Editorial Open Access
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Psychiatr. Mar 22, 2016; 6(1): 7-17
Published online Mar 22, 2016. doi: 10.5498/wjp.v6.i1.7
Gender differences in caregiving among family - caregivers of people with mental illnesses
Nidhi Sharma, Subho Chakrabarti, Sandeep Grover
Nidhi Sharma, Subho Chakrabarti, Sandeep Grover, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
Author contributions: Sharma N, Chakrabarti S and Grover S equally contributed to this paper.
Conflict-of-interest statement: The authors declare no conflicts of interest regarding this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Subho Chakrabarti, MD, MAMS, FRCPsych, Professor, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, PGIMER, Sector-12, Chandigarh 160012, India. subhochd@yahoo.com
Telephone: +91-172-2756808 Fax: +91-172-2744401
Received: June 1, 2015
Peer-review started: June 1, 2015
First decision: August 22, 2015
Revised: September 15, 2015
Accepted: December 13, 2015
Article in press: December 14, 2015
Published online: March 22, 2016

Abstract

All over the world women are the predominant providers of informal care for family members with chronic medical conditions or disabilities, including the elderly and adults with mental illnesses. It has been suggested that there are several societal and cultural demands on women to adopt the role of a family-caregiver. Stress-coping theories propose that women are more likely to be exposed to caregiving stressors, and are likely to perceive, report and cope with these stressors differently from men. Many studies, which have examined gender differences among family-caregivers of people with mental illnesses, have concluded that women spend more time in providing care and carry out personal-care tasks more often than men. These studies have also found that women experience greater mental and physical strain, greater caregiver-burden, and higher levels of psychological distress while providing care. However, almost an equal number of studies have not found any differences between men and women on these aspects. This has led to the view that though there may be certain differences between male and female caregivers, most of these are small in magnitude and of doubtful clinical significance. Accordingly, caregiver-gender is thought to explain only a minor proportion of the variance in negative caregiving outcomes. A similar inconsistency characterizes the explanations provided for gender differences in caregiving such as role expectations, differences in stress, coping and social support, and response biases in reporting distress. Apart from the equivocal and inconsistent evidence, there are other problems in the literature on gender differences in caregiving. Most of the evidence has been derived from studies on caregivers of elderly people who either suffer from dementia or other physical conditions. Similar research on other mental illnesses such as schizophrenia or mood disorders is relatively scarce. With changing demographics and social norms men are increasingly assuming roles as caregivers. However, the experience of men while providing care has not been explored adequately. The impact of gender on caregiving outcomes may be mediated by several other variables including patient-related factors, socio-demographic variables, and effects of kinship status, culture and ethnicity, but these have seldom been considered in the research on gender differences. Finally, it is apparent that methodological variations in samples, designs and assessments between studies contribute a great deal to the observed gender differences. This review highlights all these issues and concludes that there is much need for further research in this area if the true nature of gender differences in family-caregiving of mental illnesses is to be discerned.

Key Words: Gender, Family-caregiving, Schizophrenia, Elderly, Dementia, Mood disorders

Core tip: Women form the bulk of those who provide care for people with mental illnesses. Many studies have found that they are more exposed to caregiving stressors and report greater strain, burden and distress than men. However, the evidence for such gender differences in caregiving is equivocal and inconsistent leading to the view that caregiver-gender explains only a minor proportion of the variance in negative caregiving outcomes. Moreover, the evidence is not representative and often methodologically flawed. There is, thus, much scope for further research to understand the true nature of gender differences in family-caregiving of mental illnesses.



INTRODUCTION

Caring for someone with a mental illness has always been a family endeavour. This is true for developed as well as developing countries. Despite their relatively greater mental health-care resources, changing demographics and health-care norms in developed countries have shifted the locus of care from institutions to communities[1,2]. Social and health-policy changes have also placed greater emphasis on home and family-care for the chronically mentally ill in these countries. In contrast, families have always been the mainstays of care for the mentally ill in developing countries[3,4].

Family-caregiving is a term used for unpaid care provided by family members or friends to chronically ill or functionally impaired persons[1,5]. The amount of assistance provided by the family-caregiver usually exceeds the level of help provided under ordinary circumstances. Not only is the majority of informal care provided by family members, but the majority of family-caregiving is also carried out by women[6,7]. All over the world, women are the predominant providers of informal care for family members with chronic medical conditions or disabilities, including the elderly and those with other mental illnesses[6-14]. Family-caregiving still remains a predominantly feminine activity despite the fact that with changing demographics and changes in social structures and norms, men are increasingly assuming roles as caregivers[15]. While providing care may have its rewards for family-caregivers, it often entails bearing emotional, physical, social and financial burden, which makes the experience stressful. Despite the voluminous amount of literature on family-caregiving, there is much that remains to be understood about why people take on strenuous caregiving duties, how they approach their caregiving responsibilities, and the consequences of taking up the role of a caregiver[16,17]. For an improved grasp of the experience of caregiving, a more accurate understanding of the caregiving-context which includes gender, familial relationship and cultural background of the caregiver is required[16]. Among these contextual factors, the impact of gender on caregiving has attracted the maximum research attention. The bulk of this research has been carried out among family-caregivers of the elderly with dementia or physical conditions, while gender differences among caregivers of other mental illnesses have been relatively neglected. However, even in this body of research there is considerable disagreement about the exact nature of gender differences in caregiving, and no consistent explanations about how gender influences caregiving.

GENDER DIFFERENCES IN FAMILY-CAREGIVING AMONG THE ELDERLY

Research on gender differences among caregivers of the elderly with dementia and physical illnesses have brought to the fore several themes of interest.

Women predominate among caregivers of the elderly

Worldwide, nearly 70% to 80% of the impaired elderly are cared for at home by their family members[5-7,9,11,17-20]. Varying estimates across different countries indicate that 57% to 81% of all caregivers of the elderly are women[1,6-8,10,12-14,17-26]. In most cases female caregivers are wives or adult daughters of the elderly person. They are usually middle-aged, with a considerable proportion of them being over 65 years themselves. They are also more likely to be employed outside home than in the past[7,17,19,27]. The elderly recipients of care are either frail or chronically physically ill; the majority, however, have dementia or other forms of mental illnesses[7]. Despite the preponderance of women, increased life expectancy, more women working outside home, and smaller families have all increased the pressures on men to assume roles as caregivers of the elderly. Studies in the eighties in the United States suggested that though women predominated as caregivers, somewhere between 20% and 33% of the caregivers of the elderly were men[6,18,19,26]. More recently, it has been reported that the proportion of men providing care for the elderly has been steadily increasing, so much so that men may constitute nearly half of the primary caregivers of the elderly[8,15,16,19,23,28-35]. Despite the increasing emergence of men as caregivers, research has not taken into account this trend and continues to maintain its traditional focus on female caregivers. Although it appears that men approach caregiving differently, the experience of caregiving among men has not been examined as often as it has been among women[8,15,23,26,29-34].

Gender differences in the experience of caregiving

A number of studies have suggested that the experience of caregiving differs among men and women. Gender-specific differences in the provision of care for those with dementia or physical illnesses have been found to exist in several areas.

Time spent on caregiving and the duration of caregiving: Gender-differences in the time spent on caregiving have been considered in several reviews and studies on the subject. Some of them have concluded that despite conflicting reports, the bulk of the evidence indicates that women devote greater time to caregiving for the elderly, compared to men[1,16,20,25,27-29,34,36,37]. In a comprehensive narrative-review of 30 research-reports, Yee et al[22] concluded that the majority of studies which had examined gender differences in the time spent on caregiving had found that women spend more time on caregiving than men. Explanations based on the gendered nature of paid work have argued that women are more likely to care for the elderly because they are less likely to be employed outside home[38]. Women’s work roles are viewed as being centred in the home and may reflect a greater sense of family obligation among them[11,16,17,23,38,39]. This increases the likelihood of women spending more time providing care. Time-intensive care among women is also more likely in those societies and cultures, which endorse the traditional value of the woman as the natural caregiver[8,11,23]. However, research findings about gender differences in the time spent on caregiving have not always been consistent. A number of reviews and studies have not found gender to be a significant predictor of the time spent on caregiving[8,10,18,26,38,40-42]. In particular, two meta-analytic reviews on the subject, one of which included 229 studies, have concluded that though women spent more time on caregiving, differences between men and women in this regard were small and of doubtful practical significance[24,43]. There is also considerable agreement that gender differences in the time spent on caregiving are confounded by several other variables such as kinship (spouses vs children), and cultural or ethnic influences[10,22,24,26,38,42,43]. Regarding the duration of caregiving, there is far greater consensus that gender does not have an impact on total duration of caregiving[8,10,24,43].

Types of tasks: The literature on gender differences in the type of caregiving tasks has also yielded conflicting findings. A distinction has been made in this literature between tasks associated with personal care such as bathing, dressing and managing incontinence, and tasks associated with management of everyday living. Some studies have found that women are more likely than men to provide assistance with tasks related to personal care[18,44], while others have not reported similar gender differences[9,10,38]. Reviews on the subject have also concluded that gender differences in the types of tasks have only been reported in some but not all studies, and only for tasks related to personal-care. Female caregivers are more likely than men to carry out these tasks[16,17,22,27-29]. Gender differences have not been found in tasks associated with everyday living[38]. These conclusions were endorsed by two meta-analytic reviews[24,43], but these further concluded that gender differences in personal-care tasks were small in magnitude. Gender differences in the types of tasks also appear to be influenced by several mediating variables such as the patient’s gender and disability levels, kinship, caregivers’ marital and employment status, family composition, social class, and race or ethnicity[10,22,27,38,45].

Role-strain and role-conflict: Caregiver role-conflicts refer to the perceived difficulties in fulfilling the caregiver-role, and the negative consequences emanating from this role[36]. Female caregivers often have to play multiple roles such as wives, daughters, mothers, or employees[16,17,38]. The pressures of enacting these conflicting roles may create difficulties for women. Role-conflicts and role-strains may manifest in many ways[16,17,38,46]. Role-conflicts arise when conflicting and incompatible demands are made of the caregiver himself/herself[16,17]. Role-strain occurs when one is unable to meet the expectations and obligations of multiple roles. Role-overload sets in when these competing demands overwhelm the person’s ability to carry out his/her role[16,17]. This might lead to role-captivity, which refers to the caregivers’ feelings of being trapped in their roles[17,46]. Role-conflicts give rise to several adverse consequences for caregivers such as physical problems, fatigue, burnout, depression and other emotional disturbances, and feelings of resentment towards the patient[17,46]. Many studies have found that female caregivers of the elderly with physical problems or dementia experience greater role-strain and role-conflict than male caregivers[1,13,14,16,20,27-29,36,39,44,47-52]. Women appear to experience greater interference and limitations in their work and social life because of their role as caregivers. They are generally believed to experience greater role-strain due to the more intense care they provide. Greater role-strain in women produces more frequent health problems, a less positive outlook on life, and a greater need for external support. From their review of nine studies on gender differences in caregiving role-strain, Yee et al[22] concluded that female caregivers report that their caregiving-roles interfered with their work and social life to a greater extent than men. However, such findings have not always been consistent, with several studies finding that caregivers’ gender has no impact on their evaluations of role-strain[20,32,42,53]. It has been suggested that differences between studies arise more from the fact that perceptions of role-strain may vary depending on whether the caregivers are spouses or children of the elderly[36,44,47,50,54].

Satisfaction with caregiving: There is a relatively small amount of research-data on gender differences in other aspects of caregiving such as satisfaction with caregiving. The findings are equivocal, with some studies reporting that women are less satisfied[55-58], while a similar number of studies have found no differences in satisfaction between male and female caregivers[10,33,59,60].

Reasons for providing care: Several authors have identified emotional and social connectedness of women towards their patients, as well as their sense of family obligation as the basis for their nurturing approach to caregiving[16,61,62]. Women appear to be more concerned about the emotional well-being of the people they provide care for. This attachment often motivates them to engage in caregiving[20,38,61-63]. A greater sense of responsibility towards the patient, altruism, and self-sacrifice has also been found to characterize women’s attitudes to providing care[10,25,27,33,38,45,61-63]. However, studies of male caregivers have suggested that caregiving among men is also driven by a similar sense of affection, commitment, and family responsibility[27,30].

Gender differences in caregiver-burden

Caregiver-burden has been defined as ‘‘a multidimensional response to physical, psychological, emotional, social, and financial stressors associated with the caregiving experience’’[5,64,65]. Caregiver-burden is often the final outcome of a stressful and negatively perceived experience of providing care[66]. Not surprisingly, the greater part of the literature on gender differences in caregiving has been devoted to the subject of caregiver-burden. However, the results have been far from conclusive. Though a number of studies have found that female caregivers report greater levels of both objective and subjective burden[8,10,11,17,23,33,34,39,44,46-48,51,65,67-73], a similar number have been unable to find any gender differences in caregiver-burden[9,12,30-32,36,50,53,54,74-83]. Moreover, some studies have found differences in only certain aspects of burden, e.g., subjective burden, and not in others[8,10,17]. Narrative reviews on the subject have been similarly uncertain in their conclusions. While some of them have concluded that caregiver-burden is higher among female caregivers[5,22,25,27,29,84-86], others have not found evidence in favour of greater levels of burden among women[12,15,30]. In their seminal narrative-review on gender differences in caregiving, Yee et al[22] extracted data on caregiver-burden from 17 of the 30 studies they had included in their review. The vast majority of these studies reported that women experienced higher levels of caregiver-burden than men. However, meta-analytic studies have come to somewhat differing conclusions. An early meta-analysis included 14 studies on caregiver stressors and burden among the frail elderly[43]. It found that though female caregivers were more likely to report greater caregiver-burden, differences between the genders were small. In another meta-analysis of 4 studies, female caregivers of patients with dementia reported poorer global self-health, but did not differ from male caregivers on other risk factors[52]. In a meta-analysis of 84 studies of caregivers of the frail elderly, Pinquart et al[87] found that higher stress and poorer well-being among caregivers were more common among older women who were spouses of the patients. However, a later meta-analysis of 176 studies of caregivers of the elderly by the same authors found that associations of caregiving stressors with health were stronger among older men proving care for those with dementia[88]. The same authors have also carried out the most comprehensive meta-analysis till date of 229 studies on gender differences in caregiving of the elderly[24]. In this meta-analysis, the authors found that female caregivers had higher levels of burden and lower levels of subjective well-being and physical health compared with men, but these differences were small and barely reached the threshold of practical significance. Thus, they concluded that the available evidence indicated that there are more similarities than differences between male and female caregivers in this regard, and that some of the apparent gender differences could have arisen from methodological variations, or the effect of other confounding factors on caregiver-burden[24].

Gender differences in psychological morbidity

In their review, Yee et al[22] found nine studies which had examined gender differences in depression among caregivers of the frail elderly, and three studies which had reported gender differences in general psychiatric symptomatology. Overall, in 10 out of these 12 studies higher levels of depression and psychological morbidity was reported among female caregivers. Other reviewers have also reported greater psychological morbidity, principally depression, among female caregivers of the elderly[20,27,34,85,89,90]. Additionally, gender differences in psychological morbidity have been found in other studies[35,48,67,69,71-73,91]. In contrast, several studies have not been able to find significant differences among male and female caregivers in depression or psychiatric symptom-scores[23,33,75-78,82,92]. Meta-analytic reviews, though finding a higher prevalence of depression among female caregivers of the elderly, have reported that these gender differences were of much smaller magnitude than expected[10,24,43,52].

GENDER DIFFERENCES IN FAMILY-CAREGIVING AMONG SCHIZOPHRENIA AND MOOD DISORDERS

The issue of gender differences in family-caregiving in schizophrenia and mood disorders, or other psychiatric conditions has not been examined as comprehensively as among the elderly. Studies, which have evaluated burden among caregivers of such illnesses, have only occasionally considered gender of the caregiver when examining the numerous correlates of caregiver-burden. Nevertheless, certain trends similar to the literature on gender differences in the elderly are still evident.

Gender and type of caregivers of patients with schizophrenia and mood disorders

In a recent review of 42 studies on caregiver-burden in schizophrenia, the majority of caregivers were mainly the parents (usually mothers), followed by spouses and siblings of patients[93]. In an earlier review, Awad et al[94] had reported that women, either wives or sisters formed the greater part of caregivers of those with schizophrenia. They quoted a United States community survey, in which women constituted 82% of caregivers, with 90% being mothers of patients; 70% of them were over 60 years of age. This trend has been endorsed by a number of other reviews, which show that most family-caregivers of those with schizophrenia are their parents, mostly mothers of patients, and they are usually elderly[95-101]. However, the number of male caregivers seems to be on the increase[94,98,102], while in certain cultures men often predominate as caregivers[93,98,103,104].

Gender differences in caregiver-burden and psychological distress

Not only is there limited research on gender differences in caregiver-burden among schizophrenia and mood disorders, but the evidence for such differences is also less obvious. In their review of caregiver-burden in schizophrenia, Caqueo-Urízar et al[93] noted that female gender, unemployment and time spent in caregiving were all associated with higher burden. In contrast, in an earlier review of patients with severe mental illnesses other than dementia, Baronet[101] had identified 10 studies, which had evaluated the relationship between burden and caregivers’ gender. None of them had found gender differences in overall burden, objective burden, subjective burden, worry, fear, or stigma. The results of individual studies conducted among family-caregivers of those with schizophrenia have also varied considerably. A number of these studies have reported higher levels of caregiver-burden, stress, burnout, psychological morbidity and poorer quality of life among female caregivers of those with schizophrenia[97,100,102-114]. However, several other studies have not found any differences in caregiver-burden between the genders[98,115-124]. Then again, very few of these studies on schizophrenia have actually conducted comprehensive examinations of gender differences among caregivers. In an Indian study, caregiver-burden was examined in 70 spousal caregivers of patients with schizophrenia. Results showed that female spouses experienced significantly greater total burden and burden in the areas of external support, caregivers’ routine, patients’ support, patients’ behaviour, and caregivers’ coping strategies[106]. Female spouses also felt more anxious, tired, frustrated or isolated, and had to face a greater work load. Another study examined differences in caregiving between mothers and fathers who had a son or daughter with schizophrenia, in 100 such caregiver-couples[115]. The results showed that men and women were equally vulnerable to caregiving stressors. Studies among caregivers of patients with bipolar disorder are fewer. Perlick et al[125] examined gender differences among 150 primary caregivers of patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder. They found that men and women did not differ on depression or caregiver-strain. Some of the other studies of bipolar disorder have found higher levels of caregiver-burden or poorer quality of life among female caregivers[111,126,127], while others have not[128]. In a study of depressed patients with both unipolar and bipolar depression, wives were found to be more isolated and upset compared to their husbands[129]. However, results of other studies on depressive disorders have been mixed, with some reporting higher caregiver-burden or greater levels of depression among female caregivers[97,130,131], while others have not found significant gender differences in either burden or psychological morbidity[128,132]. In a recent study, a comprehensive examination of burden, psychological morbidity and other caregiving-indices was undertaken among male and female caregivers of 100 Indian patients with schizophrenia and recurrent mood disorders[133]. The majority of female caregivers were housewives. Male caregivers were more likely to be in paid employment than the female caregivers, had significantly higher income and were more likely to belong to the upper socio-economic strata than female caregivers. A significant gender difference emerged in the time spent on caregiving, with female caregivers spending more time providing care for their patients. Female caregivers also scored significantly higher in one domain of negative appraisal, while male caregivers had significantly higher scores on family-cohesion. Men cited family tradition, familial obligation, and concern about the patient’s ill health as their reasons for providing care more often than women. Women, on the other hand, were more likely than men to report dependence, especially socio-economic dependence on their male patients, feelings of affection and sympathy for them, and a greater concern about the patient’s future as their reasons for providing care. However, there were no significant differences between male and female caregivers in any of the areas of objective or subjective burden, or psychological morbidity. Moreover, there were no differences in coping strategies, availability of social support, or personality traits such as neuroticism and rumination between men and women. The correlates of caregiver-burden and distress were largely similar among male and female caregivers. Finally, multivariate analyses showed that caregiver-gender explained only a minor proportion of the variance in caregiver-burden and distress. The results of this study thus endorsed what appears to be the consensus view in literature, largely derived from research among the elderly, that gender differences in caregiving though present are minor in nature, and caregiver-gender explains only a very small proportion of the variance in caregiver-burden and distress.

GENDER DIFFERENCES IN FAMILY-CAREGIVING: PROBABLE EXPLANATIONS

Several theories have been advanced to explain gender differences among caregivers of the elderly. Sociological explanations have emphasized expectations of traditional gender roles, in which women are expected to adopt the role of a caregiver. This is ingrained in females through their social and cultural experiences starting from childhood, and leads to a different approach to caregiving compared to men. Additionally, theories of segregation of labour indicate that since women are more likely to stay at home it is natural for them to take up the caregiver role[11,16,17,24,36,38,39,45]. Men are not traditionally expected to become caregivers, which leads to a dissimilar approach towards caregiving among them. Due to their role-socialization, men may also be less adept at expressing their difficulties or emotions. This could result in a response-bias, in which men may be less likely to report difficulties in providing care than women[8-11,23,27,72]. However, it has been noted that empirical support for these theories is lacking[10,17,24,43,52]. Therefore, a second set of explanations based on the “stress-coping” theory has been proposed. It has been argued that gender differences arise because female caregivers have greater exposure to caregiving stressors, and differ in their appraisal, coping and availability of social support while managing these demands[10,11,17,22,24,65]. Though this theory has found more support from different studies, but unequivocal evidence of gender differences in appraisal, coping and social support is also lacking[8-11,39,22-24,27,48,68,72,73,134]. Some studies have indicated that gender differences in caregiver-burden and distress could be due to a differentiated appraisal of the caregiving situation among men and women[10,73], but the evidence for such gender differences is limited. Gender differences in coping strategies have been examined more extensively. Among family-caregivers of the elderly, a number of studies have found that women use emotion-focused coping and other ineffective coping styles such as fantasy, wishful thinking denial, escape, or avoidance, more frequently than men. In contrast, men have a wider coping repertoire than women, and use more effective coping strategies such as problem-solving, acceptance, detachment or distancing more frequently[11,25,48,72,77,134]. These differences in coping strategies could potentially explain the higher levels of caregiver-burden and psychological morbidity among women[8,11,22,23,48]. Similar gender differences in coping have occasionally been reported among caregivers of patients with schizophrenia and mood disorders[106,135,136]. However, the number of such studies is limited, both among the elderly, as well as in schizophrenia and mood disorders. Contrary findings of lack of differences in coping between male and female caregivers have also been reported[22,73]. Some authors have proposed that female caregivers experience higher burden and distress because of lack of available social support[8,16,22,67]. According to them, women who care for the elderly are less likely to seek or receive support, because of the restrictions imposed on them by their caregiving roles. Men, on the other hand, are more inclined to seek and receive outside help for caregiving from formal and informal sources. Women seem to have larger social networks and more available sources of informal support, while men who have less access to formal and informal support, may be more motivated to seek help from these sources[22,24,137]. A greater lack of social support among women has also been found in spouses of patients with schizophrenia or mood disorders[106,129]. Again, the available results evidence are inconsistent in this regard, and gender differences in social support are not as pronounced as expected[10,22,24], either among caregivers of elderly persons or those with other psychiatric illnesses. Neuroticism, the greater propensity to break down under stress has been shown to have a significant influence on burden and psychological morbidity among caregivers. Some of the evidence indicates that the higher levels of depression and psychiatric symptoms among female caregivers could be partly accounted for by their higher neuroticism and greater use of escape-avoidance coping, but the number of such studies is small[22,46,72].

Since gender differences in appraisal, coping, social support and personality traits have been minimal and inconsistent, other explanations have been sought to account for differences in family-caregiving between men and women. It has been argued that the impact of gender is mediated by several other variables. These include characteristics of the patients, the severity of their illnesses including behavioural problems and associated disabilities, composition of the family, caregivers’ demographics such as age, marital status, education, employment and socioeconomic status, their relationship with the patient, and the effects of culture, and ethnicity[5,8-11,22-28,34,38,39,44,46,50,67,68,73,79,86]. The influence of culture and ethnicity and kinship with the patient and has been explored in a number of studies. It is an undisputed fact that culture and ethnicity have a seminal influence on caregiving[138]. However, whether cultural and ethnic factors impact gender differences in caregiving is a matter of some dispute. Certain authors have stated that studies from various cultures generally find that female caregivers are at greatest risk for caregiver-burden[5,93]. Others have proposed that gender differences in caregiving are less likely in cultural and ethnic groups with more positive attitudes towards the elderly, a traditional emphasis on women as caregivers, and the relative unavailability of formal sources of care[8-11,13,14,38,45,50,73,79,139]. It has also been suggested that among certain cultural or ethnic groups, familial-cultural variables such as familism, family-support, filial responsibility and family-cohesion may contribute to the gender differences in caregiving[5,8,10,11,73]. Familism refers to the precedence given to the family needs over the needs of the individual, while family-cohesion refers to the emotional bonding that family members have towards one another, and filial responsibility or piety refers to the tradition of caring for one’s elders[5,140]. However, the exact direction of gender differences due to familial-cultural variables is unclear, because both higher burden among female caregivers[5,8,10,11,73], or similar levels of burden between the two genders[12,79,133,141] has been reported among cultural or ethnic groups with these familial-cultural values. Kinship status of the primary caregiver is another factor, which is thought to have a significant bearing on gender differences in caregiving[5,20,22,24,26,27,34,39,45,46,54,65,86]. Many studies have found greater burden or strain among spouses (usually wives) than children[9,11,23,38,79]; others have found the obverse[39,47,67], while some have found no effect of kinship ties on gender differences among caregivers[50,74].

GENDER DIFFERENCES IN CAREGIVING: METHODOLOGICAL VARIATIONS

Methodological variables contribute a great deal to the observed gender differences[15,24,29,86,101]. It has been repeatedly pointed out that there is a great deal of difference across studies in their samples, designs, assessment-procedures, data analyses and theoretical frameworks. These methodological variations could account for a large proportion of the variance in findings, and may give rise apparent rather actual differences between male and female caregivers[1,15,22-24,27,29,36,43,52,85,86,89,101].

GENDER DIFFERENCES IN CAREGIVING: CONCLUSIONS AND FUTURE DIRECTIONS

Across the world women still constitute the majority of caregivers either of the elderly, or of those with other psychiatric disorders. However, the proportion of men taking up the caregiver’s role is steadily increasing. Although a large body of the evidence seems to indicate that women suffer more from the negative consequences of providing care, several other trends apparent in research need to be noted. Despite extensive examination of the area, gender differences in caregiving have not been consistently or conclusively documented. The magnitude and significance of the gender differences, which have been found is also uncertain. The majority of studies have been carried out among women; the experience of male caregivers has been relatively neglected. The bulk of the evidence comes from studies conducted among the elderly; gender differences in conditions such as schizophrenia or mood disorders have not been examined as comprehensively. Many explanations have been provided for greater burden and distress among female caregivers, but most of them are not supported by data. The effect of several variables, which mediate the influence of gender on outcomes of caregiving is uncertain. Finally, methodological variations between studies may conceal the true nature and extent of gender differences. Future research will need to address all these deficiencies before a better understanding of the subject can be obtained. If significant gender differences are indeed found, these will have major implications for development of gender-specific caregiver interventions, and social policy recommendations to improve the plight of female caregivers. It is for this very reason that there is much scope for further research in this area.

Footnotes

P- Reviewer: Schweiger U S- Editor: Qi Y L- Editor: A E- Editor: Jiao XK

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