four broader categories: caregivers appraising their own situation, caregivers assessing the care recipient’s situation, caregivers evaluating personal capabilities, and caregivers evaluating the caregiver-care receiver relationship. These findings expand beyond Lawton’s domains, framing caregiving appraisal as a comprehensive, evolving, and context-flexible construct that includes general and context-specific evaluations. Such conceptual expansion underscores the need to reassess Lawton’s Caregiving Appraisal Model and refine measurement tools in line with contemporary healthcare practices. Future studies must clearly define caregiving appraisal, avoid using a single dimension to reflect holistic caregiving appraisal, and provide a valid reason for focusing only on one (or several) domains when using caregiving appraisal as the concept of interest. Chapter 3 used secondary data from the National Study of Caregiving (NSOC) IV, Round 12, to empirically identify caregiving appraisal domains using principal component analysis (PCA), followed by PCA replication using NSOC Round 14 data. In Round 12, N=2159 caregivers were included in the initial sample (39 initial items), with the final PCA including N=1749 caregivers after removing those with missing PCA items. Following Promax rotation, a 31-item scale with three orthogonal factors was identified: Psychological Well-being (eigenvalue 7.25, consisting of 14 items); Caregiving Burden (eigenvalue 2.04, consisting of 11 items); and Positive Appraisal (eigenvalue 1.98, consisting of 6 items). The standardized Cronbach’s alpha values were 0.89, 0.81, and 0.75 for the Psychological Well-being Subscale, Caregiving Burden Subscale, and Positive Appraisal Subscale, respectively. The standardized Cronbach’s alpha for the overall scale was 0.89. A median correlation of r= 0.47 (p < .0001) was observed between the Psychological Well-being Subscale and the Caregiving Burden Subscale. The correlations with the Positive Appraisal Subscale were smaller, with r=0.22 (p < .0001) for Psychological Well-being and r=0.17 (p < .0001) for Caregiving Burden. Findings from Rd 14 closely replicated the Rd 12 pattern, with nearly identical reliability estimates (α = 0.89, 0.81, and 0.77 for the three subscales) and similar magnitudes of inter-subscale correlations. Tucker’s congruence coefficients (φ) indicated strong cross-wave replication of the three-factor structure (φ = 0.98, φ = 0.93, and φ = 0.95, respectively). Together, the underlying domains of caregiving appraisal are highly stable across NSOC survey waves. This chapter significantly contributes to updates in the caregiving appraisal framework, offering insights into subdomains and item generation of caregiving appraisal. Chapter 4 aimed to explore caregiving appraisal among family caregivers of individuals with chronic illnesses or disabilities using a qualitative descriptive design. The Consolidated criteria for reporting qualitative research (COREQ) guided study reporting. Twenty in-depth interviews were conducted and analyzed using conventional content analysis. This study identified the multidimensionality of caregiving appraisal with five key themes: caregiving gain and loss tradeoff, caregiving competency, caregiving motivation, caregiving dyadic relationship, and caregiving meaning. Gain and loss tradeoff appraisal reflected the balance between loss (social isolation, personal relationship loss, identity loss, emotional strain, lack of self-care, restrictions on autonomy, career sacrifices) and benefits (emotional growth, skill enhancement, positive emotions, increased awareness) associated with caregiving. Competency appraisal encompassed caregivers’ confidence and preparedness, shaped by professional and personal experiences, external support, and personal challenges. Motivation appraisal highlighted the dynamic interplay between voluntary versus obligatory drivers, influenced by cultural norms, social expectations, familial commitment, personal fulfillment, love and affection, and practical responsibilities. Dyadic relationship appraisal assessed the quality and evolution of caregiver-care recipient relationships, shaped by mutual interactions and emotional bonds. Meaning appraisal centered on caregivers’ perceptions, beliefs, and emotional responses related to what caregiving represents to them. Our findings highlighted the multidimensional nature of caregiving appraisal, extending current frameworks by emphasizing the balance of burdens and benefits, the interplay of motivations, and the emotional and relational impact of caregiving. Future research should explore cultural influences and use longitudinal designs to examine how these appraisals may evolve over time. Our findings also underscore the need for culturally responsive caregiving support programs and inform the development of caregiving motivation appraisal scales. These tools can guide tailored interventions that address caregivers’ practical, relational, and emotional needs based on their motivational profiles (voluntary vs. obligatory). Chapter 5 addresses the measurement gap identified in Chapter 3 by introducing and validating the Caregiver Motivation Appraisal Scale (CMAS), an instrument developed to assess both voluntary and obligatory caregiving motivations. The items were generated through qualitative interviews with 20 family caregivers and refined using expert review and caregiver feedback. A final set of 11 items was evaluated for psychometric properties using a sample of 222 caregivers recruited via Amazon CloudResearch. Exploratory factor analysis (EFA) supported a two-factor model representing positive and negative caregiving motivations, accounting for 64.07% of the variance. Confirmatory factor analysis (CFA) indicated excellent model fit (CFI = 0.96, GFI = 0.91, RMSEA = 0.06, SRMR = 0.08). The CMAS demonstrated strong internal consistency (α = 0.83, α = 0.92 for the voluntary motivation subscale and α = 0.69 for the obligatory motivation subscale). Findings supported the CMAS as a psychometrically sound measure with practical utility. The scale offered a nuanced tool for assessing caregiving motivations and advancing research on caregiver well-being. Future work should focus on refining the obligatory motivation subscale, addressing ceiling effects of several items, and expanding validation across diverse populations. The CMAS had the potential to guide clinical, research, and policy efforts aimed at supporting family caregivers across healthcare contexts.Keywords: Caregiving Appraisal, Family Caregiving, Chronic Illness, Caregiving Motivation, Dyadic Relationship