Women as caregivers is a significant issue because it has been hypothesized by many scholars that the stress associated with multiple roles can be conducive to physical and mental health problems. However, this is a controversial topic because they are some experts who contend that benefits are gained with this additional responsibility. There appears to be a myriad of literature that places emphasis on the stress of women engaging in multiple roles.
Women have always been considered responsible for domestic chores. parenting and in some instances caring for elderly parents. A few decades ago women were not required to work outside the home; they remained home performing those duties. These challenging economic times compel them to work outside the home in addition to carrying out their traditional responsibilities.
In this treatise the significance of this issue on women’s health will be discussed. The various controversial aspects will also be included. The relevance to further nursing research and nursing practice will also be presented.
Critical Review of Literature
Throughout the world many women are now compelled to play the role of wife, mother and paid employee. In many cases they are also the caregiver of a seriously ill relative. If one analyzes the multiple roles and caregiving of women it becomes apparent that these
responsibilities may lead to detrimental consequences Even some professionals, particularly mental health professionals, have articulated apprehension about women’s health and raised questions about whether they can manage the demands of multiple roles without negative consequences (Barnett, 2004). The effect of multiple roles on the health women is still controversial since many experts are uncertain about this issue.( Arber,1991,1997; Avison,1995; Waldron et al., 1998; Maclean et al., 2004)..In this treatise it assumed that while employment outside the home may have financial benefits it is conducive to significant increase in stress for women; especially married women with children; this stress may have negative effects on the physical and mental health of women.
The scholars maintain that while there is mixed proof that pertaining to the effects of various role combinations on women’s health, the ability to balance these roles is contingent on(a) nature of the role, (b) specific combination of roles and (a) socio-economic context of women’s lives (Barnett and Marshall,1991; Maclean et al., 2004). The writer of this study agrees with the researchers who contend that paid employment may positively or negatively affect women’s health depending on their marital status, husband’s contribution to domestic chores, parental status, and attitude toward employment and job characteristics (Repetti et al., 1989). It must be noted that different employment arrangements, such as part-time employment and full-time employment may contribute to women’s health in different ways (Lahelma et al., 2002). Since the general significance of each aspect varies depending on the characteristics of a woman and her particular job, the effect of paid employment on women’s health may vary for different women (Repetti et al., 1989). Unfortunately, most women are compelled to assume the responsibilities of work and family independently (Reskin & Padavic,1994). The primary problems is that society has still not modernized motherhood, reorganized family and changed along with the varying character of women’s lives (Peters,1997). As one researcher contends employment offers numerous advantages which runthe gamut from increased income to better access to health care and contact with individuals who may offer social, society still perceives women as mothers and homemakers (Repeti et al., 1989). This problem appears to be universal. Dako-Gyeke and Ibrahim (2012) conducted a study to determine the relationship between multiple roles ans psychosocial well-being among non-academic female staff in a public university in Ghana, In this study there was an inverse relationship between working mothers’psychosocial well-being and household chores. In this study it was found that women’s careers conflicted with traditional feminine roles, such as housework and childcare. There was a significant inverse relationship with certain aspects of childcare in this study; these findings suggest that as working mothers perform these activities which run the gamut from assisting children with homework to preparing food for the child their psychosocial well-being decreases.
The writer of this treatise also assumes that there is a link between role overload and women’s mental health. Role overload is defined as the extent to which a person feels overwhelmed by their total responsibilities, it is strongly associated with mental health ( Baruch& Barnett,1997; Coverman,1989; Hech,2001). The scholars indicate there is a dearth of knowledge pertaining to its relative significance to well-established social determinations of mental health such as income and education.( Glynn,MacLean, Forte,& Cohen,2009).. Glynn et al (2009) conducted a research study pertaining the link between role overload and women’s mental health. In their study they included a Canadian national random sample, cross sectional telephone survey in 2003 assessed
the association among role overload types and quality of roles (parent, employee, spouse). The findings of their study indicated that the role overload is stalwartly connected with women’s mental health In fact it was found that feeling overwhelmed by social role obligations has a greater impact than have some of the well-known social determinants of mental health, such as income, marital status and employment ( Glynn et al.,2009).. However, if one analyzes this finding it is not so unparalleled; other researchers have maintained the same theory. Many women, as indicated earlier have a myriad of responsibilities which makes them feel overloaded. individuals who feel overloaded suffer from poor psychological health (Barnett & Baruch, 1985).
Traditionally, caregiving refers to raising children; presently caregiving may refer to caring and supporting older adults. In most instances the family, usually the mothers and daughters are responsible for the care of older disabled or seriously ill adults. In the past most of these caregivers were in their 40s but it is becoming more common to see women over age 60 caring for a 90 year old relative (Godfrey& Warsaw, 2009). It has been maintained that 30% of family members caring for seniors are over 65, which suggests that they may have medical problems that require supervision. It has been concurred by the researchers that in some cases women will spend 18 years caring for elderly parents; this is as much time as they spent caring for their own children; as many as 48% of caregivers have full time jobs above and beyond the time spent providing care (Godfrey & Warsaw,2009). The caregivers who are employed outside the home are compelled to alter their work schedules or take an unpaid leave of absence to provide care. It is safe to assume the stress caused by this arrangement could lead to health problems for the caregiver.
The role of caregiver is further complicated by the fact that many of these women are forced to work full-time; some are single or the primary earner. Thus they have job responsibilities and perpetual care duties. Many women are having children in their 40s which indicates that they may be obligated to care both children and at least one ill parent ( Godfrey & Warsaw, 2009). As indicated earlier many of the caregivers are in their 60s and responsible for caring for a parent in their 90s. These issues will develop as the population ages. In some cases older caregivers may neglect their own health while they are caring for a parent. It is common knowledge that this can be very stressful and conducive to increase in physical and mental health problems among these caregivers. However, some experts assert that caregiving comes naturally some individuals; but for those who are inept for caregiving, the level of stress will be augmented (Roepke,Mausbach, von Kanel et al., 2009). It has been indicated by some researchers that the preceding association between parent and child. It is apparent that a relationship that has been helpful and courteous will be less stressful. Therefore the primary aspects, professed skills and caretaker relationship, powerfully influence a woman’s stress status and should be measured in assessing her emotional and physical health ( Roepke,Mausbach, von Kanel et al., 2009).
It has been asserted by a myriad of researchers that any type of caregiving is very stressful; this includes caring for children, the seriously ill, the disabled and the elderly. Cargiving for someone with dementia is conducive to a higher level of stress (Ory, Hoffman, Yee, Tennstedt & Schultz,1999). It is not surprising to learn that dementia caregiving has been linked with such negative results as depression, high blood pressure and heart problems (Vitaliano, Zhang & Scalan, 2003). The author of this treatise assumes that women who are already other
responsibilities and are compelled to care a dementia are susceptible to a myriad of physical and mental health problems. It is not surprising to learn that there is a link between caring for dementia patients and cortisol, the stress hormone. Nevertheless, no study has been conducted to examine the cortisol as a treatment outcome although cortisol is considered by many researchers as a critical biological intermediary by which chronic stress gets underneath the skin and leads to disease (Sapolsky, Romero, & Munck, 2000). It was interesting to learn that a study was conducted to ameliorate the understanding of the association between caregiving and cortisol by (1) examining psychosocial predictors of daily cortisol levels at baseline which have been shown to be related to caregiver physical health (Vitaliano et al, 2003) among Caucasian and Latina/Hispanic women caring for a family member with dementia and (2) testing the efficacy of a cognitive-behavior-based psychoeducational intervention (Coping with \Caregiving (CWC); Gallaher-Thompson, Coon et al., 2003) in endorsing adaptive changes in cortisol.
In reading the literature it was revealed that stressful situations, like caregiving, frequently stimulate hypothalamic-pituitary adrenocortical (HPA) axis functioning, activation of this hormonal response ultimately results increased blood levels of cortisol, frequently referred to as the ‘stress hormone’ (Lovallo,2005). Of the hormones involved in this process, cortisol has received the most attention because of its ease of measurement and far-reaching regulatory influence in the central nervous system, metabolic system and immune system (Saplosky et al., 2000). If one considers its powerful effect, dysregulated cortisol production can have an intense impact on an individual’s health. In fact prolonged cortisol increases ( because of chronic stress or other factors) can increase allostatic load and compromise the immune system, ultimately increasing one’s risk for auto-immune-related and metabolic disorders (Sapolsky et al., 2000).
Suppression of the cortisol response has been linked to mental and physical problems, such as post-traumatic stress disorder (Yehuda, Teicher,Trestman, Levengood, & Siever, 1996), depression (Taylor et al., 2006) and breast cancer (Giesse-Davis, DiMiceli, Sephton & Speigel, 2006).
In conditions of chronic stress such as these cortisol’s normal diurnal rhythm characterized by peak levels at or near wake that then abruptly decrease across the day) can become compacted as levels of cortisol in the body remain more elevated throughout the day (Ockenfels et al., 1995; Smyth et al., 1997). Therefore a daily pattern by peak levels of cortisol at wake and steep negative slope is generally considered a ‘normal,’; whereas a shallower or flatter cortisol slope is typically considered less adaptive. Miller,Chen, and Zhou’s 2007 recent meta-analysis supported this concept and discovered that compared with non-stressed controls, chronically stressed groups generally had dysregulated pattern of hormone secretion, with lower than normal morning output but higher than anticipated secretion across the rest of the day, yielding a flattened diurnal pattern.
Although there is a definite association between dementia caregiving and increased risk for health results (Vitaliano et al., 2003), only minimql number of intervention studies have examined physical health as an outcome. A relatively smaller number have used objective biomarkers of physiological functioning, which may be less influenced by response biases and other confounds compared with self-report measures of health (Ward, 1994; Wittink,Rogers, Sukennik & Carr,2003). Studies have used these more objective measures which have yielded
more encouraging results. One example includes a brief psychosocial intervention five 90 minute weekly sessions) which placed emphasis on instruction caregivers about stress and how to participate in relaxation has a positive impact on dementia caregivers immune functioning (i.e., augmentation of natural-killer cell activity at post-treatment (Hosaka & Suglyama, 2003). An intervention that emphasized education in dementia, managing challenging care recipient demeanors and developing a social support network formed significant ameliorations in dementia caregiver immune system functioning (i.e., T-cell proliferation (Garand et al., 2002). Holland et al (2011 formulated a study pertaining to cortisol outcomes among Caucasian and Latina Hispanic women caring for a family member with dementia. In this study they examined the influence of a cognitive-behavior based psychoeducational intervention (Coping with Caregiving) on cortisol at a post-treatment assessment compared with minimal support condition. The findings of this study indicated that caregivers with high concentration caregiving circumstances which included long hours of care and co-residence with the care recipient, usually has less adaptive cortisol patterns. Nevertheless, it was discovered the caregivers who were more susceptible to the cortisol problems benefited from the Coping with Caregiving intervention and had more normal cortisol patterns following treatment compared with caregivers in the central condition.
If one personally analyzes caregiving it appears to be one of the more stressful roles women play. The physical and mental health consequences appear to be the most deleterious. However, and family support can lessen some of the stress this role entails.
Integration/Summary of Research Literature Review
There was an acute death of very current literature pertaining to single mothers. Most of the very recent peer reviewed literature pertained to married women. There is a need for information pertaining to the diversity of work women are now performing; most of the literature discussed women in the traditional professions. There was little or no material pertaining to the stress of mothers in the more demanding professions such as law and medicine.
Ironically, most of the material pertains to traditional families; there were few if any studies pertaining to same sex couple’s intergenerational families and multi-family arrangements.
Relevant Implications Research
Nursing research should include more information pertaining to the understanding of the impact multiple roles on women’s multiple health. It should be conducive to learning more about the more serious physical and mental consequences of too much stress. The research should include methods to alleviate the stress associated with women’s multiple roles.
Relevant Implications for Policy/Programming
There should be an increase in the number of intervention programs that would reduce the stress women suffer from multiple roles.
In this treatise it was indicated that the stress associated with multiple roles can be conducive to physical and mental health problems. However, it was also mentioned that this is a very controversial topic since some researchers have discussed the benefits of women working outside the home and performing domestic duties. It was also found that numerous researchers and mental health professional question women’s ability to manage so many roles and maintain good physical and mental health.
The impact of role overload in women’s health was discussed. It was asserted that there is a an acute dearth of material pertaining to social fortitudes of mental health such as income and education. While the role of working mother is stressful; it was found in this treatise that dementia caregiving is one of the most stressful responsibilities of women.
Arber,S. (1997). Comparing inequalities in women and men’s health: Britain in the 1990s.
Social Science Medicine, 44, 773-787.
Avison,W.R. (1995). Roles and resources: The effects of family structure and employment on
women’s psychosocial resources and psychological distress. Research of Community
Health, 8, 233-256.
Barnett,R.C. (2004). Women and multiple roles: Myths and reality. Harvard Review of
Psychiatry, 12(3), 158-164.
Barnett, R.C. and Marshall, N.L. (1991). The Relationship between Women’s work and Family
Roles and their Subjective Well-Being and Psychosocial Distress. In Frankenhauser
M.U. Lundenberg and M. Chesney (Eds), Women and work and Health; Stress and
Opportunities ( pp. 111-136). New York, N.Y.: Plenum Press.
Barnett, R.C. & Baruch, G.I. (1985). Women’s involvement in multiple roles and psychological
distress. Journal of Personality Social Psychology, 49, 135-145.
Baruch,G.K. & Barnett, R.C. (1986). Role quality,multiple involvement and psychological
well-being in midlife women. Journal of Personality, Social Psychology, 51, 578-585.
Coverman, S. (1989). Role overload, role conflict and stress: Addressing Consequences of
multiple role demands. Social Forces, 69, 965-982.
Gallagher-Thompson,D., Coon,D.W., Solano, N., Ambler,C., Rabinowitz, V. & Thompson,
L.W.. (2003). Changes in indices of distress among Lationo and Anglo female caregivers
of elderly relatives with dementia: Site specific results from REACH national collaborative
study. The Gerontologist, 43, 580-591.
Garand,L. Buckwalter,K.C., Lubaroff,D. Tripp-Reiman,T., Frantz,R.A. & Ansley.T.N. (2002).
A pilot study of immune and mood outocmes of community-based interventions for dementia
caregivers; The PLST Intervention. Archives of Psychiatric Nursing, 4, 156-167.
Giese-Davis,J., DiMicelle,S., Stephon, S., & Spiegel, D. (2006). Emotional expression and
diurnal cortisol slope in women with metastatic breast cancer in supportive expressive group
therapy: A preliminary study. Biological Psychology, 73, 190-198.
Glynn, K., MacLean, H., Forte, T. & Cohen, M. (2009).The Association between role overload
and women’s mental health. Journal of Women’s Health, 18 (2), 217-223.
Godfrey, J.R. & Warsov, G..A. (2009). Toward optimal health: Considering the enhanced
healthcare needs of women caregivers. Journal of Women’s Health, 18 (11), 1739-1744.
Gyeke-Dako, M. & Ibrahim,U. Multiple Roles and Women’s Psychosocial Well-being.
Current Research Journal of Social Sciences, 4, (6), 400-406.
Hech,L.M. (2001). Role conflict and role overload: Different concepts, different consequences.
Sociology Inquiry, 71, 111-121.
Hosaka, T, & Sugiyama,Y. (2003). Structured intervention in family caregivers of the demented
elderly and changes in their immune function. Psychiatry and Clinical Neurosciences,
Lahelma,E.S., Arber,S., Nivela,K. & Roos,E. (2002). Multiple Roles and Health among British
and Finnish women; The influence of socioeconomic circumstances. Social Science
Medicine, 54, (5), 72-740.
Lovallo,W.R. (2005). Stress & Health;Biological interactions. Thoiusand Oaks,CA; Sage.
\MacLean,H., Glynn,K. & Ansana, D. (2004). Multiple Roles and women;\’s mental health in
Canada. BMC Women’s Health, 4 (1), 1-25.
Miller, G., Chen, E. & Zhou,E. (2007). If it goes up,must come down? Chronic Stress and the
hypothalamic-pituitary adrenocortisol axis in humans. Psychological Bulletin, 133, 25-45.
Ockenfels,M., Porter,L., Smyth, J. Kirschbaum,C., Hellhammer,D., & Stone,A. (1995). Effect of
chronic stress associated with unemployment on salivary cortisol; Overall cortisol levels,
diurnal rhythm and acute stress reactivity. Psychosomatic Medicine, 37, 460-467.
Ory, M., Hoffman,R.R., Yee,J.l. Tennstedt,S., Schulz, R. (1999). Prevalence and impact of
caregiving; A detailed comparison between dementia and non-dementita caregivers. The
Geronologist, 39 (2), 177-185.
Repetti, R.L.,Matthews, K.A. & Waldron, I. (1989). Employment and women’s health; Effects
of women’’s mental and physical health. American Psycholofgy, 44 (11), 1394-1401.
Reskin,B.F, & Padavi, I. (1994). Women and men at work. Thousand Oaks;,CA; Pine Forge Press.
Roepke,S. Mausbach,B., von Hankel R. et al. (2009). The moderating role of personal mastery
in the relationship between caregiving status and multiple dimensions of fatigue.
International Journal of Geriatric Psychiatry 24 (120, 143-162.
Sapolsky,R,M., Romero,LM. & Munch,A.B. (2000). How do glucortisols influence stress
responses? Integrating permissive, suppressive, stimulatorty and preparative actions.
Endocrine Reviews, 21, 55-59.
Smyth,J.m., Ockenfela,M..C., Goren,A.A., Caltey,D., Porter, L.S., Krischbaum,C & Stone,A.A.
(1997). Individual differences in the diurnal cycle of cortisol. Psychoneuroendocrinology
Vitaliano, P.R., Zhang,J. & Scanalan, J.M. (2003). Is caregiving hazardous to one’ s physical
health/ a meta-analyses. Psychological Bulletine,1129, 946-972.
Waldron,I., Weiss, C.C. & Hughes, M.E. (1989). Interacting effects of multiple roles on
women’s health. Journal of Health and Social Behavior, 39 (3), 216-236.
Ward,M.M.(1994). Are patient self-report measures of arthritis acitivity confounded by mood?
A longitudinal study of patients with rheumatoid arthritis. Journal of Rheumatology, 21,
Yehuda, R. Teicher,M.H., Trestman, R.L., Livengood, R.A. & Siver, L.J. (1996). Cortisol
regulation in posttraumatic stress; disorder and major depression; A chronological analyses.
Biological Psychiatry, 40, 79-88.
Although there is a definite association between dementia caregiving and increased risk for harmful health results (Vitaliano et al., 2003), only a minimal number of intervention studies have examined physical health as an outcome A relatively smaller number have used objective biomarkers of physiological functioning, which may be less influenced by response biases and other confounds compared with self-report measures of health (Ward, 1994; Wittink, Rogers, Sukennik, & Carr, 2003). Studies have used these more objective measures have yielded more encouraging results. One example includes a brief psychosocial intervention five 90 minute weekly sessions) which placed emphasis on instructing caregivers about stress and how to
participate in relaxation, had a positive impact on dementia caregvers immune functioning (i.e augmentation of natural killer cell activity at post-treatment (Hoska & Suglyama, 2003). An intervention that emphasized education on dementia, managing challenging care recipient demeanors and developing a social support network formed significant ameliorations in dementia caregiver immune system functioning ( i.e., T-cell proliferation (Garand et al., 2002). Another study conducted by (Grant el al., 2003) found improvements in sympatho-adrenal-medullary activation (i.e. reduction in plasma epinephrine) in dementia caregivers determined to be ‘vulnerable’ to stress (individuals with many caregiving responsibilities and little help), following a brief in-home respite-based intervention.
Holland et al (2011) formulated a study constructed on the findings of previous studies. The study measures such variables as caregiver stress, positive emotions, social support and living situation. Concurrently, this study investigates the link between cortisol and a number of psychosocial factors that have been shown to be relevant to caregiver physical health (Vitaliano et al, 2003), more comprehensive than past studies of caregiving. This study also presents a chance to examine the effect of an empirically confirmed caregiver intervention in supporting changes in cortisol, compared with minimal support control condition. The CWC (Coping with Caregiving) program used in this study is a psychoeducational intervention based on cognitive-behavioral principles, that advocates the attainment of skills such as managing problem behaviors, engaging in pleasant activities and challenging negative thoughts (Holland et al., 2011). This involvement has been found to be conducive to creating more significant reductions in caregiver stress and psychiatric symptoms, compared with a telephone support control (TSC) condition (Gallagher-Thompson, Gray, Dupart, Jimenez, & Thompson,2008).
The sample in this study is limited to 175 Caucasian and Latina/Hispanic women, as this study who are caring for a family member with dementia. It has been indicated that dementia caregivers’ culture and background can play a pivotal role in determining the manner in which they observe the caregiving experience, in terms of their sense of ‘duty’ to care for an ailing family member, the meaning attributed to memory problems (e.g. as shameful or as natural progression of a disease) and/or the acceptability of receiving help from outsiders (Gallagher-Thompson, Haley et al., 2003).
The primary objective of this study is to observe a diversity of psychosocial predictors of diurnal cortisol patterns at baseline. In adherence with the Vitaliano et al. 2003) theoretical model, the researchers considered caregivers resources, weaknesses and exposure to stress-all of which can have an effect on physiological responses to caregiving. A myriad of factors have been assumed in earlier studies to increase caregivers susceptibility to serious health problems, including high caregiver emotional distress, lack of positive experiences for the caregiver, low care recipient functioning, lack of social support for the caregiver and high-intensity living situation characterized by long hours of caregiving and co-residence with the care recipient (Cohen,Colantonio, & Vernch,2002; Connell,Janevic & Gallant, 2001; Pinquart & Sorensen, 2007). In this particular study these aspects are explored and are assumed to be linked with a more dysregulated cortisol pattern (i.e., characterized by lower cortisol levels at wake and a flattened diurnal slope; (Miller et al., 2007)
The second objective to perceive the efficacy) of the CWC intervention, which is assumed to decrease caregiver stress and promote more normal cortisol patterns compared with the TSC (
telephone support control) condition, Interaction effects between treatment condition and baseline psychosocial issues will also be investigated. It is assumed that caregivers who are originally found to be the most susceptible will attain the most benefits from CWC (Coping with Caregiving Intervention) (Holland et al., 2011).
In this study the findings seem to indicate that women with the most demanding caregiving situations, characterized by long hours of providing care and co-residence with the care recipient, tend to have lower waking cortisol, and flatter diurnal slopes- a pattern that has been shown to be common among persistently stressed groups (Miller et al., 2007).
The hypothesis in this study pertaining to the psychosocial domains was not fulfilled. It was found that social support for caregiver, care recipient functioning, caregiver positive feedings/outlook and caregiver stress were not strongly related to cortisol levels at baseline (Holland et al., 2011). It is important to be cognizant of the fact that while these results are subject to a myriad of explanations, it seems possible that broad-based measures that inquire about different facets of caregivers’ lives over the past month or in the recent past ( as was the case for many of our measures) may not totally detect the daily vicissitudes experienced by caregivers which would ostensibly be more strongly linked with moment-to-moment vacillations in cortisol levels across the day Nevertheless, other variables must considered. It is believed that since these measures also require participants to individually assess their feelings and life circumstances, they could be influenced by personality and demand characteristics ( e.g. presenting an overly optimistic picture; Robins & John,1997), which might conceal associations with more objective biomarkers of stress. In contrast to this type of datum, straightforward
information about a caregiver’s living situation and number of hours worked might be less influenced by these biases.