Review of studies on spousal caregivers of frail spouses in South Korea

Abstract

The first aim of this study is to review and critique the empirical literature on dyadic problems of spousal caregivers. A total of 18 relevant studies published between 1990 and 2015 were identified via several databases in South Korea. Four major results were identified: (1) assuming caregiving roles easily caused various caregiving-related problems, such as stress and burden; (2) care recipients’ health conditions and problems were one of the crucial factors influencing caregiving-related problems in spousal caregivers; (3) caregiving easily caused marital problems in couples with frail spouses; and (4) spousal caregivers had negative communications with their care recipients.

Keywords

Caregivers caregiving problems couple relationships Korean marital conflicts spousal caregivers

Introduction

Generally, it is well-known that spousal caregivers live in vulnerable positions. Previous caregiving research has indicated that spousal caregivers report more caregiving burdens and higher depressive symptoms than those who are not spousal caregivers (Cho et al., 2009). This is because spousal caregivers are much more likely to live with their care recipients, spend more time in caregiving, and be much more involved in their care recipient’s activities than others (Pinquart and Sörensen, 2011). Also, many spousal caregivers face a variety of communication problems (e.g. criticizing one’s spouse) that may challenge the spousal relationship. For example, couples facing cancer may criticize one another for smoking and drinking (a major cause of cancer), avoid discussion of cancer-related concerns, and/or pressure one another to discuss concerns (Chapple et al., 2004; Manne and Badr, 2010). Facing various caregiving problems, economic and occupational strains become arduous stressors for spousal caregivers. Van Houtven et al. (2010) indicated that spousal caregivers faced a higher economic burden than other relative or friend caregivers.

In South Korea, caregiving in family systems has changed rapidly. After the 1997 financial crisis, Korean society experienced the erosion or decline of the male breadwinner model resulting from family changes that have led to family breakdowns, more fluidity in intimate relationships, and a large increase in single-person households (Song, 2008). These changes mean that the family system does not have enough resources to satisfy the care needs of family members whose health is failing. In this situation, Korean couples are vulnerable to their spouse’s health problems because they tend to share various external and internal resources and relationships (Lee and Han, 2010). In other words, if a spousal caregiver and his or her frail spouse belong to the same community and have the same affiliations, people (e.g. friends) in the community may support and/or supplement the frail spouse’s needs more than the spouse caregiver. Because of these interconnections, many spousal caregivers have limited external resources such as social supports. In such a situation, it is difficult to distinguish the couple’s own unique portion of resources from the total resources shared and interwoven in the family unit. This interconnection of spouse and frail spouse’s resources can be the decisive factor comprising obstacles, obscuring the specific caregiving problems spousal caregivers face in the caregiving setting. Moreover, in South Korea, wife caregivers report limited social relationships with others (e.g. friends) and few leisure activities (Kang, 2012; Lee and Han, 2010). This is because many Korean wives have experienced career interruption due to marriage and childbirth.

Also, couples easily face financial problems due to their health problems. In South Korea, the central government has established and managed the National Health Insurance (NHI) system. Because of the NHI, every Korean has identical coverage rate for any health service. Despite the benefits, frail persons in Korea still face financial problems in health care settings (Yoon, 2013). Specifically, the total annual health care expense per person in 2016 was about $1080, an increase from the 2011 figure of approximately $840 (National Health Insurance Service, 2016). This result means that health care and medical costs are still a huge burden for spousal caregivers, especially those who are retired or do not have enough resources to pay for medical care for their frail spouse (Moon et al., 2014).

In light of the difficulties associated with providing care, spousal caregivers’ caregiving problems should be understood in terms of couple relationships, which involve distinctly different situations and problems compared to caregiving problems faced by other types of family caregivers. Without considering the specific caregiving circumstances of spousal caregivers in South Korea, health professionals might experience difficulty in explaining the peculiar caregiving burdens in couples with caregiving problems. To date, to the best of our knowledge, no one has summarized all of the problems related to couple (interpersonal) relationships in South Korea. Also, the interpersonal problems of Korean couples have yet to receive such systematic attention. However, the problems and relationships frail couples face need to be reviewed in order to establish where researchers should go next to fill gaps in knowledge and develop a deeper understanding of spousal caregivers in South Korea. This study is intended to fill that void by providing a comprehensive review of couple problems faced by spousal caregivers.

This article summarizes and reviews the findings to date on various couple problems faced by spousal caregivers of frail individuals in South Korea. Reviewing research on Korean spousal caregivers can serve as a valuable milestone in understanding what peculiar situations and problems are related to mental health, caregiving burdens, and the interpersonal problems of each Korean couple experiencing a caregiving situation. The findings of this review may also prove helpful to other researchers working with frail couples in East Asia, affording them a better understanding of the couple problems and providing a possible model not only to reduce spousal caregivers’ stress, but also to improve the caregiving experiences of family members in East Asia.

Research background

Family caregiving in South Korea

In South Korea, caregiving for frail individuals (e.g. children, parents, spouses) has been dominated by family members (i.e. informal caregivers). One reason for this trend (the prevailing caregiving role of family members) is the social norm and value of caregiving suggesting that moral people should take care of their frail family members. Thus, traditionally, younger people (e.g. adult children) have taken responsibility for caregiving for older adults in the family unit. However, recently, this caregiving trend has changed as children are no longer a major resource for caregiving. In family systems, spouses usually take care of their fail spouses and partners (Song, 2008). According to the Korea Institute for Health and Social Affairs (Jung et al., 2012), 53 percent of family caregivers were spousal in 2011. This is a 23.3 percent increase from the 29.7 percent of older adults who took care of their spouses in 2004. This change is driven by social shifts in South Korean society, such as the nuclearization of family (family breakdowns), more fluidity in intimate relationships, expansion of social activities for women, and large increases in single-person households (Lee and Han, 2010; Song, 2008). In addition, older Korean adult couples were dependent on care from their spouses more than from other family members because the frail ones could easily ask for help and support from their spouses living in the household (Hong et al., 2012).

Spousal caregiver and stressful situations

In general, family caregiving has been studied in terms of the life stress paradigm starting at age 60–70 with the development of programs concerning life changes and daily events (Ensel and Lin, 1991). The paradigm regards role strains and daily disturbances as a stressor, and this stressor disrupts an individual’s psychological well-being (Ensel and Lin, 1991). Within this paradigm, Hobfoll (1988) suggested the conservation of resource (COR) theory. According to the basic tenet of COR theory, individuals strive to obtain, retain, protect, and foster their personal and social resources. In COR theory, a resource is a constellation of people’s personal strengths, social attachments, and cultural belonging to survive in the world. People experience stress when their circumstances are threatened or result in loss of these valued states. That is, resource loss is the principal factor in stressful situations. The COR theory is highly relevant for explaining why spouse caregivers have higher levels of stress and burdens than other types of caregivers, and why they need to obtain additional resources, mainly external resources, to reduce their stress. Given the basic tenet of COR theory, spousal caregivers of frail individuals experience the most severe loss of care resources and the highest levels of distress, which makes them the most vulnerable population among family caregivers.

Spousal status has been investigated as a potential stressor in caregiving settings. According to Rhee et al. (2008), Korean spouses living with a frail spouse reported significantly more depressed mood and numerous specific burdens compared to those living with a healthy spouse. Also, Kim and Lee (1999) showed that spousal caregivers had significantly higher depressive symptoms than other types of caregivers, such as older adults and relatives. In Korean couples, gender is an important factor in informal caregiving. Not surprisingly, most informal caregivers in Korean couples are female and middle-aged or older. Although increasing numbers of women have participated in the labor market since the Korean financial crisis of 1997, many women still take on great responsibility for caregiving for their spouses (Kim, 2006). Prior studies on caregiving in the West (Cantor, 1983; Cho et al., 2009; Li et al., 1997) have also reported that spousal caregivers had significantly more caregiving burdens and higher levels of depressive symptoms than those who were not a spouse. One possible reason for this phenomenon is that spousal caregivers provide higher levels of support for their care recipients than other types of caregivers. According to Pinquart and Sörensen (2011), spousal caregivers are much more likely to live with the care recipients, spend more time caregiving, and be much more involved in their spouse’s activities than other caregivers. After a spouse becomes a frail patient, their spousal caregivers may reduce time spent on other activities, such as leisure activities. The reduced time can cause caregiving stress, role strain, and reduced social networks. In turn, these problems eventually decrease the amount of total resources.

In Korean couples, the couple relationship functions as a curtailing factor influencing the caregiving burdens and stresses of spousal caregivers (Lee and Kim, 2009). Lee and Kim (2009) reported that spousal caregivers who had high levels of trust in their couple relationship and a good reciprocal relationship demonstrated positive experiences related to their caregiving roles, whereas spousal caregivers with a level of distrust or dissatisfaction with their care recipients had negative caregiving experiences. Regarding couple problems, previous cancer studies in the United States (Badr and Taylor, 2006; Zhang and Siminoff, 2003) have reported similar results, indicating that spousal caregivers experienced various communication problems with their care recipients having a cancer diagnosis: couples avoided discussing the cancer itself and their sexual relationship, caregivers downplayed physical symptoms, caregivers refused to listen to survivors’ distress, and couples stopped communicating their true feelings and needs. Because of these problems, spousal caregivers often display mental health problems. Siminoff et al. (2010) revealed that couples’ higher depressive symptoms were significantly attributed to blaming each other. In terms of COR theory, couple problems can be interpreted as a loss of resources or a shrinkage in total resources (Hobfoll, 1988). For example, a person whose spouse becomes ill or disabled may experience a loss of emotional resources from the frail spouse. In this situation, the loss of emotional resources including love, affection, and reciprocity of exchange (e.g. positive communication) with the spouse is a major cause of pain and primary source of strain among spousal caregivers (Li et al., 1997).

As mentioned earlier, the Korean family has experienced erosion of the traditional male breadwinner model and extended family system based on social change. This change has decreased the informal caregiving and labor that younger people tended to perform in the family system (Song, 2008), resulting in an increase in old-age caregivers in caregiving settings. Middle-aged and older spousal caregivers in South Korea encounter more socio-economic disadvantages in taking care of their frail spouses than other caregivers do (Choi and Kim, 2013; Kim and Lee, 1999). In 2016, on average, Korean older adults (>65 years of age) visited hospitals more than 30 times for health problems, and the annual out-of-pocket medical cost was $3250 (Health Insurance Review & Assessment Service, 2016). The results indicate that older adults spent an average of 17.5 percent of their income on out-of-pocket medical expenses (Lee, 2015), which is a significantly higher rate than the 2 percent spent by the total population. In Western societies many spousal caregivers are also middle-aged and older (Silverstein and Giarrusso, 2010), and their age functions as an accelerator of caregiving problems. According to previous caregiving research (Pinquart and Sörensen, 2007), caregivers’ age was associated with high levels of caregiving burden and depression and low levels of physical health. Schulz and Beach (1999) also reported that caregivers (>65 years) of cancer patients showed significant health problems affected by their caregiving roles. Caldwell (2006) reported that the age of family caregivers significantly predicted their poor physical health as well as lower levels of employment.

Regarding the results of prior caregiving studies, spousal caregivers had worse physical health, more severe caregiving burdens, and more serious depressive symptoms than other types of family caregivers. This limitation and weakness can be also interpreted in terms of COR theory. As mentioned earlier, spouse caregivers of their frail spouses constitute the most vulnerable population among family caregivers. This means that spouse caregivers have relatively lower levels of baseline resources than other family caregivers, and they have a high possibility of experiencing stress due to their limited resources. In other words, people with a strong resource reservoir (e.g. young and rich caregivers) have a higher possibility of fitting their abilities and resources to meet their various needs, such as care service and health information (Oh and Cho, 2015), than individuals with a weak resource reservoir.

Methods

Search strategy

For the purpose of this research, this review identified studies of spousal caregiving published between 1990 and 2015 in Korean journals. Papers were primarily identified through a systematic search of electronic databases: RISS (http://www.riss.kr), KISS (http://kiss.kstudy.com), and DBpia (http://www.dbpia.co.kr). Secondary methods included (1) checking the reference lists of articles retrieved and (2) online searching of key journals (Korean Journal of Family Social Work, Korean Journal of Social Welfare Studies, Family and Culture, and Journal of Korean Academy of Adult Nursing). Keywords used for searches in Korean included spousal caregivers, couples with chronic disease, frail couple, anger, blame, caregiving burdens, communication problems, depressive symptoms, financial problems, interpersonal problems, less life satisfaction, role strain or conflict, stress and psychological distress, and lower leisure activity. In addition to the electronic searches, the reference lists of the identified articles were also hand-searched for further relevant studies.

Inclusion/exclusion criteria

Articles were identified and included in two stages. First, each article abstract was scanned to make an initial judgment about the article’s suitability for inclusion. Second, the authors read and assessed the remaining articles independently using the exclusion criteria. The inclusion criteria applied were as follows: (1) the individuals (i.e. care recipients and caregivers) in the caregiving studies are married couples or partners living together, (2) the care recipients in the caregiving studies are frail or have been diagnosed with a chronic disease (e.g. cancer, Alzheimer’s), (3) the spouses in the caregiving studies take care of their spouse or partner as caregivers, and (4) articles are published in Korean journals (i.e. not conference proceedings or papers) and use empirical data (e.g. data from survey, interview, intervention research, or experimental design). The exclusion criteria are as follows: (1) caregiving studies include other types of family caregivers (e.g. adult children and relatives), (2) the study does not examine the problems of spousal caregiving and caregiving issues pertaining to frail spouses (i.e. studies that examined marital and family problems related to divorce, caregiving and education for children, and caregiving for parents are excluded), and (3) research participants are Korean or people living in South Korea (i.e. published articles using research participants living in other countries or foreigners are excluded).

Study selection and extraction

The search strategy yielded 174 articles (Figure 1). All articles used in this study were collected from the three electronic sources, and screening of the reference lists did not reveal additional relevant articles. After filtering 35 duplicates, 139 articles’ abstracts were scanned to make an initial judgment about its suitability for inclusion. Among those studies, 52 articles were excluded: (1) eight forums, (2) 12 conference proceedings, and (3) 32 articles that did not use empirical data. In this stage, the remaining studies were read independently by reviewers. In all, 69 articles were excluded: 6 studies met the exclusion criteria including family caregivers such as adult children and relatives, 10 studies met the exclusion criteria using the data collected in other countries (e.g. the US, the UK, East Asia, and Japan), 7 studies met the exclusion criteria focusing on care systems and services only rather than spousal caregiving, and 46 studies investigated children’s education and caregiving, parents’ caregiving, and bereavement only (i.e. they did not examine the issue of spousal caregiving).

Figure 1.

The identification of eligible studies for systematic review.

Results

Study design and features

The research designs and participants’ features are shown in Table 1. In the Results section, article numbers presented in Table 1 are used instead of specific references for the sake of brevity. In all reviewed articles, most research participants were female (N = 1246, 57.8%). Nine studies used both males and females, while eight studies included either females only (2, 4, 7, 13) or males only (1, 3, 14, 17). One study did not specify the gender of participants (12). Five articles used a qualitative design (1, 5, 7, 8, 14), 12 studies used a quantitative design (2, 3, 4, 6, 9, 10, 11, 13, 15, 16, 17, 18), and one study used a mixed-methods approach (12). Eleven studies used variables related to both caregivers and their care recipients (2, 4, 9, 10, 11, 12, 13, 15, 16, 17, 18). The study populations ranged in size from 7 (1, 7) to 335 (16) participants. The average age of caregivers was 58.2 years. However, some studies did not indicate participants’ mean age (4, 5, 7, 8).

Table 1.

Characteristics of spousal caregiving studies.

Study	Sample	Mean age, age range, and gender (frequency)	Measured variables	Results
1. Kwon and Yi (2013) (Qualitative research)	Spousal caregivers who take care of breast cancer survivors (N = 7)	48 years (does not specify age range) Male (N = 7)	Not applicable	Having fear for future life without wife Feeling guilty for wife’s diagnosis with breast cancer Consoling wife for her loss of hair after diagnosis with cancer Taking multi-tasks in household
2. Kwon et al. (2003) (Quantitative Survey)	Spouses taking care of brain-injured patients (N = 109)	46.4 years (30–59 years) Female (N = 109)	Predictors (CG): age, marital satisfaction, caregiving hours in hospital, having paid care workers, having people who help with house chores Predictors (CR): the period of patients’ hospitalization, experiences (burden) of caregiving for husband before hospitalization, patients’ injured condition, patients’ convalescence Outcomes: role stress, physical health status, psychological health status	Caregivers’ lower age, lower marital satisfaction, more caregiving hours, having no paid care workers, having no person who helps with house chores were significantly associated with higher role stress Patients’ longer period of hospitalization, more severe injuries, and worse convalescence were significantly associated with higher role stress in caregivers Caregivers’ higher marital satisfactions, patients’ less severe injuries, and better convalescence were significantly associated with better physical health There was a negative correlation between role stress and psychological health status (p < .05)
3. Kim and Lee (2006) (Quantitative Survey)	Spousal caregivers taking care of gynecological cancer survivors (N = 71)	49.1 years (20–60 years and older) Male (N = 71)	Predictors (CG): spousal stress, family resources, and situational definition Outcome: spousal adaptation	Higher stress, lower family resources, and lower levels of situational definition were correlated with lower levels of spousal adaptation
4. Kim and Park (2014) (Quantitative Survey)	Spousal caregivers of frail elderly (N = 227)	Mean age not specified (65–75 years) Female (N = 227)	Predictors (CG): age, education, religion, health satisfaction, and subjective income status Predictors (CR): use of long-term care service Outcomes: depressive symptoms, self-esteem, marital satisfaction, and marital conflict	Higher age, lower health satisfaction, and using long-term care service were significantly associated with higher depressive symptoms Higher education, higher health satisfaction, and having religion were significantly associated with higher self-esteem Higher health satisfaction and no use of long-term care service were significantly associated with lower marital satisfaction Lower health satisfaction was significantly associated with higher marital conflict
5. Kim (2005) (Qualitative research)	Spousal caregivers of hemodialysis patients (N = 15)	Mean age not specified (37–68 years) Male (n = 10) Female (n = 5)	Not applicable	Re-established life (4 stages) 1. Escaping (pursuing meaning of life, gathering information) 2. Accepting (understanding and/or avoiding stimulus, paying for hemodialysis expense) 3. Enduring (devoted caring, receiving love and care, receiving comfort, giving hope) 4. Transcending (positive thinking, thanksgiving, participating in local community)
6. Ahn et al. (2005) (Quantitative Survey)	Spousal caregivers of patients with stroke (N = 160)	59.9 years (28–81 years) Male (n = 127) Female (n = 33)	Predictors (CG): well-being, physical and psychological health status Outcome: burden	Lower levels of psychological health and lower levels of well-being were significantly associated with higher burden
7. Yoon and Kim (2009) (Qualitative research)	Spousal caregivers of veteran husbands (N = 7)	Mean age not specified (65–70 years) Female (N = 7)	Not applicable	No personal time for themselves (caregivers) As elderly, feeling frail themselves Not prepared for future life Ambivalent feeling about the country Accepting reality of caregiving situations
8. Lee and Kim (2009) (Qualitative research)	Frail elderly couples (N = 8)	Mean age not specified (about 60–80 years) Male (n = 4) Female (n = 4)	Not applicable	Unexpected caregiving role (perceived negative event) Care recipients had high levels of suicide intention due to feeling sorry for their spousal caregivers Marital conflicts due to caregiving Blame each other Limited communication in the couple’s relationship Domestic violence to wife (i.e. battering)
9. Lee and Kim (2012) (Quantitative Survey)	Spousal caregivers to cancer survivors (N = 203)	52.6 years (20–70 years and older) Male (n = 84) Female (n = 119)	Predictors (CG): caregiving burden, social support, age, gender, income, and education Predictors (CR): period of illness and cancer stage Outcome: marital adjustment	Caregivers’ higher levels of caregiving burden, lower social support, being male, and lower education levels were significantly associated with lower levels of marital adjustment Survivors’ longer period of illness was significantly associated with lower levels of marital adjustment in caregivers
10. Lee and Han (2010) (Quantitative Survey)	Spousal caregivers to cancer survivors (N = 197)	52.7 years (20–79 years) Male (n = 80) Female (n = 117)	Predictors (CG): social support, self-esteem, age, gender, income, education, number of children, years of marriage Predictors (CR): period of illness and cancer stage Outcome: caregiving burden	Caregivers’ lower levels of social support, lower self-esteem, and being female were significantly associated with higher levels of caregiving burden
11. Jeon (2011) (Quantitative Survey)	Spousal caregivers to mental illness patients (N = 109)	46.5 years (21–65 years and older) Male (n = 61) Female (n = 48)	Predictors (CG): age, gender, religion, education, income, number of children, and age of first child Predictors (CR): types of mental illness, symptoms of mental illness, period of illness, medication management, and time since onset Predictors (couple): reciprocal communication and sexual satisfaction Outcome: family stress	Caregivers’ lower levels of reciprocal communication, greater numbers of children, and lower age of first child were significantly associated with higher levels of stress in spousal caregivers Patients having no medication management was significantly associated with higher levels of stress in spousal caregivers
12. Choi and Eun (2000) (Mixed method approach: Quantitative survey and Qualitative interview)	Spousal caregivers to spouses with chronic diseases (N = 183 for quantitative method; N = 23 for qualitative method)	55.2 years (age range not specified) Gender (not specified)	Predictors (CG): income, education, employment, religion, number of family members, and caregivers’ seriousness Predictors (CR): age, education, number of hospitalizations, treatment options, patient’s anxiety, patient’s seriousness, and patient’s dependence Outcome: caregiving burden	In quantitative method, patients’ higher age, seriousness, and dependence and caregivers’ higher seriousness were significantly associated with higher burden in caregivers In qualitative method, caregivers expressed negative experiences related to caregiving, including taking care of patients’ symptoms, having caregiving role, doing house chores, managing self-coping, facing financial problems, meeting limitations in life, and having various problems related to aging In qualitative method, caregivers showed various coping strategies, such as having coping behaviors, using social (family) support, and having a sense of companionship toward their care recipients
13. Choi et al. (2000) (Quantitative survey)	Spousal caregivers to rheumatoid arthritis patients (N = 107)	48 years (39 or less to 9 years) Female (N = 107)	Predictors (CG): age, religion, years since marriage, education, income, number of family members, having chronic diseases, and perceived seriousness Predictors (CR): year of diagnosis, having hospitalization, number of hospitalizations, type of treatment, perceived discomfort, perceived seriousness, and dependence Outcome: caregiving burden	Caregivers’ higher age and higher levels of perceived seriousness were significantly associated with higher levels of caregiving burden Patients’ higher age and higher levels of dependence were significantly associated with higher levels of caregiving burden of caregivers
14. Choi (2012) (Qualitative research)	Spousal caregivers to frail spouses (N = 14)	78.3 years (66–85 years) Male (N = 14)	Not applicable	Feeling burden for taking multiple roles Unexpected caregiving role (perceived negative event) Blame offspring due to limited supports Feeling uncertain
15. Han and Son (2009) (Quantitative Survey)	Spousal caregivers to frail spouses (N = 321)	73.7 years (50–80 years and older) Male (n = 151) Female (n = 170)	Predictors (CG): gender, income, health status (self-rated health), period of caregiving, motivation of caregiving, and quality of family relationship Predictors (CR): functional disability and cognitive disability Outcomes: caregiving burden	Caregivers’ higher income, lower health status, and negative family relationships after caregiving were significantly associated with higher levels of caregiving burden Caregivers’ higher income, higher period of caregiving, positive family relationships before caregiving and more positive family relationships after caregiving were significantly associated with higher levels of gain from caregiving experiences
16. Han and Lee (2009) (Quantitative Survey)	Spousal caregivers to frail spouses (N = 355)	73.3 years (age range not specified) Male (n = 126) Female (n = 229)	Predictors (CG): age, education, house type (couple), health status, income, period of caregiving, motivation of caregiving, and social support Predictors (CR): cognitive disability and ADL Outcomes: caregiving burden (financial, emotional, and physical burdens)	Shorter period of caregiving and higher motivation (no options) were significantly associated with higher levels of financial burden in male caregivers Care recipients’ lower levels of ADL and lower social support were significantly associated with higher levels of financial burden in female caregivers Lower health status and care recipients’ lower levels of ADL were significantly associated with higher levels of physical burden in male and female caregivers Higher education and higher motivation (no options) were significantly associated with higher levels of emotional burden in male caregivers Being couple households and care recipients’ lower levels of ADL were significantly associated with higher levels of emotional burden in female caregivers
17. Han and Park (2012) (Quantitative Survey)	Male spousal caregivers to wives with stroke (N = 121)	71.3 years (65–85 years) Male (N = 121)	Predictors (CG): age, income, health status, income, depression, family support, quality of patients’ and caregivers’ relationship, and caregivers’ activity time for caregiving (min/day) Predictors (CR): cognitive status and dependencies Outcomes: caregiving burden and health-related quality of life (HRQOL)	Caregivers’ higher activity time for caregiving and higher depression were significantly associated with higher levels of caregiving burden Patients’ higher levels of dependence and lower levels of cognitive status were significantly associated with higher levels of caregiving burden in caregivers Caregivers’ lower levels of depression, lower objective health status, and higher subjective health status were significantly associated with higher levels of HRQOL Patients’ higher cognitive status was significantly associated with higher levels of HRQOL in caregivers
18. Hong et al. (2012) (Quantitative Survey)	Spousal caregivers to spouses with chronic diseases (N = 142)	60.6 years (65–85 years) Male (n = 52) Female (n = 89) No answer (n = 1)	Predictors (CG): age, gender health status, economic status, period of caregiving, interpersonal personality (extroversion and neurosis), marital satisfaction, and social support Predictors (CR): ADL Outcomes: depression	Caregivers’ higher levels of neurosis and patients’ higher ADL were significantly associated with higher levels of depression in caregivers

CG: caregiver; CR: care receiver; ADL: activities of daily living.

Measures

Among various caregiving problems mentioned in the articles, the caregiving burden was the most frequent variable used in the studies, followed by stress (1, 2, 11), depression (4, 18), adaptation and adjustment (3, 9), and marital satisfaction and conflict (4). To measure the caregivers’ burden, three studies (6, 12, 16) used the Zarit burden instrument (Zarit et al., 1986). Other studies used different scales to measure caregiving burdens: role captivity (15) developed by Pearlin et al. (1990), the subjective burden scale (15) developed by Montgomery et al. (1985), the sense of competence questionnaire (17) translated by Choi-Kwon et al. (2005), and the caregiver reaction assessment (10) developed by Given et al. (1992). Some research included caregiving factors faced by spousal caregivers: caregiving hours (2, 17), period of caregiving (15, 16, 18), motivation of caregiving (15, 16), situational definition (3), and perceived seriousness of caregiving (12, 13). In addition, factors related to marriage, marital life, and family were included: years since marriage (10, 13), quality of family relationship (15), quality of patients and caregivers’ relationship (17), and marital satisfaction (2, 18).

Significantly, various studies included factors related to care recipients in the caregiving settings to predict the problems of spousal caregivers. Specifically, some studies included factors related to care recipients such as care-receiving and health conditions, period of hospitalization and number of health problems (2, 9, 10, 11, 12, 13), health conditions and symptoms (2, 11), cancer stage (10), use of long-term care service (4), medication management (11), and time of onset (11). Also, many studies measured factors related to cognitive ability and mental health: seriousness and dependence (12, 13, 17), cognitive ability (15, 16, 17), anxiety (12), and activities of daily living (ADL) (16, 18). One study (11) included reciprocal communication and sexual satisfaction as predictors in its research model. In addition, various predictors were used in these studies. Among demographic characteristics, age was the most frequently used variable (2, 4, 9, 10, 11, 13, 16, 17, 18), followed by income, education, gender, religion, and employment.

Caregiving problems in spousal caregivers

The articles reviewed in this study analyzed various caregiving problems and couple conflicts. Many studies found that assuming the caregiving role caused various caregiving-related problems in spousal caregivers (2, 4, 6, 10, 11, 12, 13, 15, 16, 17, 18): stress, caregiving burdens, and depressive symptoms. In the studies, spousal caregivers’ higher caregiving hours and perceived lower social and care support significantly predicted their higher levels of stress (2, 11). Also, care recipients’ reactions and conditions also predicted the caregiving stress of spousal caregivers. For example, one study revealed that care recipients’ longer period of hospitalization, more severe injuries, and worse convalescence were significantly associated with higher stress in their spousal caregivers (11). Spousal caregivers’ higher caregiving burden has been significantly associated with more caregiving hours and tasks (17), lower health status (6, 15), lower social support (10), lower self-esteem (10), worse depression (17), higher levels of perceived seriousness (12, 13), negative family relationships (15), being female (10), and higher age (13).

Care recipients’ health conditions and problems were one of the crucial factors influencing caregiving-related problems (e.g. burden and stress) in spousal caregivers. In the articles, the caregivers’ higher burden was predicted by various physical and mental health conditions and the demographics of their care recipients: higher age (12), higher dependence (12, 13, 17), lower levels of ADL (16, 17), lower levels of cognitive status (17), and higher age (13). One of the qualitative studies reported that spousal caregivers had various negative feelings after their wives were diagnosed with breast cancer (1). For example, the husbands worried about future life without their wives and felt guilty about their wives’ diagnosis with cancer. These results suggest that spousal caregivers’ caregiving problems can be predicted not only by caregivers’ caregiving-related factors, but also by the characteristics and vulnerabilities (e.g. health problems) of their care recipients.

Many researchers have found that caregiving causes marital problems. Some researchers have reported that care recipients’ longer period of illness was significantly associated with lower levels of marital adjustment on the part of the caregivers (9). One study showed that spousal caregivers’ lower health satisfaction and no use of long-term care service for care recipients was significantly associated with lower marital satisfaction, and lower health satisfaction of spousal caregivers was significantly associated with higher marital conflict (4). With regard to marital problems, some qualitative studies have revealed results presenting marital problems (1, 8, 14). According to these studies, couples experienced marital conflicts due to caregiving roles and tasks. One of the reasons reported was that the couples felt isolated from communities and social ties (8). They experienced very limited social and family support and had to depend on each other. This increased dependence led to additional expectations and required that each fulfill more roles for the other. Consequently, these demands caused marital conflicts. Other quantitative studies (12, 13, 17) have supported this result: higher levels of dependence in care recipients significantly predicted higher caregiving burden for spousal caregivers.

The relationships between caregiving and negative communication in the couples (i.e. both spousal caregivers and care recipients) have been documented. For example, one study (11) showed that lower levels of reciprocal communication were significantly associated with higher levels of stress in spousal caregivers. Another study reported that frail elderly couples blamed each other for caregiving issues (e.g. caregiving burdens and care recipients’ limited expression of appreciation for caregiving), and they reported limited communication regarding their couple relationship (8). This is because the elderly couples distrusted each other; care recipients were highly demanding and imposed great responsibilities and duties on caregivers (e.g. self-sacrifice, endeavor) and caregivers expected certain attitudes from care recipients (e.g. gratitude, respect). However, these responsibilities and attitudes generally did not match each spouse’s expectations, and these unmet needs caused communication and relationship problems.

Summary

In the reviewed studies, most spousal caregivers were elderly females. This sample structure was similar to that of prior caregiving research in Western countries. However, this study also confirmed that many Korean male elderly cared for their wives in caregiving settings. The reviewed studies included various indexes and scales measuring objective and subjective caregiving-related stressors faced by spousal caregivers. Objective stressors stem directly from the care receiver’s disease and reflect the care needs and caregiving tasks related to such needs (Pearlin et al., 1990). The objective stressors in the research reviewed were, for example, caregiving hours and periods of caregiving. Various subjective stressors, such as perceived seriousness, subjective burden, and role captivity, were also measured in those studies. Subjective stressors reflect the individuals’ subjective perceptions or appraisal of their role – specifically, their caregiving role (Pearlin et al., 1990). Using these factors, the examined studies focused on the negative perceptions of spouse caregivers toward their care receivers because spouse caregivers have a high prevalence of negative perceptions arising from caregiving situations (e.g. frail spouses’ health problems), which highly affects the appraisal of their caregiving role.

Spousal caregivers remain in a vulnerable position because they must cope with various caregiving burdens arising from their spouse’s health problems and conditions. Many couples experience various mental problems (e.g. depression, fear), physical problems (e.g. side effects), and caregiving demands regarded as caregiving-related stressors. For example, some couples experience side effects such as hair loss while taking medical treatments, as well as mental problems such as feelings of guilt and fear (Kwon and Yi, 2013). Moreover, caregivers typically take on additional caregiving tasks such as house chores and financial responsibilities (Choi and Eun, 2000; Kwon and Yi, 2013). In addition, according to the studies examined, there is evidence of correlations between the frail spouse’s physical/health problems and the spousal caregiver’s burden and mental health problems. Some researchers reported that the frail spouse’s low levels of ADL predicted caregivers’ high levels of caregiving burdens (Han and Lee, 2009; Hong et al., 2012). Also, care recipients’ high physical limitations and poor cognitive status were significantly associated with their caregivers’ high levels of depression (Han and Park, 2012). The negative experiences of caregivers have also been widely documented in prior caregiving studies (Hoffman et al., 2007; Van Houtven et al., 2010) conducted in Western countries. Based on systematic review, Meyler et al. (2007) reported evidence of concordant mental and physical health as well as health behaviors (e.g. smoking) among couples.

Couple communication related to caregiving and health problems does not occur in a vacuum, but it is a subset of couples’ general communication affecting their marital satisfaction and psychological state (Kornblith et al., 2006). Previous studies on cancer caregiving (Hilton and Koop, 1994; Manne et al., 2006) identified two different communication patterns affecting couples’ mental conditions: (1) mutual avoidance and demand withdrawal communication (i.e. negative pattern) and (2) constructive communication (i.e. positive pattern). In the reviewed articles, Korean couples also showed both negative patterns (Lee and Kim, 2009) and positive patterns (Kwon and Yi, 2013). Despite the positive patterns, from this review this study confirms that marital and communication problems can derive from caregiving burdens. In other words, negative couple communication is influenced by various caregiving burdens. In turn, this affects the mental health (e.g. depression) of caregivers.

Discussion

This study reviewed 18 spousal caregiving studies to identify caregiving problems in Korean couples with one frail spouse. In most caregiving research reviewed, the research participants were middle-aged or older adults. Some studies showed a gender difference in caregiving problems (Lee and Han, 2010; Lee and Kim, 2012), but many studies did not.

Given the results from the articles reviewed, in Korean couples, caregivers’ caregiving burden and stress were related to caregiving situations (e.g. tasks, hours), relationships with others (e.g. social supports), and care recipients’ vulnerabilities (e.g. health conditions, dependence). As care recipients’ physical symptoms increase, spousal caregivers take on additional roles and adjust their daily lives to their frail spouse’s needs (i.e. changes in household chores). The changed roles and responsibilities create a burden for caregivers (Choi, 2012; Choi and Eun, 2000; Lee and Kim, 2009). In addition, some studies reviewed (Han and Lee, 2009; Yoon and Kim, 2009) reported that care recipients’ poor health conditions were related to caregivers’ financial strain and schedule disruption. Although caregivers’ burden was significantly predicted by their spouse’s health problems, there is clear evidence of the mutual influence of mental and physical health on both spouses. This finding corroborates the findings of previous caregiving research conducted in Western societies: caregivers have to endure reducing working hours (Wilson et al., 2007), wage penalties (Heitmuellera and Inglisb, 2007), more time off work (Curt et al., 2000), significant outlays for medical treatment (Grunfeld et al., 2004), as well as caregiving, which leads to sacrificed leisure time (Van Houtven et al., 2010).

This study also found that couples had communication problems. With caregiving stress, communication problems were among the main reasons aggravating couples’ relationships (e.g. marital conflicts). This study verified that caregiving stress and burden were the main factors causing negative couple communication between Korean couples. According to the papers reviewed, many couples showed negative communication, and this type of communication easily caused severe marital conflicts. One study reported that a male spousal caregiver (husband) battered his wife because of conflicts related to caregiving (Lee and Kim, 2009). Some couples blamed each other for caregiving issues and showed limited communication (Jeon, 2011; Lee and Kim, 2009). Also, these negative communication patterns easily caused marital conflicts and marital dissatisfaction. Most of the research is concentrated on caregiving burdens, couple communication, and marital satisfaction. Many studies have found much evidence for close relationships between couple communication and caregiving burden, but they have limitations in showing patterns of couple communication. In other words, positive couple communication (e.g. mutual constructive communication) has received less attention than negative communication patterns. As mentioned earlier, couple communications have binary functions and each function strongly affects the caregiving burdens of the caregiver. The reviewed research usually focused on negative communication in couples, and there is limited knowledge related to this relationship in care settings for Korean couples.

It is worth noting that none of the reviewed research employed a longitudinal design. Longitudinal studies would permit examination of relationships between caregiving-related stressors and burdens, and between communication problems and burdens, over time. Such longitudinal investigations of a frail spouse, such as a cancer patient, may be particularly informative when change is examined across the cancer survivorship trajectory (e.g. active treatment, adjuvant therapy, long-term survivorship, palliation, end-of-life care). Thus, longitudinal designs can enhance the understanding of how relationships between couples evolve in the process of caregiving. One obvious gap in the reviewed studies is the paucity of attention paid to theory, that is, an atheoretical approach. Thus, there is limited knowledge about how various theories related to couple interactions can apply to explanations of the relationships among caregiving stress, couple problems, and caregiving burden in Korean couples. By extension, the theoretical mechanisms leading to correlations of health problems among couples are unknown.

Regarding caregiving situations, COR theory can be regarded as a relevant theoretical framework to review the relationship between various stressful contexts and caregiving burdens. According to COR theory, individuals experience stress when situations threaten or result in the loss of their valued materials, status, and relationships. Regarding this theoretical view, caregiving problems faced by Korean spousal caregivers were caused by a loss in their total resources. After taking on caregiving roles, spousal caregivers took on multiple tasks (e.g. caregiving, house chores) and experienced less leisure time and social support from their social networks. In addition, they endured limited communication, support, and help from their frail spouses. All these limitations demonstrate the loss of their resources or failure to gain other resources (e.g. limited leisure), and the loss contributes to their stress in caregiving settings. Moreover, a problematic event involving an individual, either caregiver or care recipient, caused a similar (or different) result in their family member. Milkie (2010) referred to this family situation as stress transfer. She suggested that stress transfer occurs when an event or strain affects one person of the family unit, which in turn affects the roles and living conditions of others in the family unit. Regarding the notion of stress transfer, the articles reviewed in this study revealed that being frail or being a care recipient not only resulted in behavioral restrictions of the frail one, but also introduced restrictions on their caregiver’s work and social activities.

Conclusion

Several limitations are acknowledged in this study. It is possible that some eligible studies could be missed because they were not published in peer-reviewed Korean journals. Also, this study has included only literature published in Korean and in Korean journals regarding issues of spousal caregiving. Since this article was restricted to studies published in Korean journals and did not include a search of other academic papers, only a small number of studies were reviewed. Therefore the researchers cannot be completely certain that other spousal caregiving studies do not exist.

Future research directions related to spousal caregiving are recommended regarding research design, theory, and the view of couple relationships. Many studies employed a cross-sectional design – thus no causal explanations can be based on the associations among care-related stressors, couple problems, and caregiving burdens. A longitudinal design allows for the exploration of reciprocal patterns over time in spousal caregivers’ experiences. Ideally, future research needs to explore the whole phase of spousal caregivers’ experience in caregiving settings, from the time of becoming caregivers to later years (Li et al., 2013), such as the bereavement phase. Another recommendation concerns theoretical frameworks. A theoretical framework has led us to conclude that further research into understanding caregiving problems (Oh, 2015) and limitations based on the view of couple relationships is warranted. If future research adopts a theoretical framework (e.g. stress paradigm), it would help other researchers more easily understand the peculiar problems the spouse caregivers face and thus more readily suggest intervention programs. In conclusion, future study is also needed to develop intervention research for couples with caregiving problems based on (1) theoretical frameworks focusing on couples, (2) the unmet needs of spousal caregivers and care recipients, and (3) couple problems revealed in this review study.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biographies

Youngsam Oh (MSW, Ph.D,) is currently assistant professor in the department of public administration, Pukyong National University in South Korea. His research interests lie in the areas of caregiving, health care and health information seeking. He has presented internationally on these topics in various research papers since 2015.

Eunyoung Han (MSW) is currently a Phd candidate at the Graduate School of Social Welfare at Yonsei University in Seoul, South Korea. She is interested in administration of social work, Human service organizations and community work.

References

Ahn

S.Y.

Kwon

Y.E.

Hong

J.J.

(2005) ‘A Study on the Burden, Health Status and Well-Being in Spouse Caregivers of Patients with Stroke’, Journal of Korean Academy of Adult Nursing 17: 287–97.

Badr

Taylor

C.L.C.

(2006) ‘Social Constraints and Spousal Communication in Lung Cancer’, Psycho-Oncology 15: 673–83.

Caldwell

(2006) ‘Consumer-Directed Supports: Economic, Health, and Social Outcomes for Families’, Mental Retardation 44: 405–17.

Cantor

M.H.

(1983) ‘Strain among Caregivers: A Study of Experience in the United States’, The Gerontologist 23: 97–604.

Chapple

Ziebland

McPherson

(2004) ‘Stigma, Shame, and Blame Experienced by Patients with Lung Cancer: Qualitative Study’, British Medical Journal 328: 1470.

Cho

Zarit

S.H.

Chiriboga

D.A.

(2009) ‘Wives and Daughters: The Differential Role of Day Care Use in the Nursing Home Placement of Cognitively Impaired Family Members’, Gerontologist 49: 57–67.

Choi

H.K.

(2012) ‘A Ground Theory Study on Elderly Male Caregivers of Spouses: Focused on the Structure and Types of Care’, Family and Culture 24: 45–81.

Choi

I.-H.

Kim

J.-H.

(2013) ‘Characteristics of Certified Family Care Providers and Informal Caregivers, and Predictors of Their Caregiving Burden’, Family and Culture 25: 159–85.

Choi

K.S.

Eun

(2000) ‘A Theory Construction on the Care Experience for Spouses of Patients with Chronic Illness’, Journal of Korean Academy of Nursing 30: 122–36.

10.

Choi

K.S.

Eun

Ham

M.-Y.

(2000) ‘A study on Burden of Middle Aged Spouses of Rheumatoid Arthritic Patients’, The Journal of Muscle and Joint Health 7: 241–57.

11.

Choi-Kwon

Kim

H.-S.

Kwon

S.U.

Kim

J.S.

(2005) ‘Factors Affecting the Burden on Caregivers of Stroke Survivors in South Korea’, Archives of Physical Medicine and Rehabilitation 86: 1043–8.

12.

Curt

G.A.

Breitbart

Cella

Groopman

J.E.

Horning

S.J.

Itri

L.M.

Johnson

D.H.

Miaskowski

Scherr

S.L.

Portenoy

R.K.

Vogelzang

N.J.

(2000) ‘Impact of Cancer-Related Fatigue on the Lives of Patients: New Findings from the Fatigue Coalition’, The Oncologist 5: 353–60.

13.

Ensel

W.M.

Lin

(1991) ‘The Life Stress Paradigm and Psychological Distress’, Journal of Health and Social Behavior 32: 321–41.

14.

Given

C.W.

Given

Stommel

Collins

King

Franklin

(1992) ‘The Caregiver Reaction Assessment (CRA) for Caregivers to Persons with Chronic Physical and Mental Impairments’, Research in Nursing & Health 15: 271–83.

15.

Grunfeld

Coyle

Whelan

Clinch

Reyno

Earle

C.C.

Willan

Viola

Coristine

Janz

Glossop

(2004) ‘Family Caregiver Burden: Results of a Longitudinal Study of Breast Cancer Patients and Their Principal Caregivers’, Canadian Medical Association Journal 170: 1795–801.

16.

Han

G.H.

Lee

S.Y.

(2009) ‘The Effect of Motivation and Social Support on Burden of Spouse Caregivers: Focused on Gender Differences’. Journal of Korean Gerontology Society 29: 683–699.

17.

Han

G.-H.

Son

J.-Y.

(2009) ‘The Effects of Motives for Caregiving and Family Relationship Quality on Caregiving Burden/Reward of the Spouse Caregivers of Frail Elderly in Korea: A Focus on Gender Differences’, Journal of Korean Family Study Association 21: 81–109.

18.

Han

J.-H.

Park

Y.-H.

(2012) ‘Caregiver’s Burden and Quality of Life of Male Spouses with Stroke Wives’, The Journal of Korean Academic Society of Adult Nursing 24: 615–26.

19.

Health Insurance Review & Assessment Service (2016) ‘Korea’s statistics for medical expenses during the first half year of 2016’. Available online at: http://www.hira.or.kr/dummy.do

20.

Heitmuellera

Inglisb

(2007) ‘The Earnings of Informal Carers: Wage Differentials and Opportunity Costs’, Journal of Health Economics 26: 821–41.

21.

Hilton

B.A.

Koop

P.M.

(1994) ‘Family Communication Patterns in Coping with Early Breast Cancer’, Western Journal of Nursing Research 16: 366–91.

22.

Hobfoll

S.E.

(1988) The Ecology of Stress. Washington, DC: Hemisphere.

23.

Hoffman

A.J.

Given

B.A.

von Eye

Gift

A.G.

Given

C.W.

(2007) ‘Relationships among Pain, Fatigue, Insomnia, and Gender in Persons with Lung Cancer’, Oncology Nursing Forum 34: 785–92.

24.

Hong

C.Y.

Kim

M.H.

Bang

H.J.

(2012) ‘The Effect of Psychological Factors on Caregiver Burden and Depression of Spousal Caregivers’, Korean Journal of Psychological and Social Issues 18: 367–87.

25.

Jeon

H.S.

(2011) ‘Influencing Factors on Stress of Caregivers with Spouses Having a Mental Illness: Focused on the Biopsychosocial Perspectives’, Korean Journal of Family Social Work 33: 349–73.

26.

Jung

Lee

Y-K

Park

Lee

S.J.

Lee

Y.H.

(2012) Analysis of the Survey of Living Conditions and Welfare Needs of Korean Older Persons. Seoul, Korea: Korea Institute for Health and Social Affairs, pp. 1–183.

27.

Kang

H.J.

(2012) ‘A Study on Elderly Care in the View of Feminism’, Korean Academy of Social Welfare Support 7: 131–51.

28.

Kim

H.-B.

(2005) ‘A Study on Caring Experience from their Spouses Perceived by Hemodialysis Patients: A Grounded Theory’, The Korean Journal of Rehabilitation Nursing 8: 157–64.

29.

Kim

S.H.

Lee

E.S.

(2006) ‘The Stress and Adaptation of the Spouses of Patients with Gynecological Cancer’, Journal of Korean Oncology Nursing 6: 162–71.

30.

Kim

T.-H.

Park

J.-H.

(2014) ‘A Study on Long-Term Care Insurance Service of Elderly Women Spouse Caregiver and Implication of Policy Direction: Focused on Psychological Well-Being and Marital Quality of Elderly Women’, Journal of Family Relations 19: 169–85.

31.

Kim

(2006) ‘New Social Risks, Women’s Poverty, and Poverty Policy’, Korean Journal of Sociology 40: 189–226.

32.

Kim

Y.J.

Lee

P.S.

(1999) ‘A Study on the Burdens and Depressive Reactions on Families Who Cared for Patients Suffering from Senile Dementia’, Journal of Korean Academy of Nursing 29: 766–79.

33.

Kornblith

A.B.

Regan

M.M.

Kim

Greer

Parker

Bennett

Winer

(2006) ‘Cancer-Related Communication between Female Patients and Male Partners Scale: A Pilot Study’, Psycho-Oncology 15: 780–94.

34.

Kwon

E.H.

Koh

H.J.

Park

K.M.

(2003) ‘A Study on Perceived Role Stress and Health Status of Wife Caregivers for Brain Injured Patients’, Journal of Korean Society of Maternal and Child Health 7: 41–55.

35.

Kwon

J.E.

(2013) ‘Husbands’ Caring Experiences for Women with Breast Cancer in Korea’, Asian Oncology Nursing 13: 18–27.

36.

Lee

E.Y.

(2015) ‘Living Arrangements of the Elderly after the Introduction of the Basic Old-Age Pension’, Pension Forum 60: 56–65.

37.

Lee

I.-J.

Han

I.-Y.

(2010) ‘Care Burden among Partners of Cancer Patients’, Korean Journal of Family Social Work 30: 197–224.

38.

Lee

I.J.

Kim

M.Y.

(2012) ‘The Moderating Effects of Social Support on the Relationship between Care Burden and Marital Adjustment in Cancer Patients Spouse’, Korean Journal of Social Welfare Studies 43: 125–50.

39.

Lee

S.-M.

Kim

H.-K.

(2009) ‘Elderly Husbands’ Caregiving for Their Sick Wives: Narratives of Husbands and Wives’, Family and Culture 21: 63–94.

40.

L.W.

Seltzer

M.M.

Greenberg

J.S.

(1997) ‘Social Support and Depressive Symptoms: Differential Patterns in Wife and Daughter Caregivers’, The Journals of Gerontology: Series B 52B: S200–11.

41.

Mak

Loke

(2013) ‘Spouses’ Experience of Caregiving for Cancer Patients: A Literature Review’, International Nursing Review 60: 178–87.

42.

Manne

S.L.

Badr

(2010) ‘Intimacy Processes and Psychological Distress among Couples Coping with Head and Neck or Lung Cancers’, Psycho-Oncology 19: 941–54.

43.

Manne

S.L.

Ostroff

J.S.

Norton

T.R.

Fox

Goldstein

Grana

(2006) ‘Cancer-Related Relationship Communication in Couples Coping with Early Stage Breast Cancer’, Psycho-Oncology 15: 234–47.

44.

Meyler

Stimpson

J.P.

Peek

M.K.

(2007) ‘Health Concordance within Couples: A Systematic Review’, Social Science & Medicine 64: 2297–310.

45.

Milkie

M.A.

(2010) ‘The Stress Process Model: Some Family-Level Considerations’, in Avison

W.R.

Aneshensel

C.S.

Schieman

Wheaton

(eds) Advances in the Conceptualization of the Stress Process, 93–108. New York: Springer.

46.

Montgomery

R.J.V.

Gonyea

J.G.

Hooyman

N.R.

(1985) ‘Caregiving and the Experience of Subjective and Objective Burden’, Family Relations 34: 19–26.

47.

Moon

J.Y.

Choi

Y.J.

Seo

N.K.

(2014) ‘A Comparative Study on Factors Related to the Health Expenditure of Different Household Types of the Elderly with Chronic Disease’, Health and Social Science 36: 285–307.

48.

National Health Insurance Service (2016) ‘Health Insurance Statistics 2015’. Available online at: http://www.nhis.or.kr

49.

Y.S.

(2015) ‘Effects of Voucher System on the Respite Care Service in South Korea: In the View of Social Exchange Theory’, Human Service Organizations: Management, Leadership & Governance 39: 208–18.

50.

Y.S.

Cho

(2015) ‘Examining the Relationships Between Resources and Online Health Information Seeking Among Patients With Chronic Diseases and Healthy People’, Social Work in Health Care 54: 83–100.

51.

Pearlin

L.I.

Mullan

J.T.

Semple

S.J.

Skaff

M.M.

(1990) ‘Caregiving and the Stress Process: An Overview of Concepts and Their Measures’, Gerontologist 30: 583–94.

52.

Pinquart

Sörensen

(2007) ‘Correlates of Physical Health of Informal Caregivers: A Meta-Analysis’, The Journals of Gerontology: Series B 62: P126–37.

53.

Pinquart

Sörensen

(2011) ‘Spouses, Adult Children, and Children-in-Law as Caregivers of Older Adults: A Meta-Analytic Comparison’, Psychology and Aging 26: 1–14.

54.

Rhee

Y.S.

Yun

Y.H.

Park

Shin

D.O.

Lee

K.M.

Yoo

H.J.

Kim

J.H.

Kim

S.O.

Lee

Y.O.

Kim

N.S.

(2008) ‘Depression in Family Caregivers of Cancer Patients: The Feeling of Burden as a Predictor of Depression’, Journal of Clinical Oncology 26: 5890–5.

55.

Schulz

Beach

S.R.

(1999) ‘Caregiving as a Risk Factor for Mortality: The Caregiver Health Effects Study’, JAMA 282: 2215–9.

56.

Silverstein

Giarrusso

(2010) ‘Aging and Family Life: A Decade Review’, Journal of Marriage and Family 72: 1039–58.

57.

Siminoff

L.A.

Wilson-Genderson

Baker

(2010) ‘Depressive Symptoms in Lung Cancer Patients and Their Family Caregivers and the Influence of Family Environment’, Psycho-Oncology 19: 1285–93.

58.

Song

D.-Y.

(2008) ‘A Study on the Development of Family Support Service for Work and Family Compatibility’, Journal of Korean Social Welfare Policy 34: 7–33.

59.

Van Houtven

C.H.

Ramsey

S.D.

Hornbrook

M.C.

Atienza

A.A.

van Ryn

(2010) ‘Economic Burden for Informal Caregivers of Lung and Colorectal Cancer Patients’, Oncologist 15: 883–93.

60.

Wilson

M.R.W.

Van Houtven

C.H.

Stearns

S.C.

Clipp

E.C.

(2007) ‘Depression and Missed Work among Informal Caregivers of Older Individuals with Dementia’, Journal of Family and Economic Issues 28: 684–98.

61.

Yoon

H.-S.

(2013) ‘Korea: Balancing Economic Growth and Social Protection for Older Adults’, The Gerontologist 53(3): 361–8.

62.

Yoon

J.H.

Kim

Y.K.

(2009) ‘Elderly Spouses’ Experience in Caring for their Veterans Husband’, Qualitative Research 10: 103–16.

63.

Zarit

S.H.

Todd

P.A.

Zarit

J.M.

(1986) ‘Subjective Burden of Husbands and Wives as Caregivers: A Longitudinal Study 1’, The Gerontologist 26: 260–6.

64.

Zhang

A.Y.

Siminoff

L.A.

(2003) ‘Silence and Cancer: Why do Families and Patients Fail to Communicate?’, Health Communication 15: 415–29.