Abstract

Summary: Formidable communication and social support demands are placed on caregivers of family members with Alzheimer’s disease (AD) or related dementia, especially among the growing Hispanic population. The goals of this study are to explore relational health communication competence, social support, and perceived general coping among Hispanic caregivers for family members having AD or related dementia; and to test the Relational Health Communication Competence Model using data obtained in Spanish and English. The results indicate that: Highly communication competent individuals are significantly more satisfied with the social support received than those with moderate/low communication competence; highly communication competent individuals maintain larger social networks than those with moderate/low communication competence; social support satisfaction is a better discriminator of high communication competence than the reported number of social network members; and highly communication competent individuals do not report a higher degree of perceived general coping than those with moderate/low communication competence. These results further reinforce the prior well-established finding that communication competence is an integral part of social support and perceived coping processes among lay caregivers of loved ones with AD or related dementia. Implications from these findings, key study limitations, and directions for future inquiry are examined.
Keywords: Alzheimer’s disease, caregiving, health communication, communication competence, social support, perceived coping, Hispanic caregivers.
Citation: Weathers MR, Query JL, Kreps GL. A multivariate test of communication competence, social support, and coping among Hispanic lay caregivers for loved ones with Alzheimer’s disease: an extension of the relational health communication competence model. J Participat Med. 2010 Dec 5; 2:e14.
Published: December 5, 2010.
Competing Interests: The authors have declared that no competing interests exist.

Health and Aging

Drawing from the US Census Bureau’s 2006 population estimates, more than 37.3 million Americans are 65 or older and over 5.3 million Americans are 85 or older.[1] What is often glossed over in such projections, however, is the rising number of minority elders. As Gallagher-Thompson and colleagues lamented, “Less appreciated is the fact that the number of people in ethnic and racial minority groups who are over 65 years of age is increasing faster than other segments of the population.[2]” By 2030, minorities will comprise well over 25% of the older population, increasing the importance of cultural and ethnic influences on health and aging.[2][3] Currently, there are an estimated 5.3 million people in the US living with AD[4], and 9.9 million unpaid lay caregivers for AD[[6] “It has been estimated that between 2.4 and 3.1 million spouses or partners, relatives, and friends take care of people with AD,” according to Aranda and colleagues[7] Lay caregivers are usually female, older, of modest means, unemployed, and in poor health themselves.[8] In the few studies that have been conducted among Hispanic[^a] families, it was reported that Hispanic caregivers are more likely to be younger, less educated, poorer, and in worse health than non-Hispanic Caucasian caregivers.[7][9][10][11][12][13] Since most caregivers for individuals with AD are not trained, they may lack the necessary skills and experience needed to care for a chronically ill person.[8]

Lay caregivers and social networks caring for individuals with AD face a multitude of health, emotional, familial, and occupational challenges.[14][6] The problems associated with caregiving include chronic fatigue, anger, depression, anxiety, relationship and financial strain, and isolation.[6][15][16][17][18][19][20]The ability to fulfill family responsibilities is also challenged by the strain of caring for an individual with AD. Pratt and colleagues found that most caregivers were concerned with issues regarding family obligations and careers.[21] Work-related stress is also problematic for AD caregivers.[8][22][23]

Caregiving and Hispanic Cultural Attributes

“Like all cultures, Hispanic culture is characterized by values that shape behaviors and give substance to the development of individual identity,” as Cox and Monk stated.[18] Specific values linked to Hispanic culture include familism, simpatía, respeto, fatalism, espiritismo, and machismo.[2][24][25] For the purposes of the present investigation, familism has the most salience.

Familism has been defined as “a cultural value that involves individual’s strong identification with and attachment to their nuclear and extended families, and strong feelings of loyalty, reciprocity, and solidarity among members of the same family.[24]” Within Hispanic culture, emphasis is placed on the family unit rather than on the individual.[18][2] Familism also involves providing “both practical and emotional support to elderly people.[18]” Thus, in Hispanic culture, it is considered a privilege for the extended family to serve as the primary support for an individual with AD[2][26] and thus, formal support services are less likely to be used.[2][27]

Relational Health Communication Competence and Caregiving

Lay caregivers do not work in an information vacuum. They must coordinate efforts with health care providers, extended family members, and, possibly, social service personnel and/or clergy members. Competent relational health communication skills help caregivers elicit cooperation from key health care partners.[28][29] As posited by Query and Kreps, communication competence is defined as “the perceived tendency to seek out meaningful interaction with others, render support, be relaxed, appreciate others’ plight, and turn-take appropriately.[30]” As such, individuals who perceive themselves as communication competent are able to play a fundamental role in assembling and maintaining support systems, as well as influence an array of important health outcomes, such as quality of life, for individuals with AD and their caregivers.[8][31][32]

Relational Health Communication Competence Model

The Relational Health Communication Competence Model (RHCCM) describes a process by which communication competence influences health outcomes.[28] The model depicts a wheel with spokes representing consumer health networks (health care providers, family members, support group members) and the hub of the wheel represents consumers. The health network shapes the quality of an individual’s health care journey. The terrain upon which the wheel travels represents communication contexts, with more challenging terrains requiring a higher level of communication competence among health care participants to enable the wheel to roll forward, accomplishing health-related goals.[30] That is, “high levels of communication competence positively influence health communication goals, such as increased interpersonal satisfaction, therapeutic communication outcomes, cooperation between providers and consumers, social support, and effective information exchange.[28]” Individuals with insufficient levels of communication competence, however, are less likely to move the wheel forward to achieve health goals.[30] Since many Hispanics struggle with language barriers in the US,[33] they may experience communication competence challenges when communicating about health issues.

The RHCCM serves as the theoretical framework for this study. The model has guided studies examining communication competence, social support, perceived stress, and cognitive depression ([32]). Additionally, the model has been applied to a variety of contexts and populations including caregivers for individuals with AD,[34] support groups,[30][35][36] retirement community residents,[37] recovering alcoholics,[38] OB-GYN client interactions,[39] battered minority women,[40] breast cancer survivors,[41] and non-traditional students.[42] While the RHCCM has previously been examined among AD caregivers, this is the first study to examine the RHCCM among Hispanic AD caregivers.

Social Support

“Social support is a process inextricably woven into communication behavior,[43]” as Albrecht and Adelman noted. Kahn defined social support as “interpersonal interactions that include one or more of the following: The expression of positive affect of one person towards another; the endorsement of another person’s behaviors, perceptions, or expressed views; and/or the giving of symbolic or material aid to another.[44]” The affective dimension of social support, including self-worth, social identity, and group identity, is clearly linked to perceived communication competence.[37][42][45][46][47] The present investigation focuses on caregiver perceptions of social support as “health outcomes are best predicted by the individual’s perceptions of the quality and availability of support, not structural features of social networks[48]” (see also Wethington and Kessler[49]).

Social support may be viewed as “emotional, instrumental, and financial products delivered through the web of friends and acquaintances that surround an individual.[37]” Those friends and acquaintances are an individual’s social support network.[37][50][51][52]

Social Network Size

Social network size has been associated with communication skill levels, or communication competence.[53] Query and James found that individuals with high communication competence maintained larger social networks than low communication competent individuals. This suggests that “elderly individuals who perceive themselves as competent communicators are better able to develop and mobilize social networks to meet their needs than elders who view themselves as less competent communicators.[37]” The authors thus advanced the following hypothesis:

H1: Hispanic lay caregivers who report a high degree of communication competence will report a greater number of social support relationships than Hispanic lay caregivers who report a low degree of communication competence.

Social Network Satisfaction

Krause and colleagues found that changes in satisfaction with support among elderly individuals tend to precede the onset of depressive symptoms.[54] Additionally, a study conducted by Wright indicated a predictive relationship between online group satisfaction and perceived life stress. Interpreting the results, Wright stated, “Online supportive relationships may be similar to face-to-face support relationships in terms of the positive effects they can have on our psychological wellbeing.[55]”

In addition to its role as a mediator of life events, social support satisfaction is thought to be related to communication skill levels.[42] Some evidence suggests that the absence or underdevelopment of these skills may trigger feelings of dissatisfaction since less competent individuals will be less likely to elicit and provide social support during times of need.[30][37][42][56] Thus, the authors advanced the following hypothesis:

H2: Hispanic lay caregivers who report a high degree of communication competence will report greater satisfaction with social support relationships than Hispanic lay caregivers who report a low degree of communication competence.

Communication Competence, Social Support Satisfaction, and Network Size

Query and James noted that an affective component of social support (ie, satisfaction) will be a better discriminator of high communication competence levels rather than a quantitative component (ie, social network size).[30][37] Conner and colleagues found that the number of persons interacted with, and the frequency of the interaction, were of little importance for the adjustment of older people. Hence, the quality rather than the quantity of social interactions was found crucial to understanding adaptation to old age.[57] (see also Burleson and colleagues,[48] and Wethington and Kessler.[49]).
Conversely, Maddox[58] suggested that the quantification of a social network (ie, size) is a better discriminator than the affective measurement of a social network (ie, support satisfaction) in predicting elders who were satisfied and possessed of high morale.[37] Maddox also argued that individuals with larger social networks would be more satisfied. Thus, communication competent individuals would more likely be satisfied with the quantity of their social support than would low communication competent individuals. To test the value of these two competing perspectives, social support satisfaction was selected a priori as more powerful than the quantitative discriminator (ie, amount of social support).

Therefore, the authors advanced the following hypothesis:

H3: A linear combination of social support satisfaction and number of social supports will discriminate between Hispanic caregivers high in communication competence and Hispanic caregivers low in social support, with satisfaction being the better aid to discrimination between the groups.

Perceived General Coping

According to Leatham and Duck, “Coping is the mobilization of personal resources, both psychological and tangible, to deal with life stresses.[59]” Social support, however, may also be established by gaining access to resources that are controlled by others.[36][59] Caring for an individual with AD is very stressful, and its effect on lay caregivers’ wellbeing can be minimized using effective coping practices.[60] The authors thus posed the following hypothesis:

H4: Hispanic lay caregivers who report a high degree of communication competence will report a higher degree of perceived general coping than Hispanic lay caregivers who report a low degree of communication competence.

Method

This investigation sampled Hispanic caregivers of individuals with AD. Online and printed questionnaires (in English and Spanish) elicited demographic information, communication competence levels, social support satisfaction, network size, and perceived general coping levels.[^b] Paper copies were made available in self-addressed, stamped envelopes accompanied by an informed consent form. These were distributed through local contacts such as a southwestern chapter of the Alzheimer’s Association, a Wendy’s restaurant, snowball sampling, and via Craigslist.

Sample

The sample included 95 Hispanic lay caregivers, of whom 64 were female and 32 male. Twenty-one respondents completed the paper form and 75 completed the online questionnaire. Eighty-five respondents completed the English and 11 completed the Spanish questionnaire. Participants represented all age ranges included on the questionnaire with approximately 53% being 40 years of age or older.

Instruments

The Caregiver Questionnaire consisted of five scales to assess demographic information, communication competence, social support, perceived coping, and lay caregivers’ experiences[^c] in providing care for their loved ones. This is the first study to examine these concepts among Hispanic lay caregivers of loved ones with AD. For this reason, previous reliability levels for the Spanish version of the scales are not available.

Communication Competence

To measure lay caregiver communication competence levels, this study used Wiemann’s Communication Competence Scale (CCS)[61] as modified by Brunner.[62] Building on Wiemann and Brunner, Query and Kreps used the revised CCS in their investigation, and reported a Cronbach’s alpha of .899.[30] Other studies have employed the scale yielding reliabilities from .788 to .920.[36][37][42][62] In the present study, the reliability coefficient for the CCS was .860.

Social Support

To gauge lay caregiver social support network size and social support satisfaction, the shortened form of the Social Support Questionnaire (SSQ) created by Sarason and colleagues was used.[63][64] This revision also reflected the slight modifications advanced by Query.[35][65] The reliability coefficient for the SSQ in this study was calculated at .905 for the number of social supports subscale and .876 for the social support satisfaction subscale.

Perceived Coping

To assess lay caregiver perceived general coping, the Perceived Stress Scale (PSS) formulated by Cohen and colleagues was administered.[66] A recent study demonstrated the instrument’s reliability in a sample of older adults between the ages of 50-79, where the reliability coefficient was .85 [36]. In the present study, Cronbach’s alpha for the PSS was .737.

Statistical Procedures

This study used a three-group MANOVA with three levels of the predictor or grouping variable and three dependent variables. The predictor variable was communication competence, with a high group (n = 31), moderate group (n = 33), and low group (n = 32). To establish these equivalent groups, the following cutoffs were employed after examining the frequency distribution of the data: For the high group, 38.1; for moderate group, 40.03; and for low group, 40.04 and greater. This three-group approach has been used previously and has been shown to enhance statistical power.[36][41][67] The dependent variables were number of social supports, social support satisfaction, and perceived general coping. All hypotheses were initially tested at the p< .05 level.

Results

The MANOVA findings for H1, H2, and H4 are presented first. The stepwise discriminant analysis results for H3 then follow. The multivariate analysis of variance for the tests of H1, H2, and H4 was significant (Wilks Lamda = .737, F = 3.717, p = .000).

In light of the significant omnibus test, the univariates were then examined. For H1, the group means for the number of social supports indicated the mean for the high communication competent group was 17.2, the mean for the moderate communication competent group was 11.6, and the mean for the low communication competent group was 11.2. Two univariates were statistically significant: Number of social supports (F = 5.3, p = .007) and social support satisfaction (F = 9.56, p = .000). A third univariate approached significance: perceived general coping (F = 2.96, p = .057). For H2, the group means for social support satisfaction indicated the mean for the high communication competence group was 28.8, the mean for the moderate communication competent group was 27.1, and the mean for the low communication competence group was 23.2. For H4, the group means for perceived general coping indicated the mean for the high communication competence group was 15.5, the mean for the moderate communication competent group was 17.2, and the mean for the low communication competent group was 18.3. Subsequently, H1 and H2 were confirmed; however, H4 revealed non-significant findings and therefore was not confirmed.

To test H3, a stepwise discriminant analysis was conducted. At each step of the analysis, the variable that reduced the size of Wilks Lambda was entered. At step zero, both number of social supports and social support satisfaction were entered. At step one, number of social supports was removed. As the findings revealed, the one remaining discriminant function, with only social support satisfaction remaining in the model, accounted for 88% of the variance. The canonical correlation, .455, coupled with the relatively large chi-square, 24.76, indicated that the remaining function discriminated among communication competent groups fairly well.[68]

Discussion

Interpretation of Hypothesis 1

H1 suggested that Hispanic lay caregivers who report high communication competence levels would report a greater number of social network relationships than Hispanic lay caregivers reporting low communication competence. The results confirmed statistically significant differences of social support network sizes in all group means for low, moderate, and high communication competent groups. The sample in this study presented a high level of formal education with the majority of participants reporting having some college experience or holding a baccalaureate and/or graduate degree (n = 69%). This unique characteristic, relative to other similar samples,[32] may have influenced these Hispanic lay caregivers to better develop and mobilize their social support networks. This would have been facilitated, in part, by relatively high communication competence levels which may have been shaped by the caregivers’ higher levels of education.

This significant finding may also be attributed, in part, to the relatively large number of female participants in this study. In particular, female caregivers are much more prevalent in North America than male caregivers, and it is well-documented that females in North America tend to develop and hone relational skills integral to social support processes more than males.[69][70][71] In addition, women are the predominant lay caregivers in Hispanic cultures.[19][72][73]

Finally, social support processes may be affected by a Hispanic person’s cultural desire for collectivism versus individualism. According to Query and colleagues, “Collectivist societies, such as Mexico and most of Central and South America, often place family interests first.[73]” (See also Allen and colleagues[74]) While many of the present study’s respondents may have numerous outside social support network members (through school, work, academic organizations, etc.) a majority (n = 52) identified family members (mother, father, brother, sister, husband, wife, etc) as social support providers. This cultural tradition, where Hispanics rely more heavily on family members (ie, familism) may have played a role in the statistically significant finding (see Query and colleagues regarding collectivist cultural influences[73]).

By confirming H1, further support for the RHCCM has been derived. A key tenet of this model is that as the contextual terrain’s difficulty increases (eg, through caring for a loved one with AD or related dementia), it becomes more essential to effectively marshal one’s support network to help better negotiate the many pitfalls and challenges posed by AD and related dementia. While the preceding finding may seem somewhat contradictory to earlier research that clearly positioned social support satisfaction as more closely related to communication competence level,[30][32][37][65][72] the present authors suggest that the emphasis on familism prevalent in Hispanic culture relative to decision making and caregiving should temper such a concern.

Interpretation of Hypothesis 2

H2 suggested that Hispanic lay caregivers reporting high communication competence would report greater satisfaction with social network relationships than Hispanic lay caregivers reporting low or moderate communication competence. Similar to H1, the group means were in the direction predicted and the findings were statistically significant. The extent to which Hispanic lay caregivers are supported and perceive themselves as being helped is due, in part, to their abilities to negotiate life obstacles through ongoing communication with significant others. Social support satisfaction is thus partially forged by communication competence level since many Hispanic lay caregivers strive to maintain a network of care providers that can aid them across the many trials and tribulations of AD and related dementia.

Relative to the RHCCM, the preceding finding is confirmatory and consistent with prior research.[30][32][36][37][65][75] Social support satisfaction is one of the therapeutic outcomes posited by the RHCCM. This finding has at least two important ramifications. First, it reinforces the inextricable role between communication competence level and social support satisfaction, both of which will be extensively tested during caregiving for a loved one with AD or related dementia. Second, it helps demonstrate that the quality of support is a fundamental ingredient to managing the caregiving process.

Interpretation of Hypothesis 4

H4 suggested that Hispanic lay caregivers who report a high degree of communication competence would report a higher degree of perceived general coping than Hispanic lay caregivers who report a low degree of communication competence. Although the group means were in the direction predicted, the findings were not statistically significant. Prior research had demonstrated this predicted relationship;[32][36][75] however, in those studies, participation was not limited to one ethnic group. In this case, Hispanic culture may have played a key role in the nonsignificant finding. Adding to the unique challenges faced by large numbers of Hispanic families is the cultural belief that “any form of dementia should remain a family secret and be managed by only the family while disregarding any formal assistance services offered by the community or medical industry.[72]” Such a belief, trepidation to use public facilities such as hospitals and social establishments or the inability to afford such services,[76][77] may be harmful to the family member with AD, and to their family caregivers.

A second possibility which could have shaped the nonsignificant result was that these Hispanic caregivers believed their social networks could be easily activated and were sufficient to meet their needs. Since this sample reported relatively high levels of communication competence and social support, it seems reasonable that their networks were seen as adequately meeting varied needs. Additional research should continue to explore the suspected link among communication competence level, as well as perceived general coping.

Interpretation of Hypothesis 3

H3 tested the assumption that a linear combination of social support satisfaction and number of social supports would discriminate between Hispanic lay caregivers high in communication competence and low in social support, and that satisfaction would provide the greater contribution to the discriminative function. This hypothesis was confirmed. As noted earlier, social support satisfaction accounted for 88% of the variance, indicating its ability to separate individuals across communication competent groups reasonably well.[68] By confirming the ability of social support satisfaction to again distinguish among high, moderate, and low communication competence levels, additional support has been obtained to strengthen the generalizability of previous studies. The present results indicate that social support satisfaction has again played an integral role in shaping communication competence.[37]

In addition to supporting the findings of previous research, the confirmation of H3 also casts further doubt on the explanatory power of Maddox’s activity theory.[58] According to Query and Kreps, “because communication skills are the primary means through which humans recognize and interpret life events, Maddox was in effect suggesting the number of social supports would be a better predictor of communication competence level than would satisfaction with network relationships (social support satisfaction).[30]”

Limitations and Direction for Future Research

Despite the clear confirmation of the RHCCM, there were various limitations to this study. Whether respondents completed the paper or online version of the survey may have influenced the outcome of this study. While the paper version of the questionnaire might have been more accessible to many older individuals, the online questionnaire required more technical or online expertise. Another limitation was the length of the questionnaire: 15 pages for the paper version and 75 items for the online version. Due to the amount of missing data, response fatigue appeared to be a concern. Furthermore, the study involved a relatively small number of individuals, thus lowering external validity. Note also that since only a small number (n = 11%) of the respondents completed the Spanish-language survey, higher acculturation levels than the general Hispanic population may have positively skewed the results. Since the study was conducted primarily in a large southwestern urban region, a predominately English-speaking area, it seems plausible to surmise that the majority of the participants either learned English at a very young age, or grew up with English as their first language. Future research should thus incorporate acculturation as an independent variable in the RHCCM and assess its impacts using a more diverse sample. As previously described, a fairly large percentage (n = 44%) reported Mexico as their roots/origin. Future research should also explore the potential impact of various self-identifications (eg, Hispanic, Hispanic-American, Latino/a, Chicano/a).

Summary

The RHCCM serves as a vehicle for “interpersonal interaction between consumers and providers of health care…by guiding strategic health behavior.[29]” With another confirmation of the model’s utility and among a previously underexplored population, it can assist others in developing community-based interventions designed to help Hispanic caregivers cope with the trials of AD.

Endnotes

a. While acknowledging the contested nature of the many terms used to describe this culture, the authors have chosen to use the term “Hispanic” throughout this paper, understanding that other terms may be used and preferred (Chicano(a), Latino(a), Hispanic-American, etc.). The authors would like to emphasize that this choice of a term is not intended to show disrespect toward any reader. For a detailed discussion concerning the use of “Hispanic”, please see Garcia-Preto[78] and Query and colleagues[73] ↩

b. Although not reported here, the Caregiver Questionnaire also posed two broad, open-ended statements guided by the CIT[79][80][81] to better learn about Hispanic caregivers’ experiences as they have provided care. It was not possible, however, to effectively condense that narrative data into this manuscript. ↩

c. The narrative data are reported in Weathers and Kreps.[82] ↩

Acknowledgements

The authors extend their appreciation to Dr. Martha Haun (School of Communication, University of Houston), Dr. Mark Kunik (Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine), Mr. Richard Elbein (CEO of Houston and Southeast Texas Alzheimer’s Association), Michael West (former graduate student, University of Houston), Kalyopy Emmanouil (current undergraduate student, University of Houston), and Dung Hunyh (IT staff, University of Houston) for their comments on an earlier version of the manuscript and support in recruiting participants.

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Copyright: © 2010 Melinda R. Weathers, James L. Query, Gary L. Kreps. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author(s), with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.

 

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