Gender Differences in Caregiving of Older Adults: A Systematic Review of the Literature

Abstract Caregivers of older adults with chronic illness provide essential care that benefits individuals and society. Many factors influence health outcomes related to the caregiving role. The purpose of this review is to explore how caregiver health outcomes may vary by gender. Data sources include CINAHL, Google Scholar, Google and PsychINFO. Eligible studies focused on gender-based differences in psychological and emotional outcomes of primary informal or familial caregivers (ie, spouses, children, grandchildren, nieces, nephews, neighbors, and friends) of an older adult with chronic illness. The Caregiver Identity Theory (CIT) guided this study. Twelve studies were eligible for this review. Consistent with the CIT, negative outcomes are associated with changing role identity throughout the care recipient’s disease progression, and these outcomes differ between genders. Women tended to experience higher overall burden, stress, anxiety, shame and role strain; however, some studies found that men may be affected more during the initial transition into the caregiver role. Methodological limitations of primary research in this area included the use of cross-sectional design, poor generalization to US populations since most studies were conducted outside of the US, and disproportionately fewer male participants across studies. Overall, gender differences in health outcomes among caregivers exist, and other variables relating to gender, such as kinship and age, may also be important factors. Findings suggest health professionals should create individualized engagement, communication, and training strategies with considerations for gender differences in design. Future studies including more male caregivers and more diverse participants is warranted.

for training affects care intensity during Medicare home health. We examine 1,217 (weighted n=5,870,905) feefor-service Medicare beneficiaries who participated in the National Health and Aging Trends Study (NHATS) between 2011-2015 and received Medicare-funded home health care within one year of survey. Using propensity score adjusted, multivariable logistic and negative binomial regression, we model the relationship between family caregiver need for activity-specific training and the number/type of visits received during Medicare home health. We found that older adults whose family caregiver required training on selfcare tasks had greater odds of receiving any therapy visits (aOR: 1.70; 95% CI: 1.01, 2.86), aide visits (aOR: 2.12; 95% CI: 1.11, 4.05), or training visits (aOR: 1.49; 95% CI:1.01, 2.21). Older adults whose family caregiver required training on medication management had greater odds of receiving any nursing visits (aOR: 3.03; 95% CI: 1.06, 8.68) and incurred 1.06 (95% CI: 0.11, 2.01) additional nursing visits. Findings support the importance of connecting family caregivers to training resources. Additionally, findings suggest that home health providers should consider prioritizing training interventions which focus on caregiving activities most closely tied to resource utilization: self-care and medication management.

EXPLORING FORMAL CAREGIVER BURDEN WITHIN NURSING HOMES: AN INTEGRATIVE REVIEW
Rachel Kunkle, Claudia Chaperon, and Ann Berger,

University of Nebraska Medical Center, Omaha, Nebraska, United States
The purpose of this integrative review was to explore formal caregiver burden in nursing homes among direct care nursing staff. The aim was to gain an understanding of the state of the science of formal caregiver burden, it's measurement, and its effect on resident care. Based on PRISMA guidelines, a systematic search of CINAHL, PubMed, PsycINFO and Embase databases was conducted using terms from the definition of formal caregiver burden, three conceptual models, and the thesaurus feature of each database for years ranging from 1979-2019. Inclusion criteria consisted of peer-reviewed articles in English that focused on the key terms of formal caregiver burden among direct care nursing staff only in nursing home facilities. Out of 925 citations, 20 articles met criteria; 15 quantitative and 5 qualitative studies. Sample sizes ranged from 11-1283, number of facilities from 1-55, and bed size from 31-203. Psychometric measures used in the studies reported lower validity and reliability, a variety of conceptual definitions interchangeably, and primarily studied nursing assistants (n=19). Five studies included nurses as formal caregivers, and one studied only nurses. Variables used to identify burden were racial disparities (n=2), trauma experience (n=1), depression (n=4), distress (n=3), mental health (n=1), stress (n=2), health complaints (n=1), and alienation (n=1). Two studies evaluated the effect on resident care, one finding significant results of in-service training contributing to positive attitudes of formal caregivers toward confused residents. Current limitations in the understanding of formal caregiver burden limit the advancement of research.

FAMILY CAREGIVERS' SELF-EFFICACY AND ITS RELATIONS TO WELL-BEING: GENDER AND AGE DIFFERENCES
Yu-Ping Chang, Young Seo, and Tania Von Visger,

University at Buffalo, Buffalo, New York, United States
Family caregivers of older adults perceive their roles as beneficial as well as burdensome. They also report physical and psychological symptoms affecting their well-being. Research indicates that caregiver self-efficacy leads to positive outcomes such as decreased caregiver burden and stress. However, it is unclear how self-efficacy is related to their well-being, and how this association might differ by age and gender. We aim to explore the relationships between family caregiver self-efficacy and well-being, and determine if age or gender moderates these relationships. We analyzed responses of 2,652 family caregivers (68% female and 32% male; mean age= 61.2) from the National Study of Caregiving (NSOC) III (2017) cross-sectional survey. We used three composite variables measuring self-efficacy: feeling confident, adjusting changes, and recovering quickly. We used five composite variables measuring well-being: pain, sleep problems, positive and negative affects, and depression/anxiety. We conducted a design-based weighted logistic regression analysis to examine the relationships among variables of interest. Results indicated that low self-efficacy was associated with increased pain, sleep problems, positive and negative affects, controlling for caregivers' age, sex, and race/ethnicity. Examination of interactions indicated that the relationship between selfefficacy and pain and the relationship between self-efficacy and depression/anxiety were stronger in female caregivers, whereas age did not serve as a moderator in the relationship between self-efficacy and well-being. Our findings provide insight that can guide intervention development to improve family caregiver self-efficacy and well-being. Furthermore, future research may involve interventions with the consideration of family caregivers' gender.

GENDER DIFFERENCES IN CAREGIVING OF OLDER ADULTS: A SYSTEMATIC REVIEW OF THE LITERATURE
Michael Bueno, 1 and Jo-Ana Chase, 2 1. University of Columbia,Missouri,United States,2. University of Missouri,Columbia,Columbia,Missouri,United States Caregivers of older adults with chronic illness provide essential care that benefits individuals and society. Many factors influence health outcomes related to the caregiving role. The purpose of this review is to explore how caregiver health outcomes may vary by gender. Data sources include CINAHL, Google Scholar, Google and PsychINFO. Eligible studies focused on gender-based differences in psychological and emotional outcomes of primary informal or familial caregivers (ie, spouses, children, grandchildren, nieces, nephews, neighbors, and friends) of an older adult with chronic illness. The Caregiver Identity Theory (CIT) guided this study. Twelve studies were eligible for this review. Consistent with the CIT, negative outcomes are associated with changing role identity throughout the care recipient's disease progression, and these outcomes differ between genders. Women tended to experience higher overall burden, stress, anxiety, shame and role strain; however, some studies found that men may be affected more during the initial transition into the caregiver role. Methodological limitations of primary research in this area included the use of cross-sectional design, poor generalization to US populations since most studies were conducted outside of the US, and disproportionately fewer male participants across studies. Overall, gender differences in health outcomes among caregivers exist, and other variables relating to gender, such as kinship and age, may also be important factors. Findings suggest health professionals should create individualized engagement, communication, and training strategies with considerations for gender differences in design. Future studies including more male caregivers and more diverse participants is warranted.

HOW HEALTHCARE INTERACTIONS CONTRIBUTE TO BURDEN FOR CARE PARTNERS OF OLDER ADULTS Anne Mueller, and Beth Fields, University of Wisconsin-Madison, Madison, Wisconsin, United States
As the aging population in the U.S. continues to grow, care partners (i.e. family and friends) are assuming increasingly intense and complex caregiving responsibilities. Care partner burden is associated with poorer health outcomes for older adults and more frequent rehospitalizations. This secondary data analysis aims to examine the relationship between different types of health care interactions and care partner burden. A total of 2,588 care partners of Medicare beneficiaries age 65 and older were included. Secondary analyses were conducted using cross-sectional data from the 2017 National Study of Caregiving. Logistic regression analyses were used to determine the relationship between health care interactions and care partner burden while controlling for demographic characteristics. The average care partner was 62 years old (range 18-98), female (68.1%), and white (62.8%). More than half of the care partners (51.3%) reported financial, emotional, and/or physical difficulty as a result of helping the older adult. Logistic regression analyses show that care partners who made medical appointments (AOR=2.04), accessed online medical information (AOR=1.55), and coordinated care between medical providers (AOR=2.15) were significantly more likely to report burden. Care partners are important allies in supporting the health of older adults but may experience excess burden due to health care interactions. Practitioners and researchers may need to evaluate ways to improve the ease, efficiency, and accessibility of different types of health care interactions for care partners of older adults. A better understanding of factors that contribute to care partner burden may inform tailored interventions and future health and aging policies.

I DON'T WANT TO SEE IT END: A FAITH COMMUNITY NURSE INTERVENTION FOR OLDER ADULTS AND CAREGIVERS
Loralee Sessanna, 1 Sherry Pomeroy, 2 and Yvonne Askew, 3 1. University at Buffalo,Buffalo,New York,United States,2. Orchard Park Presbyterian Church,Buffalo,New York,United States,3. Catholic Health Buffalo,New York,Buffalo,New York,United States The Faith Community Nurse (FCN) provides populationbased and other nonclinical services in community settings that are not commonly available to the older adult population. The purpose of the FCN Connections (FCNC) study was to test the impact of the FCNC intervention on the health and well-being of clients (C) age 60 and older with chronic diseases and caregiver (CG) dyads (CCGD) by embedding a FCN in a primary care practice (PCP). A mixed method design was used with two cohorts over 18 months (N = 13 CCGD). Experienced FCNs led the components of the intervention in the CCGD home, including client health assessment, education and support while identifying their caregiver's perceived needs, providing education and spiritual/emotional support, linking to resources, and connecting the CCGD with the PCP. The CCGD completed measurements at baseline, 6 and 12 weeks. CG knowledge, preparedness, self-efficacy with caregiving activities, and spirituality were measured with statistically significant CG improvement for handling emergencies, making caregiving activities pleasant, and taking care of emotional needs of the client. Spirituality, self-esteem, function, depression, and healthy living domains were measured for clients. At 12 weeks, semistructured interviews with the CCGD were conducted and transcribed. An experiential/phenomenological framework and Reflexive Thematic Analysis were used to analyze data which generated one overarching theme, 'I don't want to see it [study]  Long-term caregiving can negatively impact caregivers' physical and psychological well-being and are associated with increased morbidity and mortality among caregivers. A more positive caregiving experience is associated with increased coping skills and resilience. Caregiver-targeted interventions designed to promote caregivers' resilience may lead to improved caregivers' well-being, the quality of caregiving, and care recipients' outcome. However, a comprehensive evaluation of effective interventions that enhance resilience among caregivers is lacking. Therefore, the purpose of this study is to critically evaluate existing training programs to inform clinical practice and future program design. A literature review was conducted to search available articles published before June 2018 in databases including PubMed, CINAHL, PsycINFO, and Scopus. Search strategies used index and keyword methods. The inclusion criteria were peer-reviewed, research studies published in English that evaluated an intervention primarily aimed to improve family caregivers of adult patients' resilience or had a primary outcome of resilience. Seven studies fit the criteria identified. Six studies used psychosocial therapy and one used pharmacological therapy to promote caregivers' resilience.