Koerner, S.S., Shirai, Y., & Kenyon, D.B. (2010). Sociocontextual circumstances in daily stress reactivity among caregivers for elder relatives. Journal of Gerontology: Psychological Sciences,
65B(5), 561–572, doi:10.1093/geronb/gbq045. Advance Access published on June 30, 2010.

Sociocontextual Circumstances in Daily Stress Reactivity
Among Caregivers for Elder Relatives
Susan Silverberg Koerner,1 Yumi Shirai,1 and DenYelle Baete Kenyon2
1Division

2Health

of Family Studies and Human Development, University of Arizona, Tucson.
Disparities Research Center, Sanford Research/University of South Dakota, Sioux Falls.

Using a daily diary design, we examined whether emotional and physical reactivity in the face of care-related stressors
is more intense for caregivers (CGs) living with lower levels of available socioemotional support and higher numbers
of extrinsic stressors. Sixty-three CGs reported their experiences based on the past 24 hr (i.e., number of caregiving
tasks, care recipient problem behaviors, family disagreements regarding care, depressive symptoms, feelings of burden, physical symptoms) on eight consecutive survey days; they also reported on extrinsic stressors and available
socioemotional support. Multilevel analyses indicated significant moderator effects: within-person patterns of reactivity to care-related stressors were especially strong for CGs with lower levels of available socioemotional support and
higher numbers of extrinsic stressors. For example, managing additional care recipient problem behaviors on a given
day was more strongly associated with increased depressive and physical health symptoms as well as feelings of burden
for CGs with relatively high numbers of extrinsic stressors. Implications for intervention are discussed.
Key Words:  Caregivers—Daily diary—Extrinsic stressors—Multilevel analysis—Socioemotional support—Stress
reactivity.

A

large body of research suggests that when adults serve
as caregivers (CGs) for an elder family member (e.g.,
parent, spouse, in-law), they place their own emotional and
physical well being at risk (Gaugler, Davey, Pearlin, &
Zarit, 2000; Pinquart & Sörensen, 2003; Turner, Killian, &
Cain, 2004). For example, studies show that compared with
non-CGs, CGs exhibit elevated psychological distress (e.g.,
depression, anxiety) and physical health problems (e.g., impaired immune response, health risk behaviors). Although
the underlying assumption is that CGs’ poorer well being
emerges from the way in which they respond and react to
the day-to-day stressors and strains of being responsible for
their relative (Pearlin, Mullan, Semple, & Skaff, 1990), very
little research has approached the question of CG well being
from a daily, stress reactivity perspective. Most research on
CG well being takes a snapshot approach to data collection;
that is, data are collected on only one occasion or are collected longitudinally, but with long intervals between waves
(e.g., 1 year). As such, most studies on CG well being, even
longitudinal studies, miss the “day-to-day fluctuations” in
care-related stressors, and they cannot capture brief episodes of distress or mental health between assessments
(Alspaugh, Stephens, Townsend, Zarit, & Greene, 1999)
that may emerge in response to the ebb and flow of carerelated stressors.
In contrast, the current study follows in the tradition of
Almeida and other stress scholars who place critical importance on the study of stress reactivity—individuals’ emotional and physical responses to the occurrence of short-term
(momentary or daily) stressors (e.g., Almeida, 2005;
Stawski, Sliwinski, Almeida, & Smyth, 2008; Tennen,
Affleck, & Armeli, 2005)—and of factors that could buffer

or exacerbate reactivity to those stressors. More and more
researchers are conducting daily (microanalytic) studies because this type of within-person methodology provides
insight into how intra-individual variability in one variable
(stressor) is related to intra-individual variability in another
(well being; e.g., Skaff et al., 2009). Moreover, empirical
research in the general fields of emotional and physical
health reveals that how intensely individuals react to shortterm stressors (in the laboratory and daily life) is a good
predictor of their short- and long-term emotional and physical well being (Krantz & Manuck, 1984; Light, Dolan,
Davis, & Sherwood, 1992; Uchino, Cacioppo, & KiecoltGlaser, 1996). Thus, we argue that it is important to understand daily, stress reactivity among CGs as well as factors that
may exacerbate or protect against CGs’ intense reactivity.
Briefly stated, the current study takes a daily, stress reactivity perspective on CG well being and examines not only
whether CGs experience changes in their emotional and
physical health in response to the daily emergence and subsidence of care-related stressors (i.e., number of caregiving
tasks, occurrence of care recipient problem behaviors, family disagreements regarding care), but also and most especially whether sociocontextual factors that differ across
CGs (i.e., social support, extrinsic stressors) buffer or exacerbate intensity of CG reactivity.

Conceptual Model and Hypotheses
A daily methodological approach and reactivity perspective on the within-person link between care-related stressors
and CG well being represents a rather novel addition to the
field. Thus, not surprisingly, no theories or conceptual
frameworks are available to serve as a direct guide to the

© The Author 2010. Published by Oxford University Press on behalf of The Gerontological Society of America.
All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.
Received April 12, 2009; Accepted May 15, 2010
Decision Editor: Rosemary Blieszner, PhD

561

562

KOERNER ET AL.

current research. In creating a conceptual model, we suggest that selected elements of existing stress theories can be
extended to a daily, reactivity perspective. For example,
Pearlin’s (1994) CG stress theory introduces the notion of
“primary” and “secondary” stressors. “Primary stressors”
stem directly from the needs of the care recipient and the
nature and extent of caregiving demanded by those needs;
key and frequently studied examples include the number of
tasks involved in caregiving and the frequency of care recipient problem behaviors (e.g., anger or aggression). “Secondary stressors” are indirectly linked to the role as CG and
come in the form of intrapsychic strains (e.g., feelings of
role captivity) and role strains (e.g., family disagreements
regarding care, job–caregiving conflict).
We propose that some of the primary and secondary stressors identified in the model of Pearlin (1994)—“number of
caregiving tasks, care recipient problem behaviors, and
family disagreements regarding care”—are relevant at a
daily (micro) level and therefore fall into our category of
daily “care-related stressors.” We make this proposal for
several reasons. First, there is evidence that each of those
stressors varies from day to day for most CGs (Koerner &
Kenyon, 2007), and, thus, those stressors are often uncertain in their occurrence. According to several stress theorists, uncertainty of stressors heightens their stressful impact
on the days that they do occur (Lazarus & Folkman, 1984;
Wheaton, 1999). Second, the occurrence of these three carerelated stressors, like other “daily hassles”—stressors that
may occur within the flow of daily life—could have a considerable impact on psychological and physical health on a
daily basis. In fact, many within-person reactivity studies
have found that on days when adults experience a greater
number of daily hassles, they report higher levels of psychological distress (e.g., Serido, Almeida, & Wethington,
2004). Thus, our “foundational hypothesis (the reactivity
hypothesis)” is that CGs will report more signs of negative
well being (i.e., depressive symptoms, feelings of burden,
physical health symptoms) on days when they report a
higher than usual number of care-related stressors (relative
to their own mean). The daily within-person link between
care-related stressors and “CG feelings of burden” will be
of special interest, in light of the fact that CG feelings of
burden (even more than CG depressive symptoms and physical health symptoms) have been consistently linked both to
CGs’ decision to institutionalize their care recipient (e.g.,
Gaugler, Yu, Krichbaum, & Wyman, 2009; Spitznagel,
Tremont, & Davis, 2006; Yaffe et al., 2002) and to CG abusive behavior (e.g., Cooper et al., 2010; Coyne, Reichman, &
Berbig, 1993).
Another important facet of Pearlin’s model and other
stress theories (Lazarus & Folkman, 1984) that we emphasize is the idea that “people exposed to seemingly similar
stressors are affected by them in dissimilar ways” (Pearlin et
al., 1990, p. 589). When applied within a daily, stress reactivity perspective, this idea suggests that intensity of stress

reactivity (be that emotional or physical) would be expected
to differ across individuals as a function of person-level
characteristics or circumstances. In our earlier work, we
found that person-level characteristics (e.g., sex, personality
traits) affect the intensity of CG stress reactivity (Koerner &
Kenyon, 2007). In our current study, we suggest that the
sociocontextual circumstances in which daily care-related
stressors occur may also help to determine (i.e., moderate)
the intensity of CGs’ emotional and physical health response
to the ebb and flow of those stressors. Specifically, and as
suggested in Pearlin’s model, differential reactivity may be
due in part to the fact that “resources [e.g., available social
support] have the capacity to influence the direction of the
stress process and to blunt its impact on individuals” (Pearlin,
1994, pp. 12–13) and that the presence of noncare-related
(extrinsic) stressors may exacerbate the impact of daily carerelated stressors on CGs (Aneshensel, Pearlin, Mullan, Zarit,
& Whitlach, 1995). Thus, in the current study, we determine
whether the within-person patterns of emotional and physical stress reactivity are stronger for CGs who provide care
under certain sociocontextual circumstances—perceptions
of low levels of available socioemotional support and relatively high numbers of extrinsic stressors. These two potential moderating factors are discussed subsequently.
Perceived Availability of Socioemotional Support as a
Moderator
Researchers who have conducted between-person–
oriented elder caregiving studies have identified social networks as an important source of support for CGs (e.g.,
Beach, Schulz, Yee, & Jackson, 2000; Roth, Mittelman,
Clay, Madan, & Haley, 2005). They have found that perceived socioemotional support from family members is associated with lower levels of feelings of burden and
depression (e.g., Harwood et al., 2000; Steffen, McKibbin,
Zeiss, Gallagher-Thompson, & Bandura, 2002) and a greater
sense of caregiving mastery (Shirai, Koerner, & Kenyon,
2009; Skaff, Pearlin, & Mullan, 1996). A careful read of the
social support literature reveals, however, that the perception of available (or anticipated) social support—feeling
that one has people to count on if the need arises—is a consistently better predictor of well being than enacted social
support, in both survey and acute stressor-reactivity studies
(Uchino & Garvey, 1997; Wethington & Kessler, 1986; see
also the stress buffering hypothesis in Cohen & Wills, 1985).
Moreover, several scholars have noted that the perception of
available social support can remain fairly constant across 3
years (e.g., Sarason, Sarason, & Shearin, 1986); therefore,
we can conceptualize it as a rather stable, between-person
(individual difference) construct.
Although there are no daily diary studies that directly address whether perceptions of available social support do
serve as a buffer to CG stress reactivity, laboratory reactivity
studies on non-CG samples suggest that the mere presence

SOCIOCONTEXTUAL CAREGIVERS

of a social support figure can buffer against heightened cardiovascular reactivity to laboratory-induced stressors (see
Uchino et al., 1996). Thus, our “second hypothesis” is that
CGs who perceive higher levels of available socioemotional
support will experience less intense emotional and physical
reactivity than their counterparts in response to a greater
than usual numbers of care-related stressors on a given day.
Extrinsic Stressors as a Moderator
Somewhat surprisingly, given the popularity of the ecological perspective in the study of other aspects of development and well being, most research on the well being of
family CGs considers only those stressors that are directly
related or indirectly related to caregiving itself (e.g., care
recipient problem behaviors, caregiving–work conflicts).
Aneshensel and colleagues (1995) point out, however, that
CGs’ lives must be viewed as embedded within a larger
context; specifically, that CGs experience various stressors
outside of their role as CGs. These other problematic life
events and frustrating or demanding occurrences, called extrinsic stressors (Aneshensel et al.), may come, for example,
from having to manage a household or respond to unexpected work demands. Although researchers typically overlook extrinsic stressors, they may be quite relevant to
caregiving stress reactivity. At the very least, they increase
the total number and degree of demands on the CG. Perhaps
even more importantly, extrinsic stressors “contribute to the
overall context within which CG stress unfolds. Thus extrinsic stressors may magnify the impact of care-related
stressors .  .  . or intensify the proliferation of stress”
(Aneshensel et al., p. 99). Thus, in the current study, we considered extrinsic stressors as a potential moderator of stress
reactivity vis-à-vis care-related stressors. Our “third hypothesis” is that, compared with their counterparts who experience
few extrinsic stressors, those CGs who face more extrinsic
stressors will experience more intense emotional and physical reactivity than their counterparts in response to a greater
than usual numbers of care-related stressors on a given day.
The potential buffering effect of available socioemotional
support and the potential exacerbating effect of extrinsic
stressors may be especially apparent in the daily withinperson link between care recipient problem behaviors and
negative CG well being. More than the other two daily stressors (i.e., caregiving tasks, family disagreements regarding
care), care recipient problem behaviors (e.g., wandering,
aggressiveness, bathroom accidents) can be especially confusing and taxing on the CG, who is unlikely to be trained
in how to respond to these sometimes unsettling and frustrating behaviors (Aneshensel et al., 1995; Brodaty, Roberts, &
Peters, 1994). The confusing and frustrating nature of care
recipient problem behaviors may heighten the need for the
confidence and calmness that available socioemotional support could afford the CG, and the uncertain nature of care
recipient problem behaviors may be especially distressing

563

in the context of additional demands associated with extrinsic stressors.

Methods

Participants and Procedures
We recruited participants via flyers at a variety of sites
in southern Arizona (e.g., family practice clinics, geriatric
clinics, medical supply and equipment store, CG support
group). When potential participants called the number on
the flyer, trained research staff members provided information about the project and asked a set of eligibility questions. To be eligible, the caller had to (a) be the primary CG
for a dependent family member (e.g., spouse, parent, inlaw) who was at least 60 years of age and (b) provide at
least 10 hr/week of assistance (e.g., dressing, showering,
ordering medications, helping with mobility). In addition, (c)
the care recipient had to be community dwelling—living in
his or her own home or in the home of the CG and could not
be receiving extensive in-home professional care. These eligibility criteria are similar to those used in other caregiving
studies (e.g., Cicirelli, 2003; Li, Seltzer, & Greenberg, 1999).
For callers deemed eligible to participate, the research
staff member asked a brief set of questions regarding the
care recipient’s impairments and then mailed an introductory letter to the caller. Within 1 week, the research staff
member mailed a packet that contained an initial questionnaire (with an envelope labeled “initial survey”), eight daily
questionnaires (DQs, with eight envelopes labeled “Day 1”
to “Day 8”), and a postage-paid, preaddressed larger envelope for return of all the completed surveys. A consent form
with a separate postage-paid, preaddressed envelope was
also included in the packet. CGs reported their daily experiences at the end of each day on eight consecutive survey
days in the DQs (e.g., caregiving tasks, care recipient problem behaviors, depressive symptoms, physical symptoms)
and reported on socioemotional support availability and demographics in the separate “initial” questionnaire. For their
participation, CGs received $40 and had a chance to win a
$100 gift card to a national retail chain.
Introductory letters and questionnaire packets were sent
to 78 CGs; 63 (81%) returned completed questionnaires.
(When we compared the demographic and contextual information [obtained during the phone screening] via t tests
from the 15 CGs who did not return completed surveys to
that from the 63 participants, we found that the two groups
were similar on most counts [e.g., age of CGs, length of
time providing care, hours of care provided each week]. The
only significant difference was in age of care recipient; the
care recipients of the 15 nonparticipants were somewhat
younger than those of the 63 participants [M = 75.07 years
vs. M = 80.92 years].) Of the 63 participants, 62 completed
all eight DQs and 1 completed only two of the DQs, resulting in a total of N = 498 daily reports. Table 1 summarizes

564

KOERNER ET AL.

Table 1.  Demographic Data for the Caregivers (CGs) and Care
Recipients (N = 63)
Variable
CGs
  Sex
   Female
   Male
  Ethnicity
   Non-Hispanic white
   Hispanic
   Other
  Relationship to care recipient
   Spouse or partner
   Child
   Child-in-law
   Grandchild
  Education
   4-year college degree or more
   Some college or
    vocation/technical school
   Completed high school only
   Some high school or less
  Annual household income
   Less than $60,000
  Age in years
Care recipients
  Sex
   Female
   Male
  Age in years

N

%

46
17

73.0
27.0

51
9
3

81.0
14.3
4.8

19
39
4
1

30.2
61.9
6.3
1.6

21
35

33
56

3
4

5
6

49

78

M

SD

Physical health symptoms. Each day, participants were
asked to think back to the past 24 hr and check all of the
physical symptoms they experienced from a list of 15 (e.g.,
headache, dizziness, and tightness in chest) plus one “other”
category (Larsen & Kasimatis, 1991). Scores reflected the
sum of the checked items and therefore could range from 0
through 16 on each day.

56.7

41
22

4-point scale with choices ranging from 1 (not at all)
through 4 (very much). Responses were averaged across the
12 items to arrive at a “feelings of caregiving burden” score
for each day.

13.2

81

Care-related stressors. —Caregiving tasks. To determine
the number of caregiving tasks engaged in each day, participants were given a list of 22 items that included activities of daily living (ADLs, e.g., bathing or showering,
in-home mobility), instrumental activities of daily living
(IADLs, e.g., meal preparation, transportation, ordering
medications), and two “other” items. Participants indicated
whether they had assisted their care recipient with each task
in the past 24 hr. Scores reflected the sum of the tasks for
that day and, thus, could range from 0 through 24 on each
day.

10

65.1
34.9

the demographic characteristics of the participating CGs
and their care recipients. The health conditions that put the
care recipients in need of caregiving varied and included
mobility problems, heart conditions, cognitive impairment,
chronic obstructive pulmonary disease, renal problems, and
diabetes. Most (n = 53) suffered from multiple conditions.
Measures
CG well being.—Depressive symptoms. Participants’
feelings of depression were assessed daily via six items
based on the revised version by Gaugler and colleagues
(2000) of the Hopkins Symptom Checklist (Derogatis,
Lipman, Rickels, Uhlenhuth, & Covi, 1974). Example items
included “I lacked enthusiasm for doing anything” and “I
cried easily or felt like crying.” CGs indicated the extent to
which they felt these emotions in the past 24 hr on a 4-point
scale with choices ranging from 1 (not at all) through 4
(very much). Responses were averaged across the six items
to arrive at a “depressive symptoms” score for each day.
Feelings of burden. Participants’ feelings of caregiving burden were assessed daily via the 12-item short version of the
Zarit Burden Interview (Bédard et al., 2001). Example items
included “In the past 24 hours, how much did you feel that
because of the time you spent with [care recipient] you
didn’t have enough time for yourself” and “. . .you should
be doing more for [care recipient].” CGs responded on a

Family disagreements regarding care. Participants reported
on the occurrence of family disagreements regarding caregiving on a daily basis via three forced-choice items designed for the current study but based in part on an existing
longer scale (Pearlin et al., 1990). Participants indicated if
there was any disagreement between them and anyone in
their family in the past 24 hr about the following: “What
should (or should not) be done for your relative; The way
you care for your relative; and How much (or how little)
they are involved in your relative’s care.” Scores reflected
the sum of the disagreements experienced in the past 24 hr
and could range from 0 through 3 on each day.
Care recipient problem behaviors. The care recipients’
problem behaviors were assessed daily with a 14-item behavior checklist adapted from The Revised Memory and
Behavior Problems Checklist (Teri et al., 1992). The CGs
indicated if their relative displayed each behavior in the past
24 hr (e.g., woke you or kept you up at night, became angry
or aggressive, was suspicious or accusing). Scores reflected
the sum of the behaviors experienced in the past 24 hr and
therefore could range from 0 through 14 on each day.
Moderators. —Socioemotional support. In the one-time,
initial questionnaire, participants reported on their level of
available socioemotional support from three sources: family
members, friends, and spouse or partner. Perceptions of available socioemotional support from each source were measured by four items developed by Walen and Lachman (2002),
for a total of 12 items. An example item was “How much do

SOCIOCONTEXTUAL CAREGIVERS

your family members understand the way you feel about
things?” For each item, CGs responded on a 4-point scale
that ranged from 1 (not at all) through 4 (a lot). The mean of
all 12 items was used as the socioemotional support score.
Extrinsic stressors. In each DQ, participants reported on the
occurrence of stressful experiences in settings outside of
caregiving (e.g., work/volunteer, relationship, parenting,
other settings) in the past 24 hr. The six-item scale was created partly on the basis of the Daily Inventory of Stressful
Events measure (Almeida, Wethington, & Kessler, 2002)
and began with the stem question “Did anything happen in
the following situations that was at all stressful?” An example item was “workplace or volunteer setting (had too
much to do, disagreed with a co-worker, etc.).” Although
each CG’s daily score reflected the sum of the stressful occurrences experienced in the past 24 hr (possible range 0
through 6), the score used in the current analyses was an
aggregate—the “average” of the eight daily scores for each
CG. In short, we created a between-person, individual difference extrinsic stressors score. (In this context, it is worth
noting that the literature shows that daily assessments are
useful because they are much less susceptible to recall error
[either over- or underestimation] when compared with retrospective reports [Smith, Leffingwell, & Ptacek, 1999].
Not surprisingly, then, aggregated daily or state assessments
are not perfectly correlated with single-shot, retrospective,
or trait assessments [e.g., Searles, Helzer, & Walter, 2000].
We are satisfied that the current aggregated measure of extrinsic stressors is a reliable reflection of each CG’s exposure to extrinsic stressors at least during the 8 survey days.)

565

(i.e., depressive symptoms, feelings of burden, physical
health symptoms), illustrated here with number of care recipient problem behaviors (Prob Beh) for each CG on a
given day as the Level 1 predictor and each CG’s physical
health symptoms (PHS) on a given day as the well-being
variable. The Level 1, time-varying predictors were personcentered (centered around each person’s mean across the 8
days) so that we would be able to address questions such as,
on days when care recipients display more problem behaviors than usual, do their CGs experience more physical
health symptoms? A chi-square statistic was used to decide
whether to constrain random variance u1i (Raudenbush &
Bryk, 2002). CG age and sex were entered as control variables for both the intercepts and slopes; however, for the
sake of simplicity, they are not included in the following
equation:
Model 1 : Level 1: PHSit = β0i + β1i (Prob Beh it − mean Prob Beh i ) + rit ,
Level 2: β 0i = γ 00 + u0i ,
β1i = γ10 + u1i .

Finally, to test our second and third hypotheses regarding
the moderating effects of socioemotional support and extrinsic stressors, the following model was used, illustrated here
with extrinsic stressors added as the between-person (Level 2)
moderator. A chi-square statistic was used to decide whether
to constrain random variance, u1i (Raudenbush & Bryk,
2002). CG age and sex were entered as control variables for
both the intercepts and slopes; however, for the sake of simplicity, they are not included in the following equation:
Model 2 : Level 1: PHSit = β0i + β1i (Prob Beh it − mean Prob Beh i ) + rit ,
Level 2: β 0i = γ 00 + γ 01 (extrinsic stressorsi ) + u0 i ,

Analytic strategy
We used multilevel random coefficient analysis, sometimes referred to by the program name, hierarchical linear
modeling (HLM; Raudenbush & Bryk, 2002) to analyze the
data. HLM allows for the independent estimation of withinperson and between-person effects (Nezlek, 2001). For
these analyses, we had two levels of data in which the daily
assessments of care-related stressors and CG well being
(Level 1) were nested within persons (Level 2) who might
differ on perceived social–emotional support and extrinsic
stressors (the between-person moderators). CG age and sex
were entered as control variables in all models.
As an initial step, unconditional HLM models (with no
predictors) were utilized to determine what proportion of
the total variance in the care-related stressors and the indicators of CG well being was within-person, across-day (as
opposed to between-person) variance.
Then, to address our foundational hypothesis (the reactivity hypothesis), we modeled the daily within-person link
between each care-related stressor (i.e., number of care
tasks, care recipient problem behaviors, family disagreements regarding care) and each indicator of CG well being

β1i = γ10 + γ11 (extrinsic stressorsi ) + u1i .

Results

Descriptive Statistics and Preliminary Analyses
Basic descriptive statistics (means, standard deviations,
ranges, and reliability) and correlations among the key study
variables and CG age are presented in Table 2; for the variables assessed on a daily basis, values are based on CG
scores averaged across 8 days.
As we have previously reported (Koerner & Kenyon,
2007), calculations based on the fully unconditional models
revealed that the proportion of total variance in the daily
assessments of care-related stressors and CG well being
that was within-person, across-day variance ranged from
27.3% to 60.9%. Thus, there was sufficient variability to
warrant further analysis.
Primary Analyses
Reactivity hypothesis.—Level-one HLM analyses revealed significant within-person stress reactivity even after

566

KOERNER ET AL.

Table 2.  Descriptive Statistics and Intercorrelations
Variable
1. Depressive symptoms
2. Feelings of burden
3. Physical health symptoms
4. Caregiving tasks
5. CR problem behaviors
6. Family disagreements regarding care
7. Extrinsic stressors
8. Socioemotional supporta
9. CG, age in years

M

SD

Observed range

a

1

2

3

4

5

6

7

8

1.58
1.80
1.71
6.82
1.80
0.27
0.72
3.07
56.7

0.55
0.55
1.58
3.26
1.38
0.52
0.66
0.54
13.2

1–4
1−3.9
0−11
0−18
0−12
0−3
0−3
1.75–4.00
20–85b

.89
.89
n/a
n/a
n/a
.75
n/a
.79
n/a

—
.713**
.642**
.025
.388**
.220
.492**
−.330**
−.274*

—
.479**
.214
.472**
.119
.521**
−.227
−.191

—
.060
.257*
.205
.610**
−.251
−.127

—
.250*
.064
.041
−.104
.094

—
.028
.133
−.079
−.097

—
.112
.153
−.269*

—
−.157
−.061

—
.006

Notes: N = 63. CG = caregiver; CR = care recipient; n/a = not applicable. To derive values for the variables that were assessed on a daily basis, an 8-day average
was calculated for each CG.
aValues in this row are based on n = 61.
bSixty-two percent of the CGs were more than age 55 years.
*p < .05; **p < .01.

controlling for the effects of CG age and sex (see Model 1
rows in Tables 3–5). (Although the effects of CG sex and
age were not the focus of this report, they were used as covariates in all HLM analyses. Sex and age did have some
significant effects. With respect to intercepts, there were
significant negative coefficients for age in relation to depressive symptoms in all analyses, suggesting that older
CGs had fewer depressive symptoms. With respect to slopes,
there were significant negative coefficients for gender [a]
for the caregiving tasks–feelings of burden link for both
moderator analyses and [b] for the care recipient problem
behaviors–physical symptoms link for the socioemotional
support moderator analyses. These findings suggest that,
compared with male CGs, female CGs are more reactive
[see also Koerner & Kenyon, 2007] especially when they
perceive little support and many extrinsic stressors. Finally,
with respect to slopes, there were significant negative coefficients for age for the care recipient problem behaviors–
feelings of burden link for both moderator analyses. These
findings suggest that younger CGs in this study, primarily
adult children, were more reactive to care recipient problem
behaviors especially when extrinsic stressors were many
and available socioemotional support was low. Coefficient
values are available upon request from the authors.) In general, on days when CGs experienced more care-related
stressors than their usual, they also reported more depressive symptoms, feelings of burden, and physical health
symptoms. For example, on days when care recipients displayed more problem behaviors than usual, CGs experienced more depressive symptoms and greater feelings of
burden; on days when CGs faced more than their usual
number of family disagreements regarding care, they experienced greater feelings of burden and more physical health
symptoms; and, at a trend level, on days when CGs engaged
in more than their usual number of caregiving tasks, they
experienced greater feelings of burden and more physical
health symptoms.
Moderator hypotheses.—For the moderator hypotheses,
we wanted to determine whether individual differences in

perceptions of available socioemotional support and in
number of extrinsic stressors moderated the within-person
daily associations between the three care-related stressors
and three indicators of CG well being. We hypothesized that
intensity of stress reactivity to daily care-related stressors
would be weaker for those CGs who perceived a greater
degree of socioemotional support and stronger for those
CGs who report a greater number of extrinsic stressors.
CGs’ “perceptions of available socioemotional support”
acted as a significant moderator for only one instance of
stress reactivity; that moderator effect was in the expected
direction (see Model 2a rows in Tables 3–5). Specifically,
having to manage additional care recipient problem behaviors on a given day was more strongly associated with increased depressive symptoms (g11 = −.07, p < .05) for CGs
with relatively low levels of perceived socioemotional support than for CGs with relatively high levels of perceived
socioemotional support.
For extrinsic stressors (see Model 2b rows in Tables 3–5),
there were several significant moderator effects suggesting,
as hypothesized, that within-person patterns of reactivity
were especially strong for CGs with relatively high numbers of extrinsic stressors (for illustrative examples, see Figure 1). Specifically, having to manage additional care
recipient problem behaviors on a given day was more
strongly associated with increased depressive symptoms
(g11 = .05, p < .05), feelings of burden (g11 = .05, p < .01),
and physical health symptoms (g11 = .27, p < .01) for CGs
with higher numbers of extrinsic stressors than for those
CGs with lower numbers of extrinsic stressors. In addition,
engaging in more caregiving tasks than usual on a given day
was more strongly associated with increased physical health
symptoms (g11 = .09, p < .01) for CGs with relatively high
numbers of extrinsic stressors, than for those with relatively
low numbers of extrinsic stressors.
Discussion
Very few researchers have viewed the caregiving experience from a daily perspective. As a result, we know little

−.01 (.02)
.02 (.01)

−.07* (.03)
.05* (.03)

−.06 (.15)
.08 (.15)

−.35** (.12)
.42*** (.09)

−.35** (.12)
.43*** (.09)

−.35** (.12)
.43*** (.09)
Family disagreements
  regarding care

Care recipient problem
  behaviors

2.22*** (.30)
3.30*** (.47)
1.91*** (.27)
2.22*** (.30)
3.30*** (.47)
1.91*** (.27)
2.22*** (.30)
3.30*** (.47)
1.91*** (.27)
Caregiving tasks

Unconditional model
Model 1
Model 2a: socioemot supp as moderatorc
Model 2b: extrinsic stressors as moderator
Model 1
Model 2a: socioemot supp as moderator
Model 2b: extrinsic stressors as moderator
Model 1
Model 2a: socioemot supp as moderator
Model 2b: extrinsic stressors as moderator

06 (.04)
.10 (.07)
.05 (.04)
.17** (.06)
.41** (.12)
.14* (.07)
.38 (.24)
.52 (.53)
.33 (.26)

Moderator
Predictor
Intercept
Model
Predictor

Notes: n/a = Not applicable. All models adjust for the effects of caregiver age and sex; for details, see the Primary Analyses/Reactivity Hypothesis section, column 1. All predictors were person-centered (i.e., centered
relative to the person’s own mean).
a p values are not available.
b  chi-square statistic was used to decide whether to constrain random variance.
A
c Socioemot supp refers to perceived available socioemotional support.
*p <.05; **p < .01; ***p < .001.

.07*** (.27)
.07*** (.26)
.08*** (.28)

n/a

.26*** (.51)
.25*** (.50)
.23*** (.49)
.19*** (.43)
.26*** (.51)
.23*** (.48)
.19*** (.44)
.26*** (.51)
.23*** (.48)
.19*** (.44)

Predictor × Moderator

.20 (.45)
.20 (.45)
.20 (.45)
.20 (.45)
.17 (.42)
.17 (.41)
.17 (.41)
.18 (.42)
.18 (.42)
.18 (.42)

Variance of slopeb
Variance of intercept

Random effects (SD)

Residuala
Fixed effects (SE)

Table 3.  Multilevel Regression Results for Daily Care–Related Stressors Predicting Daily Depressive Symptoms as Moderated by Socioemotional Support and Extrinsic Stressors

SOCIOCONTEXTUAL CAREGIVERS

567

about daily stress reactivity among CGs and even less about
which CGs tend to experience the most intense daily stress
reactivity. This gap in the literature is notable because understanding intensity of daily stress reactivity among family
CGs may be vital to predicting their short-term and longterm mental and physical health (Krantz & Manuck, 1984;
Uchino et al., 1996).
Using a daily diary approach, the current study confirms
that CGs experience more depressive symptoms, feelings of
burden, and physical health symptoms on days when they
face more than their usual number of care-related stressors
(see Koerner & Kenyon, 2007). However, the daily withinperson link between care-related stressors and fluctuations
in CG well being was not equally apparent across all daily
stressor–well-being combinations. The aspect of well being
that was linked to fluctuations in all three daily stressors
(i.e., number of caregiving tasks, care recipient problem behaviors, and family disagreements regarding care) was CG
feelings of burden (i.e., feeling that you are not doing
enough for the care recipient, feeling stressed in the presence of the care recipient, feeling that you are losing yourself and your social opportunities due to caregiving). The
fact that CG feelings of burden seem particularly sensitive
to daily fluctuations in care-related stressors is notable because feelings of burden (even more than depressive symptoms or physical health symptoms) have been consistently
linked both to CGs’ decision to institutionalize their care
recipient (e.g., Gaugler et al., 2009) and to CG abusive behavior (e.g., Cooper et al., 2010).
By embedding our daily diary approach within a sociocontextual model, the present study also helped to identify
those CGs who appear to be most reactive to the emergence
and subsidence of care-related stressors. Briefly stated, and
as might be expected in light of Pearlin’s (1994) CG stress
model, we found that extrinsic stressors exacerbated CGs’
intensity of stress reactivity and that perceptions of available
socioemotional support buffered CGs’ intensity of stress reactivity. Further discussion of these effects follows.
Contextual Moderators of Stress Reactivity: Extrinsic
Stressors and Socioemotional Support
Aneshensel and colleagues (1995) pointed out that extrinsic stressors must be viewed as important components of
the context within which CGs face and respond to carerelated stressors. Extrinsic stressors may include the frustrations and hassles of having to manage household or
relationship problems, upkeep a car, respond to unexpected
work demands, and the like. In the present study we found,
as hypothesized, that compared with their counterparts with
fewer extrinsic stressors, CGs who faced more extrinsic
stressors during the week of data collection experienced
more intense emotional and physical reactivity when they
had to face days that included higher than usual amounts
of care-related stressors—specifically, higher than usual

568

.04 (.09)
−.01 (.09)
−.23# (.13)
.43*** (.10)

.02 (.02)
.05** (.02)
−.23# (.13)
.43*** (.10)

.02 (.01)
−.00 (.01)
−.23# (.13)
.43*** (.10)

Family disagreements
  regarding care

Care recipient problem
  behaviors

2.19*** (.31)
2.93*** (.49)
1.87*** (.28)
2.19*** (.31)
2.93*** (.49)
1.87*** (.28)
2.19*** (.31)
2.93*** (.49)
1.87*** (.28)
Caregiving tasks

Unconditional model
Model 1
Model 2a: socioemot supp as moderatorc
Model 2b: extrinsic stressors as moderator
Model 1
Model 2a: socioemot supp as moderator
Model 2b: extrinsic stressors as moderator
Model 1
Model 2a: socioemot supp as moderator
Model 2b: extrinsic stressors as moderator

.06# (.03)
.00 (.05)
.06# (.03)
.29*** (.04)
.23** (.08)
.26*** (.04)
.36* (.14)
.23 (.33)
.37* (.15)

Moderator
Predictor
Intercept
Model
Predictor

Notes: n/a = Not applicable. All models adjust for the effects of caregiver age and sex; for details, see the Primary Analyses/Reactivity Hypothesis section, column 1. All predictors were person-centered (i.e., centered
relative to the person’s own mean).
a p values are not available.
b  chi-square statistic was used to decide whether to constrain random variance.
A
c Socioemot supp refers to perceived available socioemotional support.
#p < .10; *p < .05; **p < .01; ***p < .001.

.02** (.13)
.02** (.14)
.02** (.14)

n/a

.27*** (.52)
.28*** (.53)
.26*** (.51)
.21*** (.46)
.28*** (.53)
.27*** (.52)
.21*** (.46)
.28*** (.53)
.26*** (.51)
.21*** (.46)

Predictor × Moderator

.11 (.33)
.10 (.32)
.11 (.32)
.10 (.32)
.08 (.29)
.08 (.29)
.08 (.28)
.09 (.30)
.09 (.31)
.09 (.30)

Variance of slopeb
Variance of intercept

Random effects (SD)

Residuala
Fixed effects (SE)

Table 4.  Multilevel Regression Results for Daily Care–Related Stressors Predicting Daily Feelings of Burden as Moderated by Socioemotional Support and Extrinsic Stressors

KOERNER ET AL.

amounts of care recipient behavior problems and ADL and
IADL task assistance. Stated in other words, days that
brought increased numbers of care recipient problem behaviors and/or increased demands for ADL and IADL task
assistance appeared to be especially stressful when they occurred for CGs who also had to cope with numerous extrinsic stressors; those CGs experienced increased depressive
symptoms, feelings of burden, and physical health symptoms. These findings suggest that extrinsic stressors not
only add to the sheer number of demands on CGs but do
indeed magnify the negative impact of care-related stressors
on CG daily well being.
The current study also revealed that the availability of
socioemotional support can play a buffering role in CG
stress reactivity, at least to some extent. Specifically, compared with their counterparts who reported high levels of
available socioemotional support, those CGs who reported
low levels of available socioemotional support were more
reactive to daily fluctuations in care recipient problem behaviors, with more evident increases in depressive symptoms on days that included increased numbers of care
recipient problem behaviors. Without a solid schema of
available socioemotional support, CGs may more quickly
reach their tolerance for frustration with care recipient problem behaviors. In contrast, CGs who perceive greater available socioemotional support may be able to remain on a
more even keel emotionally, at least with respect to depressive symptoms.
The exact mechanism involved in this differential reactivity to care recipient problem behaviors as a function of
available socioemotional support is not clear. However,
social-cognitive theory would suggest that available socioemotional support helps to increase the CG’s sense of confidence and personal control in providing care (Bandura,
1997). In addition, CGs with higher levels of available socioemotional support may feel more assured that significant
others can be counted upon to act in the best interest of the
CG and positively evaluate his or her performance (Barrera,
1986) even in the face of increased numbers of care recipient problem behaviors. Further research is needed to determine why the moderating effects of socioemotional support
did not extend beyond reactivity to care recipient problem
behaviors.
The fact that both extrinsic stressors and socioemotional
support availability made a difference in determining CGs’
intensity of emotional and physical reactivity to one carerelated stressor in particular—care recipient problem
behaviors—bears discussion. We know from nondaily,
cross-sectional, and longitudinal studies that care recipient
problem behaviors have a significant negative impact on
CGs’ emotional and physical well being. In fact, care recipient problem behaviors can be more stressful to CGs
than other primary stressors such as care recipients’ level of
required care or cognitive status (see Pinquart & Sörensen,
2005), accounting for a greater degree of variance in well

Unconditional model
Model 1
Model 2a: socioemot supp as moderatorc
Model 2b: extrinsic stressors as moderator
Model 1
Model 2a: socioemot supp as moderator
Model 2b: extrinsic stressors as moderator
Model 1
Model 2a: socioemot supp as moderator
Model 2b: extrinsic stressors as moderator

Model
2.43*** (.90)
4.68*** (1.44)
1.33# (.74)
2.43*** (.90)
4.68*** (1.44)
1.33# (.74)
2.43*** (.90)
4.68*** (1.44)
1.33# (.74)

Intercept
.22# (.13)
.14 (.22)
.15 (.10)
.20 (.23)
.39 (.39)
.01 (.22)
.82* (.40)
.10 (.81)
.86* (.42)

Predictor

−.76* (.37)
1.50** (.26)

−.76* (.37)
1.50** (.26)

−.76* (.37)
1.50** (.26)

Moderator

.12 (.23)
−.03 (.25)

−.03 (.09)
.27** (.08)

.02 (.06)
.09** (.03)

Predictor × Moderator
1.17 (1.08)
.94 (.97)
.93 (.96)
1.03 (1.01)
.96 (.98)
.95 (.97)
.96 (.98)
1.11 (1.05)
1.13 (1.06)
1.11 (1.05)

Residuala
2.34*** (1.53)
2.35*** (1.53)
2.25*** (1.50)
1.46*** (1.21)
2.34*** (1.53)
2.24*** (1.50)
1.47*** (1.21)
2.31*** (1.52)
2.21*** (1.49)
1.44*** (1.20)

Variance of intercept

Random effects (SD)

.11* (.33)

.06*** (.25)
.06*** (.24)
.04** (.21)
.09# (.30)

n/a
.02*** (.15)
.03*** (.16)

Variance of slopeb

Daily Physical Health Symptoms

D aily Fe elings of Burde n

Da ily D epre ss ive Sy mptoms

Notes. n/a = Not applicable. All models adjust for the effects of caregiver age and sex; for details, see the Primary Analyses/Reactivity Hypothesis section, column 1. All predictors were person-centered (i.e., centered
relative to the person’s own mean).
a p values are not available.
b  chi-square statistic was used to decide whether to constrain random variance.
A
c Socioemot supp refers to perceived available socioemotional support.
#p < .10; *p < .05; **p < .01; ***p < .001.

Family disagreements
  regarding care

Care recipient problem
  behaviors

Caregiving tasks

Predictor

Fixed effects (SE)

Table 5.  Multilevel Regression Results for Daily Care–Related Stressors Predicting Daily Physical Health Symptoms as Moderated by Socioemotional Support and Extrinsic Stressors

SOCIOCONTEXTUAL CAREGIVERS

2.5

Fewer than Usual

3.5
3

Fewer than Usual

6

Fewer than Usual

569

4

3.5
3
-1SD Extrinsic
Stresso rs Gro up

+1SD Extrinsic
Stresso rs Gro up

2

1
.5
1

Daily Care Recipient Problem Behaviors

More than Usual

4

-1SD Extrinsic
Stresso rs Gro up

+1SD Extrinsic
Stresso rs Gro up

2.5
2

1
.5

1

Daily Care Recipient Problem Behaviors
M o re than Usual

12

10

8

-1SD Extrinsic
Stresso rs Gro up

+1SD Extrinsic
Stresso rs Gro up

4

2

0

Daily Care Recipient Problem Behaviors
M o re than Usual

Figure 1.  Extrinsic stressors moderate the within-person association between daily care-related stressors (care recipient problem behaviors) and daily
caregiver well being (depressive symptoms, feelings of burden, physical health
symptoms).

being across CGs. The current research, which takes a withinperson, daily perspective, concordantly reveals that on
days when CGs face more care recipient problem behaviors
than usual they report poorer well being. This should not be
altogether surprising. Some CGs may not understand that
these behaviors stem from the care recipient’s illness (e.g.,
dementia) and the vast majority of family CGs are not
trained in how to respond to these sometimes surprising,
confusing, and frustrating behaviors (Aneshensel et al.,

570

KOERNER ET AL.

1995; Brodaty, Roberts, & Peters, 1994). Moreover, care
recipient problem behaviors can be unpredictable in whether
and when they may occur, which may make them especially
unsettling for CGs on the days that they do occur (Lazarus &
Folkman, 1984; Wheaton, 1999). It is perhaps for these
reasons that the presence of extrinsic stressors can readily
exacerbate the impact of care recipient problems on CGs
and that the presence of socioemotional support plays a significant buffering role. The confusing and frustrating nature
of care recipient problem behaviors may heighten the need
for the confidence and calmness that available socioemotional support affords CGs, and the uncertain nature of care
recipient problem behaviors may be especially distressing
in the context of competing or distracting demands associated with extrinsic stressors.
Limitations and Future Directions
Although the present research contributes new findings to
the empirical literature on CG well being, those findings
should be viewed in light of the study’s limitations. First,
like many daily diary studies, the sample size was relatively
small. Although our sample size (that resulted in 498 daily
reports) provided sufficient power to test the study’s singlemoderator hypotheses, a larger sample size would have provided the statistical power needed to test the combined
impact of multiple moderator variables. Second, the sample
was fairly diverse with regard to CG relationship to care
recipient and care recipient health problems. Future research with a larger sample that could be divided into subgroups may be needed to determine whether the findings are
generalizable.
Third, the term “reactivity” implies causal associations;
specifically, that within-person changes in CG well being
resulted from proximal changes in care-related stressors,
and not vice versa. However, caution should be taken when
inferring causal direction given the current cross-sectional
design at the daily level (i.e., care-related stressors and CG
well being were reported simultaneously at the end of each
day). It is possible, though less plausible, that a change in
CG well being (e.g., an increase in feelings of burden) precedes a change in care-related stressors (e.g., an increase in
care recipient problem behavior). Additional research that
incorporates multiple within-day assessments may be able
to address this limitation.
Fourth, without an electronic date–time stamp, our paperand-pencil daily surveys do not allow us to know for certain
that the surveys were indeed completed on a daily basis.
However, in an attempt to obtain daily completion, we encouraged the participants to do so during our recruitment
phone conversation, we included easily understood written
instructions with the surveys, and we had a place to write in
the date and time on each survey. Because we were not analyzing lagged effects (i.e., how one day affects the next), any
missed days are less consequential for the present research.

Finally, because we collected only one 8-day wave of
data, we were not able to investigate patterns of change and
stability in stress reactivity for the sample as a whole or for
selected subgroups of CGs (e.g., those with consistently
high levels extrinsic stressors). Knowing whether and how
stress reactivity may change over time would provide further insight into the well being of CGs.
Implications
The present results have several implications for intervention. First, interventions designed to alleviate CG mental or physical health problems could attempt to reduce the
number and intensity of stressors outside the role of caregiving. Application of a simple checklist by which CGs,
family members, and other significant others note the CG’s
extrinsic stressors and identify additional support activities and ways they could assist would be a meaningful starting point. This checklist activity could also help CGs
to recognize socioemotional support that may in fact be
available from family and friends but has not yet been
acknowledged.
Second, respite programs could be organized for CGs
with the input of support coordinators. The support coordinators could begin by having each of their clients engage in
daily journaling for 2 weeks, noting the occurrence of specific caregiving stressors (e.g., care recipient problem behaviors) and extrinsic stressors. Patterns may be detected in
the individual client’s journals (e.g., care recipient problem behaviors may be heightened on weekends). Based on
these patterns, support coordinators could plan and schedule assistance in a more strategic, individualized fashion
(Mittleman et al., 1994).
Finally, it would be helpful for CGs to have access to a
support hotline answered by former or experienced family
CGs. For current CGs who do not have available socioemotional support or need additional support, former CGs or
experienced CGs could provide valuable information on local services, emotional comfort, and “survival” tips from
the CG perspective.
Funding
University of Arizona Agricultural Experiment Station (ARZT 136726H-07-170).
Acknowledgments
Special thanks are extended to graduate students Yu Liu, Lela Rankin,
Renée Peltz Dennison, Dorothy Esler, Cindy Simon, and Jessica Carter
and to undergraduate students Talia Retana and Pat Woelke for their assistance during various phases of the project. We also appreciate the contributions of Drs Joyce Serido and Lynne Tomasa.
Correspondence
Address correspondence to Susan Silverberg Koerner, PhD, Division of
Family Studies and Human Development, PO Box 210078, University of
Arizona, Tucson, AZ 85721-0078. Email: ssilver@ag.arizona.edu.

SOCIOCONTEXTUAL CAREGIVERS

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