International Psychogeriatrics (2012), 24:12, 19431952 C

International Psychogeriatric Association 2012

doi:10.1017/S1041610212001287
Spirituality and self-efcacy in dementia family caregiving:
trust in God and in yourself
.........................................................................................................................................................................................................................................................................................................................................................................
J. Lopez,
1
R. Romero-Moreno,
2
M. Marquez-Gonzlez
3
and A. Losada
2
1
Department of Psychology, Universidad San Pablo CEU, Madrid, Spain
2
Department of Psychology, Universidad Rey Juan Carlos, Madrid, Spain
3
Department of Biological and Health Psychology, Universidad Autnoma de Madrid, Madrid, Spain
ABSTRACT
Background: Research indicates that spirituality and self-efcacy have been associated with higher levels of
caregivers well-being. However, these two concepts have rarely been examined simultaneously. The aim of
this study was to analyze the combined effect of spirituality and self-efcacy on the caregiving stress process.
Methods: The study design was cross-sectional. Dementia family caregivers (n =122) were assessed in relation
to the following variables: stressors (time since caregiving began, daily hours caring, frequency of behavioral
problems, patients functional status); appraisal (caregivers appraisal of behavioral problems), caregivers
personal resources (self-efcacy, spiritual meaning, social support), and outcomes (depression and anxiety).
Results: Participants were divided into four groups corresponding to four proles dened by their scores on
spiritual meaning and self-efcacy: LELS = Low self-efcacy and low spirituality; HELS = High self-efcacy
and low spirituality; LEHS = Low self-efcacy and high spirituality; and HEHS = High self-efcacy and
high spirituality. No differences were found between groups in stressors, appraisal, or personal resources.
Caregivers in the HEHS group had signicantly less depression compared to the LEHS group. Regression
analysis showed that being a HEHS caregiver, low appraisal of behavioral problems and high social support
were associated with low caregiver depression. Only high appraisal of behavioral problems was associated with
high levels of anxiety.
Conclusion: The results of this study suggest that spirituality and self-efcacy had an additive effect on caregivers
well-being. A high sense of spiritual meaning and a high self-efcacy, in combination, was associated with
lower levels of depression in caregivers.
Key words: dementia caregivers, spiritual meaning, competence, stress process, coping, anxiety, depression
Introduction
Family caregiving is the oldest form of care
system. Nevertheless, relatives who assume the role
of primary caregiver are exposed to a stressful
situation that increases their risk of developing
important emotional problems, especially anxiety
and depression (Pagel et al., 1985; Schulz and
Williamson, 1991; Crespo et al., 2005; Cooper et al.,
2007). Dementia caregiving has been considered as
a prototypical chronic stressful situation, and most
of the research in this eld has been carried out
from the stress and coping theoretical model (e.g.
Pearlin et al., 1990; Lawton et al., 1991). According
to this model of stress, the degree to which the
Correspondence should be addressed to: Javier Lopez, Departamento de
Psicologia, Universidad San Pablo CEU, 28668-Boadilla del Monte, Madrid,
Spain. Phone: +34 91 372 47 00; Fax: +34 91 372 40 00. Email: jlopezm@
ceu.es. Received 27 Dec 2011; revision requested 5 Mar 2012; revised version
received 31 May 2012; accepted 27 Jun 2012. First published online 2 August
2012.
difcult situations faced by caregivers over long
periods of time (stressors such as the care recipients
behavioral problems or dependence) inuence their
own mental health (e.g. depression or anxiety) will
vary depending on their personal resources (e.g.
coping or social support). This model highlights the
importance of analyzing the inuence of personal
resources on caregiving distress. While the number
of studies analyzing caregivers stress process has
grown exponentially over the last three decades,
there are some relevant personal resources (which
may attenuate or reinforce the impact of stressors
on caregivers mental health) that deserve more
attention than they have received so far. This is
the case of spirituality and self-efcacy, which are
analyzed in the following sections.
Spirituality
Spirituality refers to the individualized and personal
response to matters such as the meaning of life,
1944 J. Lopez et al.
death, illness, and existential concerns; it is the
personal quest to understand the ultimate questions
about life, meaning, and our relationship to the
sacred or transcendent. It can be seen as comprising
elements of meaning and connection to a higher
power or something greater than the self (Fetzer
Institute and National Institute on Aging Working
Group, 1999).
The inuence of spirituality on caregiver stress
process is under-explored, even though it has been
considered to be an important coping resource
for caregivers (Marquez-Gonzlez et al., 2012). A
review of studies analyzing the role of spirituality
in caregivers well-being showed that most of them
reported either no association between spirituality
and well-being (e.g. depression) or a mixed
association (combination of positive, negative, and
non-signicant results) (Hebert et al., 2006). It
is likely that the heterogeneity of the measures
used for assessing spirituality partially explains
the inconsistency of the ndings in this research
eld. Even though spirituality is a multidimensional
construct (meaning, forgiveness, spiritual coping,
spiritual history, commitment, and so on; Fetzer
Institute and National Institute on Aging Working
Group, 1999), it is usually operationalized with
broad measures, a fact that may contribute to the
nding of cloudy results (Hebert et al., 2006).
In order to avoid ambiguous research results,
it is necessary to be specic about the dimension
of spirituality measured with caregivers. Spiritual
meaning is a specic spiritual dimension related
to the existentialism perspective. Spiritual meaning
in the context of caregiving refers to the spiritual
attributions associated with the experience of
caregiving (Farran et al., 1999). Spiritual or ultimate
meaning relates to caregivers deriving a sense of
purpose from beliefs in a greater spiritual power.
A central element of spirituality is the provision
of ultimate meaning. Spirituality allows people
to interpret events and experiences as ultimately
meaningful by linking them to a broader sense of
order (Farran et al., 1999; Quinn et al., 2010).
Self-Efcacy
A non-avoidant belief is the construct of perceived
self-efcacy. It is described as the subjective belief
that one can organize and execute courses of action
in order to manage given situations (Bandura,
1997). It refers to individuals judgment of their
ability to perform a behavior successfully. In the
caregiving area, these efcacy beliefs represent
the caregivers assessment of his/her ability to
successfully master relevant caregiving tasks. Rather
than viewing the demands of caregiving as tasks to
be avoided, those with a high sense of caregiving
self-efcacy may view them as challenges to be
overcome (Gilliam and Steffen, 2006). When
individuals face caregiving demands, those with low
self-efcacy beliefs focus on negative aspects of
the situation, including their personal deciencies
and the difculties of the task. Focus on negative
cognitions reduces motivation to initiate an activity,
impacts task persistence, and leads to negative
affective states, which then perpetuate the cycle
(Bandura, 1997). Optimal performance involves
both skills and the efcacy beliefs to use the skills.
The role of self-efcacy in the stress process,
although indicated as one of the variables that may
contribute to a reduction of the impact of caregiving
demands on health, has been under-studied. It
is especially important to consider caregiver self-
efcacy in cases in which care recipients have
dementia, given that, as this illness progresses, the
caregiving role increasingly includes responsibility
for carrying out specic care and care management
behaviors. In fact, higher caregiver self-efcacy
expectations regarding their own ability to handle
caregiving challenges has been signicantly related
to lower scores on burden, anger, anxiety, and
depression, even after controlling for objective
stressors (Marquez-Gonzlez et al., 2009).
Relationships between spirituality and
self-efcacy
It seems plausible to consider different com-
binations (or proles) of spirituality and self-
efcacy beliefs with a view to making better
predictions about caregivers well-being. In many
respects, spirituality empowers the individual. Being
connected to an all-powerful and sympathetic
Supreme Being gives spiritual people a tool that
can be used to change their situation or acquire
the strength to endure it. This may strengthen
feelings of self-efcacy and increases beliefs in ones
capability to organize and execute the courses of
action required to manage prospective situations. In
this sense, Limet al. (2011) found that spirituality is
associated with caregivers gain through the use of
the encouragement strategy to manage dementia-
related problems, suggesting that spiritual beliefs
could have provided caregivers with a framework to
positively reframe the situation and enabled them
to be more empathetic, which, in turn, promoted
efforts at encouraging the relative.
Nevertheless, one might also expect spirituality
to be positively related to control or inuence by
powerful others. Spiritual persons believe that a
higher power possesses and exerts control over the
affairs of the world. Indeed, one could predict that
spiritual involvement is related to a lower sense of
self-efcacy. Such people place all responsibility for
Caregivers Spirituality and Self-Efcacy 1945
problem-solving on God, while passively waiting to
receive solutions (Holland et al., 1999; Kinney et al.,
2003).
Kinney et al. (2003) identied three styles of
selecting solutions to problems guided by spiritual
beliefs in dementia caregivers. A collaborative
style consists of involving active personal exchange
with God. In this style, caregiver and God are
viewed as active contributors working together to
solve problems (high spirituality and high self-
efcacy). A deferring style, in which the caregiver
waits for solutions from God, seems to be part of
an externally oriented spirituality providing answers
to questions that the caregiver is not able to
resolve by him/herself. This style was associated
with lower levels of competence (high spirituality).
A self-directing style emphasizes the power of the
caregiver to direct his own life. This style appeared
to be an active coping orientation that stressed
personal agency (high self-efcacy). Spirituality
may increase external control, but at the same time a
reliance on God may actually improve ones sense of
internal control and thereby improve self-efcacy.
In our opinion, Kinney et al. (2003) skip a style
of selecting solutions to problems a lack of
expectations style in which the caregiver does
not wait for solutions from God, but does not
believe that he can organize and execute courses
of action in order to manage given situations (low
spirituality and low self-efcacy). Consistently with
this perspective, the caregiver does not expect that
the solution comes from God but he does not have
a sense of internal control either.
The dementia literature ndings on the
effect of spirituality and self-efcacy, considered
simultaneously, on the stress process are not robust.
It is possible to consider the global combined
effect of spirituality and self-efcacy. Nevertheless,
this research is interested in the four possible
proles of combination between spirituality and
self-efcacy: collaborative, deferring, self-directing,
and lack of expectations. The aim of this paper is
to analyze, drawing on the stress and coping model
framework, the combined role of spiritual meaning
and self-efcacy in dementia caregivers well-being
(depression and anxiety). We hypothesized that
caregivers with high levels of spiritual meaning
and high self-efcacy would also demonstrate fewer
levels of anxiety and depression.
Methods
Sample
Face-to-face interviews were carried out with
122 dementia caregivers. To be eligible for the
study, caregivers had to meet the following
Table 1. Sociodemographic characterist-
ics of the sample
n = 122
......................................................................................................................
Gender (%)
Female 80.3
Male 19.7
Relationship with care recipient (%)
Spouse 36.1
Son/daughter 56.6
Others (parent-in-law) 7.3
Caregivers age
Mean 59.36
SD 13.14
Range 2987
Time since caring began (months)
Mean 52.57
SD 47.11
Range 6312
Hours caring per day
Mean 11.87
SD 8.13
Range 124
Care-recipients illness (%)
Alzheimers disease 58.2
Other dementia 41.8
Care-recipients age
Mean 79.01
SD 8.80
Range 4897
Living arrangement of caregiver (%)
Living with care recipient 87.2
Not living with care recipient 12.8
SD = Standard deviation.
criteria: (1) the caregiver was providing care for
a community-dwelling dementia relative diagnosed
with dementia; (2) the caregiver identied
him/herself as the family member primarily
responsible for the patients care; (3) the caregiver
devoted at least one hour per day to caregiving tasks;
(4) the caregiver had been caring for the patient
for at least three consecutive months; and (5) the
caregiver was 18 years old or over.
Sociodemographic characteristics of the sample
(caregivers age, gender, and relationship with
care recipient; care recipients age; time since
caring began; hours spent caring per day; and
care recipients illnesses and living arrangement of
caregiver) are shown in Table 1.
The majority of caregivers were Christian
(83.6%). About one-sixth identied themselves
as non-religious persons (16.4%). The average
spiritual mean score was 12.39 (range 028).
Measures
In addition to the sociodemographic variables, and
based on the stress and coping model (Pearlin et al.,
1946 J. Lopez et al.
1990; Lawton et al., 1991), the following variables
were assessed.
STRESSORS
Frequency of behavioral problems: This variable was
assessed with the Frequency subscale from the
Revised Memory and Behavior Problems Checklist
(RMBPC; Teri et al., 1992), which consists of a 24-
item scale measuring the frequency of observable
behavioral problems (e.g. Waking you or other
family members up at night). Scores range from
0 (not at all) to 4 (extremely). In this study, the
internal consistency was 0.83 (Cronbachs ).
Functional status: Patients functional status was
measured using the Barthel Index (Mahoney and
Barthel, 1965). Caregivers respond to a ten-item
scale assessing the relatives level of independence
for activities of daily living (ADL; e.g. To what
extent is your relative able to feed her/himself?).
Total score ranges from 0 to 100. Higher scores
are indicative of higher level of independence in the
patient. Cronbachs was 0.94 in the present study.
Daily hours devoted to caregiving and time since
caregiving began were also considered as stressors.
APPRAI SAL
Caregivers appraisal of behavioral problems: This was
assessed using the Appraisal subscale from the
RMBPC (Teri et al., 1992). The 24-item scale
provided a score for the amount of distress caused
by the problem behavior (e.g. How much has it
bothered or upset you when you or other family
members have been woken up at night?). Scores
range from0 (not at all) to 4 (extremely bothered
or upset). Cronbachs was 0.89.
PERSONAL RESOURCES
Social support: The Psychosocial Support Ques-
tionnaire (Reig et al., 1991) was used. This
questionnaire has six items (e.g. When I need it,
there is always someone to encourage me and show
affection) for assessing caregivers perceptions of
the frequency of social, emotional, and instrumental
support they receive. Participants were instructed to
answer these items regarding their lives in general.
The answers range from 0 (never) to 3 (very
often). Cronbachs was 0.81.
Spiritual meaning: This was measured through the
Spanish version of the Ultimate Meaning Scale
(Farran et al., 1999; Fernndez-Capo et al., 2002).
This scale is made up of seven items (e.g. The
Lord wont give you more than you can handle,
I believe in the power of prayer; without it
I couldnt do this, I believe that the Lord
will provide), with responses ranging from 0
(strongly disagree) to 4 (strongly agree), that
were used to assess spiritual attributions associated
with the experience of caregiving. Participants were
instructed to answer these items regarding their lives
in general. Cronbachs was 0.89.
Perceived self-efcacy: This was measured using
the Spanish version of the Revised Scale for
Caregiving Self-efcacy (Steffen et al., 2002;
Marquez-Gonzlez et al., 2009). This scale is
made up of 15 items (e.g. How condent are
you that, when [. . .] asks you four times in the
rst hour after lunch when lunch is, you can
answer without raising your voice) that were
used to assess caregivers perceived self-efcacy for
obtaining respite, responding to disruptive patient
behaviors, and controlling upsetting thoughts. The
answers range from 0 (cannot do at all) to 100
(certainly can do). Cronbachs was 0.84.
OUTCOME VARI ABLES
Depression: Depressive symptomatology was as-
sessed with the Center for Epidemiological Studies
Depression Scale (CES-D; Radloff, 1977). It con-
sists of 20 items that assess howmuch the person ex-
perienced depressive symptoms during the last week
(e.g. I felt that everything I did was an effort).
Answers range from 0 (hardly ever or never) to 3
(all the time). Cronbachs was 0.90.
Anxiety: Anxiety was assessed using the Tension
subscale of the Prole of Mood States (POMS;
McNair et al., 1971), which consists of nine
items that measure caregivers levels of anxiety
(e.g. During last week, how often did you feel
nervous?), with answers ranging from 1 (not at
all) to 5 (very much). Cronbachs was 0.91.
Data analysis
Participants were coded as high or lowin spirituality
and perceived self-efcacy, respectively, based on
median splits for each variable (Md = 12 on the
spirituality and Md = 79 on the self-efcacy
scale). Four groups, corresponding to four different
proles, were formed: HEHS =High in self-efcacy
and high in spirituality; LELS =Lowin self-efcacy
and low in spirituality; HELS = High in self-
efcacy and low in spirituality; and LEHS = Low
in self-efcacy and high in spirituality. With a view
to analyzing differences between types of proles
in spirituality and self-efcacy for caregiving,
ANOVAs were carried out to permit the analysis
of differences between these groups in the following
variables: (1) stressors (hours caring per day, time
since caregiving began, level of dependency, and
frequency of behavioral problems); (2) appraisal
(caregivers appraisal of behavioral problems); (3)
Caregivers Spirituality and Self-Efcacy 1947
caregivers resources (social support); and (4)
outcome variables (depression and anxiety). In
order to test the effect size of between-group
differences in the assessed variables, partial eta-
square (p
2
) was used with the usual interpretation
(small effect = 0.010.06; medium effect = 0.06
0.14; large effect = 0.14).
Stressor-related variables (hours caring per day,
time since caregiving began, level of dependency,
and frequency of behavioral problems), appraisal
(caregivers appraisal of behavioral problems), and
caregivers resources variables (social support, and
as dummy variables the four groups corresponding
to the different spirituality and self-efcacy proles)
were introduced in a stepwise regression analysis in
order to determine howmuch weight these variables
had in the explanation of caregivers anxiety and
depression and how they were related to it.
Results
No univariate (z scores in excess of 3.29; p <
0.001) or multivariate (Mahalanobis distance at
p < 0.001) outliers were found following the
Tabachnick and Fidell (2001) criteria. Also, non-
signicant departures fromnormality (skewness and
kurtosis) were found for the assessed variables.
Caregivers were distributed in the four groups:
18.1% HEHS; 23.8% LELS; 31.1% HELS; and
27% LEHS.
ANOVA analyses revealed main group effects
only for depression (Table 2). Specically, the
LEHS caregiver group showed signicantly higher
levels of depression than the HEHS group.
The effect size was medium. There were no
group differences related to stressor variables
(months since caregiving began, hours caring per
day, frequency of behavioral problem, functional
status), appraisal (caregivers appraisal of behavioral
problems), caregivers resources variables (social
support), or anxiety. The following trends, while
not statistically signicant, were noted: the HEHS
group reported less hours of care per day and had
been caregivers for fewer years than the LEHS
group; nevertheless, the HEHS care recipient
group reported more frequency of behavioral
problems and less functional independence of the
care recipient than the LEHS group. Therefore,
caregiving is more time consuming in the LEHS
group but it implies less amount of stressors than
the HEHS. Nonetheless, there were no statistically
signicant differences among all groups.
Stepwise regression analysis showed that
three variables were signicantly associated with
depression outcome (Table 3): social support,
caregivers appraisal of behavioral problems, and
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1948 J. Lopez et al.
Table 3. Stepwise multiple regression equations to predict depression
and anxiety scores
r
2
f
.......................................................................................................................................................................................................
Dependent variable: Depression (CES-D)
Social support 0.277 0.107 12.590

Caregivers appraisal of behavioral problems 0.295 0.175 11.018

HEHS 0.203 0.215 9.394

Dependent variable: Anxiety (POMS)

Caregivers appraisal of behavioral problems 0.404 0.163 20.666

p < 0.01;

p < 0.001.
CES-D = Center for Epidemiological Studies Depression scale; HEHS = High
self-efcacy and high spirituality; POMS = Prole of Mood States.
the HEHS group. The total percentage of explained
variance of the depression outcome measure
accounted for by these three variables was 21.5%.
On the other hand, lower caregivers appraisal
of behavioral problems was correlated with lower
anxiety. This factor explained 16.3% of variance in
caregivers anxiety.
Discussion
The present study extends the data on the
relationship between self-efcacy, spirituality, and
caregiver depression, providing evidence in support
of the association between these two under-
explored aspects of caregivers personal resources
(spiritual meaning and self-efcacy), considered
simultaneously, and caregivers well-being. This
study highlights the importance of specifying the
caregivers prole dened by the combination of
the two variables: self-efcacy and spirituality (high
or low levels in each one). Taken together, these
results suggest that considering together the role of
spirituality and self-efcacy as a personal resource
is complex and warrants further study.
ANOVA analysis showed that caregivers with
a strong sense of HEHS feel less depressed than
caregivers who have a strong sense of LEHS. Acom-
bination of these two personal resources (spirituality
and self-efcacy) may better explain caregivers
depressive symptomatology than spirituality alone.
Depressive symptoms can perhaps be better
changed with the help of both personal resources
(beliefs in ones ability to successfully execute
courses of action and inuence the choices of
activity one undertakes) and a search for an ultimate
truth or higher value, than through spirituality
alone. A strong sense of spirituality in addition to
a high sense of self-efcacy may counteract feelings
of helplessness and loss of control.
The nding suggests that HEHS is associated
with a lower level of depression and that
both intrinsic or faith-related elements (spiritual
meaning) and pragmatic ones (self-efcacy) are
relevant aspects for enhancing caregivers ability
to cope with depression. Dementia caregivers are
engaged in a challenging and important role that
often consumes their health. Caregivers with a
high sense of spirituality and self-efcacy may
be protected from the negative consequences of
caregiving through the experience of a spiritual
and transcendent dimension that protects their
focus on what they are capable of accomplishing,
rather than on their past failures. Spirituality might
protect against depression because feelings of divine
protection can encourage feelings of security and
friendliness, and when a stressor is a life-threatening
disease or disability, the persons perceived support
from God may reduce reaction to the stressor
(Fetzer Institute and National Institute on Aging
Working Group, 1999). Self-efcacy beliefs can
inuence depression outcomes by determining
individuals coping responses, degree of effort, and
persistence in the face of obstacles and aversive
experiences in caregiving (Gilliam and Steffen,
2006). It appears from this research that caregivers
may benet from their spiritual meaning when it
is connected to self-efcacy. Thus, in exploring
spiritual beliefs with caregivers who are so inclined,
health professionals might include the exploration
of how those beliefs foster a greater sense of self-
efcacy, which may include a sense of being loved
by God, and also a belief that they possess the
coping resources necessary to deal with certain
situations (Kinney et al., 2003). It may also be
possible that spiritual coping strategies such as
praying or meditating, or spiritual attitudes such as
self-compassion or self-kindness, may help people
maintain or increase their self-efcacy and feelings
of internal control, as it has been suggested in
previous studies (Ai et al., 2005; Iskender, 2009).
Depressed individuals who have low levels of
caregiving self-efcacy may then experience their
spirituality in a very passive way (It is all up to
Caregivers Spirituality and Self-Efcacy 1949
God, God controls all the events and outcomes of
my life). Nevertheless, both resources (spirituality
and self-efcacy) are compatible: one can act
jointly with a Powerful Other God as a
partner to cope with stressors, and thus maintain
a sense of control and efcacy over life events.
Although most religions, if not all, afrm that the
fundamental features of life are beyond our control
and a Powerful Other controls the events of our
lives, some studies have documented that many
people (specially older adults) report working with
a Higher Being as partners in the effort to cope
with major problems in their own life (Schieman,
2003). Empirical evidence has also been found
suggesting that greater internal control is positively
related to spiritual coping strategies such as private
prayer (Ai et al., 2005). These ndings provided
evidence that a combination of HEHS may be
wellbeing-enhancing. Spiritual caregivers are not
passive in nature. The study supports the view that
our relationship to the sacred or transcendent may
imply an active exchange or interaction with a higher
power or something greater than the self.
When all variables examined in this research
are taken into account in an additive way to
explain caregiver depression (regression analysis),
both spiritual meaning and self-efcacy have been
found to play an important role in caregivers
well-being. Again, caregivers who have a strong
sense of spirituality and who report HEHS showed
fewer depressive symptoms, suggesting that these
caregivers may cope better with stressors than
caregivers who have neither a strong sense of
spirituality or self-efcacy. In sum, this study
supports the hypothesis that self-efcacy and
spirituality may be related to depression outcome
because, together, they provide better coping
strategies in caregiving situations.
Surprisingly, stronger objective stressors of
caregiving (e.g. longer period since caregiving
began, caring longer hours per day, poorer
functional status, or higher frequency of observable
behavioral problems) were not associated with
caregiver depression and anxiety. A possible
explanation for this is that the actual demands of
caregiving may not be directly related to caregivers
well-being. Instead, other personal factors (such
as caregivers appraisal of behavioral problems,
social support, and higher sense of self-efcacy
and spirituality) may be more strongly related to
caregiving outcomes, providing support for the
stress and coping model (Lawton et al., 1991; Quinn
et al., 2010).
Social support is also related to depression,
suggesting that support from the community
might function as a buffering factor, providing
a way to channel or relieve depressive feelings.
Caregivers of relatives with dementia often
live an isolated existence, breaking up their
relation with family members and former friends.
Stressors can proliferate when the caregiver has
difculty meeting ongoing demands without any
functional or emotional support. Furthermore, the
perception that one is accepted and valued in
ones interpersonal environment bolsters esteem,
condence, and efcacy, which guard against
depression. Feelings of hopelessness, sorrow, or
being alone are emotions commonly associated with
depression; individuals with a healthy social support
network can more easily handle such feelings. Close
relationships increase happiness in individuals,
because they know that they are not alone in the
world. Condence boosts fromothers help decrease
sorrow and states of sadness in individuals (Pearlin
et al., 1990; Schulz and Williamson, 1991).
Caregivers appraisal of behavioral problems is
the only variable related to both depression and
anxiety. The stress and coping theoretical model
adapted to caregiving afrms the central role played
by caregivers appraisals in the understanding and
explanation of psychological outcomes. Although
behaviors identied as problematic in dementia
have negative effects on caregiver health, they
may not be experienced in the same way by
different caregivers. Caregivers might appraise a
potentially problematic situation as upsetting
that is, as a situation that could bring distress
to oneself or to a relationship; but they might
also appraise a potentially problematic situation as
challenging, rather than distressing: as a situation
to be overcome. The amount of distress caused
by problem behaviors caregivers appraisal of
behavioral problems in persons with dementia
may inuence their interactions with that person
in ways that reduce the incidence of behavioral
problems (i.e. by helping caregivers modulate
thoughts and feelings that inuence their modes
of interaction). Therefore, it is the perception of
a caregiving situation as stressful, not the mere
presence of a potentially stressful situation, that
determines whether the event is interpreted as
manageable. In other words, how caregivers think
about the situation inuences the way they act and
emotionally respond, suggesting that appraisal plays
a mediating role between a potential stressor and
coping actions (Lawton et al., 1991).
The results of this study are consistent with
previous ndings regarding signicant associations
between caregivers well-being (depression and
anxiety) and their appraisals (Crespo et al., 2005).
Furthermore, other studies have found moderator
or mediator effects of social support (Pearlin et al.,
1990; Schulz and Williamson, 1991), self-efcacy
(Gilliam and Steffen, 2006; Romero-Moreno
1950 J. Lopez et al.
et al., 2011), and spirituality (Thompson et al.,
2002; Marquez-Gonzlez et al., 2012) on caregiver
depression. Nevertheless, Thompson et al. (2002)
found that spirituality was associated with
less depression in Latina caregivers but not
in Caucasians, suggesting the importance of
considering the inuence of cultural factors on
analyzing the association between this construct
and depression. In fact, according to a review by
Hebert et al. (2006), the effects of spirituality on
depression are unclear. However, the ndings of the
present study, in which the combination of HEHS
was signicantly related to caregivers depression,
suggest that what is important in relation to
depression outcomes is precisely their combined
effect.
Contrary to our hypotheses, caregivers with
high spiritual meaning and high self-efcacy did
not report less anxiety. There is considerable
literature on burden and depression in caregivers
of people with dementia. Anxiety has been a
relatively neglected outcome measure. Anxiety
among dementia caregivers has received far less
attention in the literature than depression, and may
require specic research. Cooper et al. (2007) found
that there is a considerable comorbidity between
anxiety and depression, and most caregivers
with depressive symptomatology also reported
symptoms of anxiety, although the converse is not
clear. Factors associated with depression may not
bear the same relationship to anxiety (Cooper et al.,
2007) and control or efcacy variables would be
more highly related to caregivers depression than
to anxiety (Pagel et al., 1985; Cooper et al., 2007).
Nevertheless, a systematic review found a lack of
evidence regarding determinants of anxiety caseness
or levels in caregivers of people with dementia
(Cooper et al., 2007).
This study has interesting implications for
the design of interventions with caregivers. High
or negative appraisal of behavioral problems
is theoretically and empirically associated with
perceptions of low self-efcacy in coping with
such behaviors (Haley et al., 1996), which, over
time, may contribute along with other factors (e.g.
absence of spiritual meaning, absence of social
support) to the development of helplessness and
depression. Increasing self-efcacy in caregivers by
training themto cope better with problembehaviors
(so that they appraise them as less stressful),
reinforcing the social support network, and nding
spiritual meaning within the caregiving experience
may help alleviate their depression level.
There were several limitations to this study that
make it necessary to interpret the study ndings
with caution. It should be acknowledged that the
convenience-based nature of the sample (made up
of voluntary caregivers recruited through health
and social centers) limits the generalization of
these ndings. Nevertheless, the sample looked
similar to other national samples of dementia
caregivers. Furthermore, the cross-sectional design
of the study precludes any kind of causal inferences
about the directionality of the inuences of the
relationships between spirituality, self-efcacy, and
caregivers well-being. It would be interesting
to analyze the directions of the relationships
between these variables with a view to explaining
caregiver depression and identifying the potential
action mechanisms of interventions. In this sense,
there is a need for longitudinal and experimental
studies. Including qualitative inquiry may also help
to further clarify the relationship among these
variables. Further, self-report bias may have been
introduced by participants in responding to sensitive
personal information such as spiritual meaning. A
limitation of the Ultimate Meaning Scale is that
it was grounded in qualitative comments made
by caregivers who reected a primarily Judeo-
Christian perspective; terms such as Lord and
God may not be appropriate for all caregivers
(Farran et al., 1999). Moreover, the present study
involves primarily Christian caregivers. It would
be useful to compare Christian beliefs with other
belief systems that are somewhat different in focus
(e.g. Buddhism). In spite of these limitations, this
study provides some useful insights about the role of
spirituality and self-efcacy in caregiver depression,
and particularly about the relevance of considering
these two variables jointly in caregiving research.
The current study is an important rst step in
understanding the combined effect of spirituality
and self-efcacy and its relationship to the
emotional functioning of dementia caregivers.
However, there is still much to be studied in
the area of spirituality and self-efcacy in families
of relatives with dementia. For example, future
research might examine whether men and women,
or parents and siblings, share similar spiritual and
self-efcacy beliefs, and how this congruence or
lack thereof inuences family functioning. Also,
different spiritual orientations could be studied,
to determine how they inuence self-efcacy.
The impact of self-efcacy and spirituality in
dementia caregiver emotional well-being may be
generalized to other situations during which other
chronic role strains arise. Developing a more
comprehensive theory of stress and coping in
caregiving contexts (including relationships with
others in the family or on the job) may be
an additional fruitful line of research. Future
research might also examine more systematically
how emotional states, such as the two assessed
in the present study, depression and anxiety,
Caregivers Spirituality and Self-Efcacy 1951
engender or are engendered by specic patterns
of spiritual and self-efcacy beliefs. It would
also be very interesting to analyze the moderator
role of self-efcacy in the relationship between
spirituality and depression. Once these relationships
are better understood, intervention programs could
be specically tailored to better support dementia
caregivers including, if appropriate, spiritual and
self-efcacy, in combination, elements.
Conict of interest
None.
Description of authors roles
Javier Lpez worked on the data analysis and the
writing of the paper; Rosa Romero-Moreno worked
on the study implementation and helped write the
paper; and Mara Mrquez-Gonzlez and Andrs
Losada designed and carried out the study, and
helped write the paper.
Acknowledgments
This work was funded by the Spanish Ministry of
Education (grant number SEJ2006-02489/PSIC)
and the Spanish Ministry of Science and Innovation
(PSI 2009-081327PSIC).
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