1 CAREGIVING PREPAREDNESS , AND ATTITUDES TOWARDS THEIR OLDER RELATIVES AMONG COLLEGE STUDENTS By GUNGEET JOSHI A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIR EMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2014
2 Â© 2014 Gungeet Joshi
3 T o m y parents, husband, and beloved children for their constant support and unconditional love. I love you all dearly
4 ACKNOWLEDGMENTS I wo uld never have been able to finish my dissertation without the guidance of my committee members, help from friends, and support from my family and husband. I would like to express my special appreciation and thanks to my advi sor and co advisor Professor Ch ris tine Stopka and Dr. Morgan Pigg , they have been tremendous mentors for me. I would like to express my deepest gratitude to my advisor Dr. Stopka for corrective criticism, strengthening my writing and social skills and providing an opportunity to work in a community based participatory research with awesome Sidney Lanier school students. Her generosity and advice on both research as well as on my career have been priceless and her enthusiasm for my subject area was often the nudge I needed to push forward . I would like to thank Dr. Pigg for his guidance and unsurpassed knowledge of behavior theories and research. His valuable suggestions not only allowed me to gr ow as a research scientist but also become a better individual as well. I owe a lot to his pati ent listening and helpful suggestions. I also greatly appreciate the guidance and support given by Dr. Salvador Gezan; his expertise in statistical analyses and simple teaching made me adept in the subject which was once most intimidating to me . I could no t have completed this research without the help and suggestions of Dr. Mark Tillman and Dr. Adam Barry . A special thank you goes to Dr. Jay Bernhardt and Dr. Thomas Clanton for providing the funding which allowed me to complete the degree, but also for giv ing me the opportunity to attend conferences and meet so many interesting people. I am blessed not only professionally, but personally. I am thankful for my parents, Rabinderjit and Kanwal Mahindra, who motivated and encouraged to set goals and work hard . I am grateful for their consistent prayers, love, suppor t, and words of
5 encouragement. I am also grateful to my brother, Bunny, for believing in what I did and said. Additionally , I am truly grateful for the prayers of my extended family as well. My Aunt Kamal, Uncle Baljit, and Cousins Sunny, Money, Kimmy, Kaku prayed for me daily. A special thank you to my brothers in law Vikas, Ankush, and Milind and sister in law Rakhee for being supportive and taking care of kids while I fulfilled my academic requir ements. I feel blessed to have Sunil, as my soul mate, best friend and husband. He has been a true and great supporter and has unconditionally loved me during my good and bad times. He has been non judgmental of me and instrumental in instilling confidence . He is the best father as he provided kids with love and affection while I worked. These past several years have not been an easy ride, both academically and personally. I truly thank Sunil for being by my side, even when I was irritable and depressed. I feel that what we both learned a lot about life and strengthened our commitment and determination to each other and live life to the fullest. I am also grateful for the sweetness of my daughters Tvisha and Tavya, who filled my life with joy and uncondition al love. A good support system is important to surviving and staying sane in grad school. I would especially like to thank Sarah Deutschlander, and Sarah Napolitano, for assisting me wh en I recruited participants, and entered data. I am also thankful to m y fellow students including Bethany Tenant, Julia Varnes, Holly Moses, Caroline Payne, and Zeerak Haider who were a great support system throughout my academic journey in Department of Health Education and Behavior . I am also thankful for the encouragement and support my friends; Preeti, Gurjit, Ankur, Pooja, Pulkit, Maninder
6 and Sameera provided. Special thank you for my friends from Sidney Lanier fitness program Mona, Jerely ne, Chelsea, Stephanie and Rebe k ha to introduce me to the amazing program and taug ht excellent editing and presentation skills . Last, but most certainly not least, I am thankful for the support and suggestions I received from the Department of Health Education behavior faculty and staff to complete the dissertation. For any errors or i nadequacies that may remain in this work, of course, the responsibility is entirely my own.
7 TABLE OF CONTENTS ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF FIGURES ................................ ................................ ................................ ........ 12 LIST OF ABBREVIATIONS ................................ ................................ ........................... 13 ABSTRACT ................................ ................................ ................................ ................... 14 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 16 Researc h P roblem ................................ ................................ ................................ .. 19 Rationale ................................ ................................ ................................ ................. 23 Significance ................................ ................................ ................................ ............ 24 Research Questions ................................ ................................ ............................... 25 Delimitations ................................ ................................ ................................ ........... 25 Limitations ................................ ................................ ................................ ............... 26 Assumptions ................................ ................................ ................................ ........... 26 Definition of Terms ................................ ................................ ................................ .. 26 2 REVIEW OF THE LITERATURE ................................ ................................ ............ 28 Role of Caregivers ................................ ................................ ................................ .. 28 Aging Population and Caregivers ................................ ................................ ..... 28 Family Caregiving ................................ ................................ ............................. 29 College students/ Young adults as Caregivers ................................ ................. 33 Factors affecting Caregivers ................................ ................................ ................... 36 Cos ts of Caregiving ................................ ................................ .......................... 36 Health Risks of Caregiving ................................ ................................ ............... 37 Cultural and Ethnic Factors in Caregiving ................................ ........................ 40 Preparedness of Caregiving ................................ ................................ ............. 43 Attitude towards older population ................................ ................................ ............ 45 Theory of Planned Behavior and Attitude towards older adults. ............................. 47 3 METHODS ................................ ................................ ................................ .............. 54 Research Design ................................ ................................ ................................ .... 54 Research Variables ................................ ................................ ................................ 54 Participants ................................ ................................ ................................ ............. 54 Instruments ................................ ................................ ................................ ............. 55 Caregivi ng Preparedness Scale ................................ ................................ ....... 56 Refined Aging Semantic Differential scale ................................ ........................ 57 General Profile Information ................................ ................................ ............... 58 Expert Review (Face validity) ................................ ................................ ........... 59 Pilot Study One ................................ ................................ ................................ ....... 59
8 Participant Recruitment ................................ ................................ .................... 59 Procedure ................................ ................................ ................................ ......... 60 Pilot study Two ................................ ................................ ................................ ....... 60 Participant Recruitment ................................ ................................ .................... 60 Procedure ................................ ................................ ................................ ......... 61 Data Analysis ................................ ................................ ................................ ... 61 Final Study ................................ ................................ ................................ .............. 61 Participant Recruitment ................................ ................................ .................... 62 Procedures ................................ ................................ ................................ ....... 62 Data Analysis ................................ ................................ ................................ ... 63 Summary ................................ ................................ ................................ ................ 65 4 RESULTS ................................ ................................ ................................ ............... 68 Demographic Characteristics ................................ ................................ .................. 68 Role as Caregivers ................................ ................................ ................................ . 69 Quality of Experiences and Interactions with OR ................................ .................... 71 Attitudes ................................ ................................ ................................ .................. 72 Preparedness to Take Care Of Older Relatives In Future ................................ ...... 74 Relationship between Attitudes towards OR and Preparedness for Caregiving ..... 76 Theory of Planned Behavior Constructs ................................ ................................ . 76 Perceived Behavioral Control ................................ ................................ ........... 76 Subjective No rms ................................ ................................ ............................. 77 Intentions ................................ ................................ ................................ .......... 77 Theory of Planned Behavior ................................ ................................ ............. 77 5 DISCUSSION ................................ ................................ ................................ ......... 99 Study Population and Previous Caregiving Activities ................................ ............ 100 Attitudes towards Older Relatives ................................ ................................ ......... 102 Preparedness to take care of older relatives in future ................................ ........... 105 Constructs of Theory of Planned Behavior ................................ ........................... 106 Implications and Future Research ................................ ................................ ........ 108 Recommendations ................................ ................................ ................................ 109 Conclusions ................................ ................................ ................................ .......... 110 APPENDIX A RELIABILITY ANALYSIS TABLES ................................ ................................ ....... 112 B INSTITUTIONAL REVIEW BOARD SUMMER 2013 SUBMISSION FORM ......... 114 C CON SENT FORM ................................ ................................ ................................ . 117 D SURVEY FORM ................................ ................................ ................................ ... 118 LIST OF REFERENCES ................................ ................................ ............................. 125
9 BIOGRAPHI CAL SKETCH ................................ ................................ .......................... 140
10 L IST OF TABLES Table page 3 1 Demographic Distribution of Pilot test Sample Population ................................ .. 66 3 2 Pilot Survey Attitude towards Older Relatives Scores and distribution ............... 66 3 3 Pilot Survey Attitude towards Older Adults Scores and distribution .................... 67 3 4 Pilot Survey Preparedness Scores and distribution ................................ ............ 67 3 5 Reliability analysis of sub scales ................................ ................................ ........ 67 4 1 Distribution of Participants by Class, Marriage, gender, SES and Major. ........... 80 4 2 Age Variable ................................ ................................ ................................ ....... 81 4 3 Frequency Analysi s Results for Provided Unpaid Care in Past 12 Months ........ 81 4 4 Frequency Analysis Results for Likely Responsible For Older R elatives ............ 81 4 5 Frequency Analysis Results for Family Members Need to Take Care ................ 81 4 6 Frequency Analysis Results for Providing Instrumental Activities of Daily Living ................................ ................................ ................................ .................. 82 4 7 Frequency Analysis Results for Providing Activities of Daily Living .................... 82 4 8 Frequency Analysis Results for Providing Other Activities ................................ . 82 4 9 Frequency Analysis Results for Use of Technology for Caregiving .................... 83 4 10 Frequency Analysis Results for Quality of experiences with Older Relatives ..... 83 4 11 Frequency Analysis Results for Quality of experiences with Older Adults .......... 84 4 12 Frequency Analysis Results for Interaction with older relatives .......................... 84 4 13 Summary of Multiple Regression Analysis of In dependent Variables Predicting Quality of Experience with OR ................................ ........................... 84 4 14 Summary of Multiple Regression Analysis of Independent Variables Predicting Quality of Experience with OR ................................ ........................... 85 4 15 ANOVA of Quality of Experience with OR with differ ent ethnic groups ............... 85 4 16 Analysis Results for Attitudes towards Older Relatives and Older Adults ........... 85
11 4 17 Summary of Multiple Regression Analysis of Independent Variables with Attitudes towards Older Relatives ................................ ................................ ....... 86 4 18 Multiple Regression Analysis of Independent Variables with Attitudes towards Older Relatives ................................ ................................ ................................ ... 86 4 19 Analysis Results for Preparedness Score N=722 ................................ ............... 87 4 20 Frequency Analysis Results for Preparedness for Caregiving ............................ 88 4 21 Summary of One way ANOVA of Preparedn ess Scores with previous caregiving activities ................................ ................................ ............................ 89 4 22 Summary of Multiple Regression Analysis of Independent Variables wi th Preparedness Scores ................................ ................................ ......................... 89 4 23 Hierarchical Regression Analysis of Independent Variables with Preparedness Scores ................................ ................................ ......................... 90 4 24 Summary of Linear Regression Analysis of Attitudes towards OR with Preparedness to take care (f=722) ................................ ................................ ..... 90 4 25 Linear Regression Analysis of Attitude Scores with Preparedness Scores ........ 90 4 26 Fre quency Analysis Results for Perceived Behavioral Control for Caregiving .... 91 4 27 Frequency Analysis Results for Subjective Norms about Caregiving ................. 92 4 28 Frequency Analysis Results for Intentions about providing c are to Older ........... 92 4 29 Summary of Hierarchical Regression Analysis of Theory of Planned Behavior Constructs with Intentions to provide care ................................ .......................... 93 4 30 Hierarchical Regression Analysis of Theory of Planned Behavior Constructs with Intentions to Provid e care ................................ ................................ ............ 94
12 LIST OF FIGURES Figure page 2 1 Theory of Planned Behavior (Source: Aizen, 1991) ................................ ............ 53 4 1 Normal P P Plot of Regression Standardized Residual of Attitude towards older adults Score ................................ ................................ ............................... 96 4 2 Normal P P Plot of Regression Standardized Residual of Preparedness Score ................................ ................................ ................................ .................. 96 4 3 Normal P P Plot of Regression Standardized Residual of Intentions Score ....... 97 4 4 Means Plot between P reparedness Mean and Provided IADL in past 12 months ................................ ................................ ................................ ................ 97 4 5 Means Plot between Preparedness Mean and Provided ADL in past 12 months ................................ ................................ ................................ ................ 98 4 6 Means Plot between Preparedness Mean and Provided Other Activities of Caregiving in past 12 months ................................ ................................ ............. 98
13 LIST OF ABBREVIATION S OA Any person 65 years and older OR Older Relative, any person 65 years and older who i s related by blood or marriage PCS Preparedness For Caregiving scale is a caregiver self rated instrument that consists of eight items that asks caregivers how well prepared they believe they are for multiple domains of caregiving RASDS Refined Aging Sem antic Differential scale is used to measure attitude towards for older adults in general.
14 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy CAREGIVING PREPAREDNESS , AND ATTITUDES TOWARDS THEIR OLDER RELATIVES AMONG COLLEGE STUDENTS By Gungeet Joshi August 2014 Chair: Christine Stopka Cochair: Morgan Pigg Major: Health and Human Performance The 2010 US census reveale d a rapidly growing population of older adults, and predicted that the U.S population will include 88.5 million (more than 21 % ) over age 65 by 2050 . As more people live to the oldest ages, they suffer from multiple chronic conditions thus creating an extr a ordinary demand for health care services. Due to the recent economic downturn and lack of professional caregivers , the burden of care tends to fall on family including young college going adults. The dependency of aged individuals cultivates different at titudes towards them among the young adults and influence s general care, and services elderly receive. Thus, it is essential to understand their attitude towards older adults and their preparedness for the role of informal family caregivers. A cross sectio nal survey research method was used which included the Caregiving Preparedness Scale (CPS), Refined Aging Semantic Differential scale (RASD) , and demographic profile information. Data from 720 university enrolled undergraduate and graduate students were en tered into SPSS and analyzed using
15 descriptive and multivariate statistics. Most of the participants were females ( 74 %), juniors (33.6%) and identified themselves as white/Caucasian (56 .1 %). Mean scores revealed a positive attitude of the students towards their older relatives (56. 19 5Â±2 6. 41, CI at 95%= 53.19 57.17 ) and other older adults ( 66.72 Â± 24.15 , CI at 95%= 64.45 68.06 ) but the mean scores from CPS reported the students were not too well prepared ( 1.85 Â± 0.97 , CI at 95%= 1 78 1.93 ) to take care of their older relatives in future. The theory of planned behavior constructs including attitude, subjective norms, and perceived behavioral control contributed significantly towards the intentions to serve as informal caregivers by the college students. I mplica tions of the study are two fold, for health care providers including geriatrics, health educators, and patient educators, to involve, educate, and develop strategies to assist this particular group of young adult population in providing care to older popul ation . For a cademic professionals who may develop curriculum to improve caregiving preparedness levels . One of the salient findings of the study was identifying TPB to explore the intentions of informal caregiving and thus has implications of including bro ader population in terms of gender, age, and ethnicity.
16 CHAPTER 1 INTRODUCTION The 2010 US census revealed a rapidly growing population of age 65 and older adults, representing 13 % (40.3 million) of the total U.S population. The census also reported a fa ster growth rate for older population than the total population. The 65 and older population grew 15.1 % , while the total US population grew 9.7 % . The 85 94 years old group grew by 29.9 % , increasing from 3.9 million to 5.1 million from 2000 to 2010 ( US Cens 1964) turned 65 in 2011. According to the US Census Bureau (2012), by 2050 the US population will include 88.5 million (more than 21 % ) over age 65. More than 37 million people in this group (60 % ) will manage more than one chronic condition by 2030 (American Hospital Association [AHA], 2007), increasing the demand of health care facilities in the society. Longevity of life may be attributed to the advancement of medical care and techn ology. On the other hand, as more people live to the oldest ages, they suffer from multiple chronic conditions. The percentage of adults aged 65 and over with both hypertension and diabetes increased from 9% to 15%; prevalence of hypertension and heart dis ease increased from 18% to 21%; and prevalence of hypertension and cancer increased from 8% to 11% from 2000 to 2010, in the respective age groups (Centers for Disease Control and Prevention [CDC], 2012). These conditions affect their performance of daily activities and in turn make them dependent on others for help. For instance, the Federal Interagency Forum on Aging Related Statistics (2010) reported about 42 % of adults over age 65 have physical limitations or need assistance with activities of daily li ving, such as eating, bathing or dressing. The National Center for
17 Health Statistics in 2011 reported that 24.4% of non institutionalized persons age 65 and over in fair or poor health and 7.3% need help with personal care from other persons. Over 1.3 milli on were nursing home residents and over 1 million utilize some kind of home care. This growing population will also create an extra ordinary demand for aging related programs, policies and services (Sidell and Smiley, 2008). Traditionally, families constit ute the backbone of US community based health care system by substantially providing care to their aging members. Over the years, as a result of delayed marriage and childbirth, high rates of divorce and smaller family size the burden of care tends to fall on fewer people in a family. Children (41.3%), spouses (38.4%) or other relatives or friends (20.4%) provide care to the older adults at home (Wolff and Kasper, 2006). Thus, families acquire the role of informal caregiver, who assume responsibility for th e physical and emotional needs of an impaired individual and provide unpaid care to family members or acquaintances (Miller and Keane, 1992., Department of Health and Human Services [DHHS], 1998). In 2004, 85% of 3.7 million of older people in the communit y received family care from their children and spouses (Houser, Gibson, Redfoot and American Association of Retired Persons [AARP], 2010 ). The National Alliance for Caregiving [NAC] and AARP, 2009 reported 51% of family caregivers between the ages 18 and 49. The dependency of aged individuals cultivates different attitudes among the favorableness or unfavorableness towards some stimulus object, behaviors and action ( Ajzen and Fishbein, 1980 ; Ajzen, 2002 ). Attitudes t owards older people influence the
18 a nd Brookover, 2002 p.720. Laditka et al , towards persons based on their advanced age. Y oung adults and men are likely to conceive a significantly negative attitude tow ards older adults (Gellis, Sherman and Lawrance, 2003; Laditka et al , 2004; Rupp, Vodanovich and Crede, 2005). An extensive literature search reports a mixed response of positive and negative attitudes of young college students towards older adults. Stude nts with positive attitudes towards older adults are likely to have favorable beliefs, feelings and behavior towards them (Lee, 2009). Experiences and direct contact with older adults has been associated with positive attitude among young adults (Funderbur k et al , 2006 ; Chase, 2011) an implication for the informal caregiving activities thus resulting in satisfaction of both the caregiver and the care receiver. The negative attitudes towards older population can be a barrier to providing compassionate care by young adults to their older relatives. Thus it is important to understand the attitude of the youth towards aged. Similarly, preparedness for caregiving (i.e ., perceived readiness for multiple domains of caregiving and dealing with the associated stres s) plays an important role for a satisfied and successful caregiving experience. Young family caregivers cater to a large domain of providing care to the elderly including providing assistance with daily activities of living, instrumental activities of dai ly living, management of resources and setting up the services available. The family members face the challenge of using complicated medical equipment and procedures, lack of training and little information for setting up health care services. A majority o f them feel prepared to either spend time
19 prepared for the more complicated tasks of caregiving. The informal role of caregiver can be demanding as well as stressful , especially when the individual does not feel prepared for the tasks and stresses of caregiving. The preparedness of the caregiver not only contributes positively to the overall health of older adults but also the mental and physical well being of the car egiver himself. A higher level of preparedness to provide care to older adults can inculcate positive attitude towards them or vice versa. The literal evidence supports the contribution of attitude, social norms, and intentions towards behavior. The Theory of Planned Behavior establishes a relationship between intentions to and actually adopting a behavior. Predictors such as attitude, subjective norms and perce ived behavior control influence the intentions to perform a behavior. A growing number of young a dults sharing responsibilities as family caregivers make it essential to understand the attitude of young population towards the older adults and their preparedness for the role of informal family caregivers. This study attempts to understand the relations hip between the attitude towards older generation and the preparedness for informal caregiving among the young adults enrolled as university students. Research P roblem Society is experiencing an augmentation in the older adult population. Consequently, ra pidly growing health care needs of the older adults pose an additional demand on health care professionals, who face a shortfall in the necessary numbers of physicians and other advanced medical professionals. The United States will face serious shortages in the combined workforce of physicians, advance practice nurses, and physician assistants over the next two decades (Sargen, Hooker, and Cooper,
20 2011). According to the Paraprofessional Healthcare Institute, Zywiak (2010) reported that the nation will nee d 1.1 million additional direct care workers; and, the Association of Schools of Public Health (ASPH) projected a shortage of 250,000 public health workers by 2020. Furthermore, the American Geriatrics Society reported the increasing demand of geriatrician supply of 36,000 by 2030. Another area experiencing shortage of health professionals include 50,000 nurses and 124,000 physicians by 2025 (Zywiak, 2010). Without an adequate supply of advanced medical professionals and caregivers, it will be impossible to meet the goals of health care for older adults. Thus, the role of family as caregivers will expand to care for their older relatives at home. Increasing at a rate of 2.3% per year during 2000 2030 (DHHS, 2011), older adults constitute the fastest growing population group; w hereas, the number of family members available to provide care is expected to increase by only 25%, at a rate of 0.8% per year (Mack and Thompson, 2001 . 57% of adult Americans either currently provide unpaid care to an adult family memb er or friend, or have provided this care in the past. Two thirds of the population (66 % ) expects to be caregivers in the future and report that it is very likely (43%), or somewhat likely (23%), that they will become a family caregiver at a future time. T hey are most likely to care for their mother (41 % ), father (12 % ), spouse or domestic partner (11 % ), mother in law (7 % ), sibling (6 % ) or father in law (2 % ) (Johnson and Johnson, 2013). The average age of adult caregivers reported is 48 years; about 51 % of caregivers are between the ages of 18 and 49 (N AC, 2009). Young adult caregivers make up between 12% and 18% of the total number of adult caregivers. Over half are male, and the average age is 21 (Levine et al , 2005). In US, Fifty two million caregiv ers provide
21 care to adults (aged 18+) with a disability or illness. Over 43 million care for someone 50+ years of age and 14.9 million care for someone who has Alzheimer's disease or other dementia. Approximately 1.3 million people 65 and older, or 3.1 % of this population, lived in skilled nursing facilities in 2010. In, 2011 c aregiver services were valued at $450 billion per year, a 20% increase from $375 billion in 2007 (AARP, 2009). Thus, family caregiving has an important implication in the current rece ssion situation. As healthcare dollars shrink, the economic burden of the society can be eased by using family members as caregivers. In the present economic downturn, u npaid family caregivers are likely to continue to be the largest source of long term ca re services in the US and it is anticipated that a larger proportion of adult children will become caregivers. 44% of primary family caregivers were adult children, and caregivers of older adults (age 50+) are likely to be taking care of their mother (34%) , grandmother (11%), or father (10%) (NAC and AARP, 2004). Thus, it will not be uncommon for some young informal caregivers to be enrolled as full time college or university students. Transition to a college is a vulnerable stage for most of the young adul ts (Pierceall and Keim, 2007). This young population struggles to balance between academic achievement, family responsibilities, and developing a college id entity (Brougham, Zail, Mendoza, & Miller, 2009). Although caregiving can be rewarding, frequently i t is associated with significant levels of physical, emotional, and financial strain. College students that reported being 2003). During a typical college semester, 52% of the st udents have reported high levels
22 of stress (Hudd et al , 2000). Including an additional responsibility of providing care to their aged relatives might aggravate their already distressful situation. Research has established that caregiving can be exacting a nd that informal caregivers are at high risk for adverse physical and psychological consequences associated with caregiving. NAC (2006) reported that approximately half (53%) of caregivers who reported their health had gotten worse due to caregiving also s aid the decline in their health has affected their ability to provide care. Similarly, NAC (2004) emotional and physical stress (29%), and balancing work and family resp onsibilities (29%). These decisions become especially challenging when an individual feels unprepared to balance and fulfill the demanding task. Preparedness for caregiving has been reported to ameliorate some, but not all aspects of this strain and burden (Scherbring, 2002 ; Archbold et al, 2007). ssentially, determines execution of behavior. A positive attitude towards the behavior tends to facilitate the adoption and accomplishment of the behavior including physical activity ( Cart er Parker et al , 2012) , healthy behaviors ( Baiocchi Wagner, and Talley, 2013) an d, voting (Friese, Smith, Plischke, Bluemke, Nosek, & Krueger, 2012 ). The literature reports attitude as a predictor of risky behaviors including Driving under the Influence ( Jornet Gibert, Gallardo Pujol, Suso, & AndrÃ©s Pueyo, 2012); eating behavior disorder ( Filaire et al , 2012), and smoking (Han et al , 2012) . Extensive evidence supports influence of attitude on adoption of behavior. There is a dearth of literature understanding the relationship between the attitude towards older adults and preparedness to execute caregiving behavior. Thus, having important
23 implications in a young society responsible for the older physical as well as emotional needs. The c ombination of attitude, perceived norms and perceived behavioral control have been reported to impact the intentions or readiness t o perform the behavior. Rationale The literature identifies attitude as a major predictor of behavior and behavioral intentions (Sample and Warland, 1973 ; Aizen and Madden, 1986). Aizen and Cote, 2008 ; as well as, Kim and Hunter, 2006 also reported strong relationship between attitude and behavior. Although an extensive literature review incorporated the attitude behavior relationship in understanding the physical activity (Carter Parker, Edwards & McCleary, 2012), smoking, and sexual behaviors none of th e studies reported understanding the attitude towards older adults and the behavior of providing care to them in the general college student population. Researchers have extensively studied college students enrolled in health majors including medicine, den tal, psychology, social work, and nursing to assess their attitude towards older adults. Similar studies conducted aimed at understanding the knowledge and course content of health majors that influenced the positive attitude towards and encouraged student s work in geriatrics field. Similarly, an extensive literature search identified the role of caregivers and impact of their role on their own mental and physical health (Lee and Gramotnev, 2007; Schulz and Martire, 2004). The subpopulation of either young adult children, or adults over 40 years, have been studied extensively (Dew Reeves and Athay, 2012; Jenkins, Blankemeyer , and Pinkard, 2005; Jenkins and Brittain, 2003) but there are few studies that have looked at young adults (Shifren and Chong, 2012).
24 To date, few studies have focused exclusively on the general population of college enrolled students to assess their attitude towards older relatives, and no study has reported preparedness to provide care to their older relatives among the population of young adult caregivers usually between the ages of 18 30 years. The issues and concerns of college going young adults make them a unique group to understand their attitudes and preparedness, to face future challenges, and strategies to cope and balance the ir academic and personal life. Addressing this gap in literature seems timely given the dearth of research studies (Levine et al , 2005). Significance This study will yield a better understanding about the attitudes of typical college er relatives and assess their preparedness levels for providing care to their older relatives. The exploratory research will assess if a relationship between the attitudes of college students towards older relatives and their perceived preparedness for a role as informal caregivers exists . The study will help guide academic institutions about how to best prepare students likely to assume these roles and to offer support to the students in the caregiver roles. Results from students will provide a clearer un derstanding in performing their roles as caregivers and in managing their academic tasks. With this work h ealth care providers will become better informed about the attitudes and preparedness of this young population and can develop strategies to assist th is particular group better .
25 Research Questions The study addresses the following research questions: 1. What is the attitude of college students towards their older relatives? 2. What is the preparedness level of the college students to take care of their ol der relatives in the future? 3. Is there a relationship between age, S ocio E conomic S tatus (SES) , gender, ethnicity, ma jors, amount of interaction, quality of experience with older relatives and attitude towards their older relatives among college population? 4. Is there a relationship between age, SES, gender, race, college majors, amount of interaction and quality of experience with old er adults, perceived behavioral control for providing care to their older relatives in future and college students preparednes s to take care of their older relatives? 5. Does the quality of experiences between college students and their older relatives have any association with gender, age, ethnicity, class, college major and SES ? 6. Does preparedness to take care of older relatives i nfluence attitudes towards older relatives among college students? 7. How do constructs of theory of planned behavior explain the intentions of college students to provide informal caregiving to their older relatives ? Delimitations The following delimitations are identified in the study: 1. Participants of this study include students enrolled in an on campus large class which was representative of a general college population including age, gender, race, class , college major, and SES . 2. The study data were collecte d during summer and fall semester s of a year in order to include a representative college student population over the two semesters . 3. The data were collected within first two weeks of the semesters during the orientation classes and in class exam periods wh ich was mandatory for the students to attend. 4. Relatively l arge sample size was included in the study. 5. The standardized scales were used in their original format, responses were collected using paper pencil survey method and not a popular online/internet me thod to overcome any discrepancy that might have affected the reliability of the scales and data collected .
26 6. The Refined Ageing Semantic Differential Scale for attitudes was included twice in the survey; one at the beginning identifying the attitudes towar ds their own older relatives and later at t he end asking specifically their attitudes towards other older adults. Limitations The following limitations are present in this study: 1. The study was based on cross sectional research design and hence reflects res ponses from the participants at a specific point in time. It did not follow respondents longitudinally to view any changes in their attitudes or preparedness for informal caregiving. 2. The data were collected only from the students present in the class on th e particular day and does not account for students absent during data collection class. 3. Convenience sample including single university and a large class was chosen because of the survey method being used was paper pencil. Convenience sampling limits the ge neralizability of study findings to other populations including the area used in this study. 4. Respondents in this study agreed to voluntarily participate and may not be representative of those who chose not to participate Assumptions Following assumptions w ere made for the study 1. Most of the students enrolled in the class completed the survey. 2. Students were able to distinguish their attitudes towards their own older relatives from other older adults. 3. The students who participated in the study answered the stu dy questions honestly. The consent form assured participants of their anonymity and encouraged them to answer truthfully. Definition of Terms ATTITIDE . An affective feeling of liking or disliking toward an object (which can be basically anything) that has an influence on behavior. ACTIVITIES OF DAILY LIVING (ADLS) . Assistance with bathing, eating, and medical needs provided by a caregiver. CAREGIVER PREPAREDNESS . Perceived readin ess for providing physical care
27 and emotional support, such as, setting up in h ome support services, and dealing with the stress of caregiving. FORMAL CAREGIVERS . Primary physicians, specialists, nurses, therapists, and counselors, who provide care for an individual in a hospital, private practice, or medical facility. INFORMAL CAR EGIVER . An individual voluntarily caring for another person (care receiver i ncluding spouses, children, other family members, and friends in a home or other informal setting. INSTRUMENTAL ACTIVITY OF DAILY LIVING (IADLS ). Managing finances and preparing mea ls provided by a caregiver. INTENTIONS . The cognitive representation of a person's readiness to perform a given behavior . SUBJECTIVE NORMS . or disapproval of the behavior . PERCEIVED BEHAVIORAL CO NTROL . Ability to perform a behavior . OLDER ADULTS . A dult s over the age of 65. OLDER RELATIVES . Adults related by blood or marriage, over the age of 65.
28 CHAPTER 2 REVIEW OF THE LITERA TURE The purpose of this section is to address to the dearth of research by identifying the attitudes of college students towards older adults, their level of preparedness to taking care of their older relatives. The study will explore the role of college students as informal caregivers enrolled at a large north central univer sity of Florida . This chapter presents a review of literature related to these topics: r ole of caregivers, family caregivers; a ttitude s of college students towards older adults; and the Theory of Reasoned Action and Attitude. Role of Caregivers Aging Popul ation and Caregivers There are 40.4 million of 65 years or older persons as of 2010 in the US . They represent 13.1% of the US population, or over one in every eight Americans (DHHS, 2011). The aging populations (65+) will increase by 101% between 2000 and 2030, at a rate of 2.3% each year ( Coughlin, 2010). Older adults are among the fastest growing 65 in 2011. More than 37 million people in this group (60%) will manage more than one chronic condition (AHA, 2007) and, an estimated 150 million people, or 48% of the population, will be living with a chronic condition by 2030 ( US Department of Health and Human Services [ US D.H.H.S] 2012; Administration on Aging, 2001; Partnershi p for Solutions, 2003). To help manage the health conditions demand for caregivers will increase in the society. In 2000, approximately 50 million individuals with terminal or chronic illnesses received some type of care from a family member or friend. O ve r the next 30 year period the number of family members who are available to provide care for
29 these older adults is expected to increase by only 25%, at a rate of 0.8% per year (Mack and Thompson, 2001). Florida has traditionally been known as a state with a large elderly population. Many elderly people retire to the state, thus requiring medical care and attention for end of life years. Florida ranks fourth in the nation for number of informal caregivers (more than 1.6 million), fourth for annual informal caregiver hours per billion, and fourth for annual dollar value of informal caregiver hours (about $15 billion). California (first), Texas (second) and New York (third) are ranked above Florida in all three categories (National Family Caregivers Associatio n and the Albert Einstein College of Medicine, 2002). Family Caregiving Family caregiving is an age old practice, where members have been involved in taking care of their sick or older relatives. Family caregivers are the majority of available caregivers. They are the unpaid persons such as family members, friends, and neighbors of all ages who are providing care for a relative (Family Caregiver Alliance [FCA], 2005 ; Healthy P eople 2020). An estimate of 120 million adult Americans (57%) are either providing or have provided in the past, unpaid care to an adult family member or friend. In the opinion research corporation survey of 1018 adults conducted in 2005 reported (Johnson and Johnson, 2013), 22 % of the population currently providing care to an adult re lative or friend and 34 % of the participants have talked with their families or friends about providing care to them in future. More than half (54%) of the respondents preferred a family member; spouse (37%) and adult child (23%) to provide care to them. The year 2011 was designated by the US Administration on Aging to commemorate the tenth anniversary of the National Family Caregiver Support Program (NFCSP) ( US Administration on Aging, 2011).Two
30 out of three (66 % ) older people with disabilities who receive Long Term Services and Support (LTSS) at home, while receiving all of their care exclusively from their family caregivers, mostly wives and adult daughters. Another quarter (26 % ) receives some combination of fa mily ca re and paid help; only 9 % receive paid help alone ( US Department of Commerce, 2009). In recent years there has been a shift in public policy toward more Home and Community Based Services(HCBS) and away from nursing home care, paradoxically contributing to an increasing reliance on potentially fewer family and friends with competing demands to provide care at home (AARP, 2011). Evidence suggests that more family caregivers are assisting older family members or friends with higher rates of disability than in the past, and are more likely to be providing hands on and often physically demanding and intimate personal help with activities such as bathing or using the toilet (Doty, 2010; Houser, Gibson, & Redfoot , & AARP, 2011 ) 29% of the US population, more than 65 million people , provide care for a chronically ill, disabled or aged family member or friend during any given year and spend an average of 20 hours per week providing care for their loved one. Today 30 million families provide care for an adult over the age of 50 a number expected to double in 25 years (AARP, 2012). Two third of the population (66%) reported very likely (43%) or somewhat likely (23%) they will need to provide care to someone in the future (Johnson and Johnson, 2013).The family structur e has changed over the years, due to delayed marriage and childbirth, high rates of divorce, and smaller family size and as a result the burden of care tends to fall on fewer people in a family. Families are now widely dispersed hence there is greater long distance caregiving, and concomitant
31 shortage of direct care workers to help families. This may reduce the availability of caregivers for the growing numbers of older people in the future (Institute of Medicine, 2008; Jacobsen., Kent, Lee, and Mather, 201 1; Pew Research Center, 2008). A major factor that has contributed to an additional caregiving burden on the family member is the fact that there is a scarcity of professional healthcare workforce (USDHHS, 2012). By 2020 there will be a shortage of up to 2 00,000 physicians and one million nurses (Auerbach, Buerhaus , & Staiger, 2007; Council on Graduate Medical Education, 2005). According to the eldercare workforce alliance, it is estimated that by 2030, 3.5 million additional health care professionals and d irect care workers will be needed . In 2006, only four in ten older adults received care from any physician they had seen at least , et al, 2009). Families are the main pipeline for managing continuity of c are for their loved ones. They are viewed as the coordination with a range of health professionals and community service providers. The presence of family members during phy sician visits has been shown to facilitate communication and increase patient satisfaction (Wolff and Roter , 2008). Family caregiving has also shown to help delay or prevent the use of nursing home care (Spillman and Long, 2010). Involving family caregiver s in discharge planning during transitions from hospital to home may not only improve quality of care but also help to prevent hospital readmissions among Medicare beneficiaries ( Arbaje , et al , 2008; Naylor, et al 2011). The family caregivers usually pro vide a variety of companionship and emotional support such as help with household tasks (preparing meals, handle bills and deal with
32 insurance claims), carry out personal care (bathing and dressing) . Also they are responsible for nursing procedures at hom e, administer and manage multiple medications, including injections, Identify arrange, and coordinate services and supports, hire and supervise direct care workers, arrange for, or provide transportation to medical appointments and community services. They communicate with health during transitions, especially from hospital to home (AARP, 2009; Levine, Halper, Peist, and Gould, 2010). Assisting with transportation needs is a major part of family caregiving. Wolf and Rotter (2008) reported that nearly four in ten (about 39 % ) Medicare beneficiaries were accompanied to routine medical visits, most often by spouses or adult children. According to an AARP 2009 study, family and friends provide 1.4 billion trips per year for older relatives (age 70+) who do not drive, and adult children provide 33 % of these trips. T he proportion of family caregiv ers handling bandaging and wound care, preparing tube feedings, managing catheters, giving injections, or operating medical equipment in the home range from 23 % to more than 53 % . Two studies based in the United Kingdom assessed the needs of informal care givers among a South Asian population caring for those with dementia (Adamson and Donovan, 2005) and a South Asian and African/Caribbean population caring for those with a variety of disabilities (Katbamna, Ahmad, Bhakta, Baker, & Parker, 2004). Adamson an d Donovan, (2005) used qualitative methods and the other study used a combination of qualitative and quantitative methods to confirm that it is expected that adult sons and daughters, including daughters in law, take care for elderly family members.
33 Owin g to a number of converging factors: the aging of the population, the increasing prevalence and costs of multiple chronic conditions, as well as critical shortages in the direct care workforce family caregiving is now recognized as a central part of health care and LTSS (AARP, 2011). The new health care law of 2010, the Affordable Care Act (P.L.111 148), promotes the central importance of person and family centered care in the design and delivery of new models of care, to improve the quality and efficiency College students/ Young adults as Caregivers By fall 2012, it is est imated that a record number of 21.6 million students will attend American colleges and universities, constituting an increase of about 6.2 million since the F all of 2000 (National Center for Education Statistics, 2012). The National Center for Education St atistics also projected that nearly 7.4 million students will attend public 2 year institutions, and half a million will attend private 2 year colleges. Some 8.1 million students are expected to attend public 4 year institutions, and about 5.6 million will attend private 4 year institutions. There are not many studies that include this growing and unique population as caregivers. An estimated 83 % of Americans say they would feel very obligated to provide assistance to their parent in a time of need (Pew Re search Center, 2010). Young adults are an important population that provides care to their family members but not always identifies themselves as caregivers. A qualitative study from Australia (Smyth, Blaxland and Cass, 2011) demonstrates that many young p eople who provide care for family members with disability or illness do not identify or
34 Australian, UK and US A research on young carers (Becker, 2007 ; Warren, 2007). Most rega family members so do not self identify as caregivers but view the relationship as participants between the ages 11 21 indicated their future intentions for serving as primary caregivers in their own home (59.3%), primary caregivers (22.2%) and secon dary or auxiliary long distance caregivers (18.5%). Technological advancements have contributed exponentially for better health care facilities. People are living longer, chronic diseases are better managed and more people are having children at a later ag e consequently, there are more instances of early caregiving than previous generations. A study reported mean age of 13.53Â±4.64 years when the participants started taking care of their relative (Shifren, 2008). A qualitative study by Dellmann Jenkins, Blan kemeyer , & Pinkard (2000) reported that a majority of grandchildren between the ages of 18 35 years (76%) acquired the role of caregiving because they felt a sense of filial duty and were willing to help traditional caregivers (parents). In the same study young adult children reported taking on caregiving roles to parents by default because no one else was available. Studies support that the college caregivers are differently challenged by the life stage of the person for whom they provide care. A qualitat ive study conducted by Sweden Ali, Ahlstrom, Rot , & Skarsater (2012) reported young adults (16 24 years) lived in constant readiness for something unexpected to happen to the person they cared for, and that their role in the relationship could change quick ly from family
35 member or friend to guardian or supervisor. Supporting a friend was considered as large a personal responsibility as supporting a family member. Baus, Dysart Gale, & Haven (2005) included 180 female students with a mean age of 21.6 Â±3.99, an d 86 male students with a mean age of 22.7 and examined the nature of care giving in behavior. There were asked to identify the age and race of the care recipient and w hether the participant was caring for a friend or family member. The study reported the frequency of caregiving being provided to 266 participants, including compan ionship and emotional support (n= 205), chores and meals ( n= 84), transportation ( n= 82), legal and financial matters (n= 35), ph one calls for medical matters (n= 31), personal care and bathing ( n= n= 24). They frequently reported providing care to friends other than to family but caregivers for family provided more caregiving behavi ors than caregivers for friends. Hamill (2012) reported that 65.5 % of adolescents helped their grandparents with some task of daily living such as eating (44.8%), walking (37.9%), grooming (31%) and that 62% reported helping their grandparents with Instr umental activities of daily living such as house work (48.3%), meal preparation (34.5%), getting places beyond walking distance (31%), shopping (27.6%) and taking medications (20.7%). Along similar lines, a study by Dellmann Jenkins, Blankemeyer, & Pinkard (2000) showed that young adult caregivers are sometimes enlisted to assist elderly relatives in meeting needs related to transportation (43%), companionship (43%), household chores (40%), phone calls (33%), personal care (28%) and legal assistance (27%). The literature has consistently
36 reports that there are more females in caregiving roles than males (Baus, Dysart Gale, & Haven, 2005). Factors affecting Caregivers Costs of Caregiving There is an average of 42.1 million caregivers at any given time, and t here were 61.6 million caregivers at the given time during the year 2009 in US , who worked for an a verage of 18.4 hours per week (AARP, 2011). Although difficult to assess, the monetary value of services provided by these caregivers is substantial and valu e of family caregiving will exceed that of nursing home care by a 2:1 margin in the new millennium (Arno, Levine, & Memmott, 1999). At any given time during the year 2009 in the state of Florida there were 4,060,000 caregivers who provided 2 , 660 million ho urs of total care with an economic value of $10.88 per hour an d had the total economic value of $29 , 000 million. The total of 61,600,000 caregivers at a time in the year 2009 provided 40,300 hours of care thus estimating the national total economic value o f $ 450,000 million (AARP, 2011). The economic value of caregiving exceeded total Medicaid LTSS spending in all states, and was more than three times as high in 42 states including Florida (Eiken, Sredl, Burwell, and Gold, 2010 ; Kasten, Eiken , & Burwell, 2 011). Some national estimates of the value of annual home care services provided by caregivers are close to $200 billion (National Family Caregivers Association, 2004). Within the past few years, researchers have assessed benefits and costs of informal car egiving. Results showed that as time spent in the informal caregiver More than half (58%) of family caregivers were employed and THE majority (74 % ) of family caregivers have worked at a paying job at some point during their caregiving
37 experience, balancing their work with their caregiving role (NAC and AARP, 2009). There is evidence that the family caregivers can face financial hardships if they must leave the labor forc e owing to caregiving demands, midlife working women especially, who begin caring for aging parents, reduce paid work hours or leave the workplace entirely (Johnson and Sasso, 2006 ; Pavalko and Henderson, 2006) About 42 % of US workers have provided elder care in the past five years, and nearly one in five (17 % ) is estimated to currently be providing care and assistance for older relatives or friends. Just under half (49 % ) of the workforce expects to be providing elder care for a family member or friend i n the coming five years (Aumann, Galinsky, Sakai, Brown, & Bond, 2010). Estimates are that US businesses lose up to $33.6 billion per year in lost productivity from full time caregiving employees. These costs include those associated with replacing employe es, absenteeism, workday distractions, supervisory time, and reductions in hours from full time to part time. The average annual cost to employers per full time employed caregiver is $2,110 (Met Life and NAC, 2006). The healthcare cost of businesses is aff ected by the responsibilities of eldercare in the work force. Society generally underestimates and under appreciates the value of caregiver time, lost wages, and medical costs for their own medical needs. If family caregivers were no longer available, the economic cost of health care would increase astronomically and, the health systems would be overwhelmed by the increasing need for supportive services (Gibson and Houser, 2007). Health Risks of Caregiving The health risks and financial hardships that may a ccompany the caregiving role are substantial and well documented. Erratic behavior of care receivers rather than the disease itself can be a cause of caregiver distress (Hebert et al, 2003; Small,
38 McDonnell, Brooks, & Papadopoulos, 2002; Gottlieb and Roone y, 2004). The needs of addressed in general clinical practice in health care. Yet ignoring family needs can place caregivers at risk for negative health consequences that ca n jeopardize their ability to provide care in the home. Strategies to strengthen and sustain caregiving families will enable them to continue as caregivers, and will reduce costs. An extensive body of research finds that providing care to a chronically ill family member or close psychological health. Both younger employees (age 18 to 39) and older employees (age 50+) providing care for an older relative were more likely to report fair or poor health in general, and they were significantly more likely to report depression, diabetes, hypertension, or pulmonary disease than non caregivers of the same age (MetLife Mature Market Institute, NAC, and University of Pittsburgh, 2010). More than two out of three (69 % ) family caregivers responding to an online survey by caring.com 2011, said that caring for a loved one was their number one source of stress and that their relationships had been negatively impacted by providing care. Caregivers commonly experience emotional strain and mental health problems, especially depression. A review of studies suggests that between 40 and 70 % of family caregivers of older adults have clinically significant symptoms of depression, with about one fourth to one half of these caregivers meeting the diagnostic criteria for major depression. However caring.com, 2011 reported 75 % of caregivers feeling a sense of pride bec ause they're making a difference for their loved one. Anngela Cole and Hilton, 2009 reported among Japanese caregivers, a lack of social support, greater health problems of the caregiver,
39 and a more negative attitude toward family care predicted higher levels of depression. Among the Caucasian caregivers, long hours of employment, lack of social services, more health problems, and a more negative attitude toward family care significantly predicte d higher levels of depression. Many factors influence the health behavior and health status of caregivers, mental restrictions of both caregiver and care receiver. About o ne third of caregivers of an elderly individual will suffer some physical or emotional distress, more than 10% will have some mental or health problems, and many will also experience chronic fatigue (Foster, Brown, Phillips , & Carlson, 2005 ; NAC and AARP, 2004). Research has shown that caregivers have poorer physical health than non caregivers, and an estimated 17 to 35 % of family caregivers perceive their health as fair to poor (NAC and AARP, 2009 ; Pinquart and Sorensen, 2007). Family caregivers face chro nic health problems of their own and health risks, such as heart disease, hypertension, stroke, poorer immune function, slower wound healing, impaired self care, sleep problems and fatigue, increased use of psychotropic drugs, and even death among highly s tressed spouse caregivers (Cannuscio , et al , 2004 ; Chritakis and Allison, 2006 ; Fredman, Cauley, Hochberg, Ensrud, & Doros, 2010 ; Norton et al , 2010 ; Haley, Roth, Howard, & Safford, 2010 ; Sparrengerger et al , 2 009). Studies also noted that due to lack o f time f or friends and family caregivers feel socially isolated and experience higher levels of ca regiving stress (Schubert et al , 2008 ; Miller, Allen, & Mor, 2009). Caregiving often compromises of which can be indicators of potential shift from caregivers to care receivers.
40 Cultural and Ethnic Factors in Caregiving According to U.S Census, 2010 besides 64 % of whites, there were 16% Hispanics, 12% Blacks and 5% Asians who were part of 308.7 millio n U.S population. According to NAC (2009), approximately one fifth of both non Hispanic White and African American populations are providing care to a loved one, while a slightly lower percentage of Asian Americans (18%) and Hispanic Americans (16%) are en gaged in informal caregiving. The census points out the diversity of the U.S populations and the concept of cultural competency has received heightened attention in recent years because of the forecasted need for more service providers to care for an incre asingly diverse aging population. New models of care that use principles of cultural competency suggest acknowledging race and ethnicity, sexual orientation, and regional variations in culture across the country. Research on caregivers has traditionally f ocused on White (Caucasian) individuals. Minorities in US experience at least twice the rate of chronic illness, including dementia, possibly due to the lack of adequate health care, financial resources, medical choices, and information about their care (N eary and Mahoney, 2005). Minority caregivers are also more likely to be younger, single, an adult child, a cousin, a grandchild, provide longer care time in the home, and be female (Pinquart and Sorensen, 2005; Neary and Mahoney, 2005). African Americans h istorically have extended the caregiving role to relatives and friends outside the immediate family to and Sandelowski, 2003 , p.659). Cultural rituals, religious experience, and tr aditions (i.e., subjective experience) affect those in the caregiver role and those who require care (Koffman and Higginson, 2003; Roff , et al , 2004).
41 When compared to their White counterparts, African Americans have a lower life expectancy and were more likely to be in poorer physical health (73.8 years for African Americans versus 78.9 years for Whites in 2010) ( US Census Bureau, 2010). Cultural socialization in African American communities helps them better deal with stressors in the caregiver role, as well as extended exposure to caregiving as children, teenagers, and eventually as adults. Moreover, this socialization is more prevalent in the African American and Hispanic/Latino communities, when compared to Caucasians thereby presenting a higher prope nsity for family invol vement (Dilworth Anderson et al , 2005; Ayalong, 2004 ; Pinquart and Sorensen, 2005). Furthermore, different studies have reported Latina caregivers to be younger, less educated, have lower incomes, and to have provided more care on a daily basis than their Caucasian counterparts (Coon et al, 2004, Montoro Rodriguez and Gallagher Thompson, 2009 ; Min and Barrio, 2009). Therefore, how an individual is socialized to view caregiving, represents another important factor when studying race an d ethnicity among caregivers (Roff et al , 2004). Research on the resources for Racial and Ethnic Approaches to Community health (REACH) program assessed differences in positive attitudes in the caregiver role and what contributed to these positive experie nces among African Americans and Caucasians. As predicted, African American caregivers reported more positive aspects as caregivers (p<.001),were lower in SES, reported lower anxiety levels, and tended to be more religi ous than Caucasians (Roff et al , 200 4). Studying cultural values and beliefs among informal caregivers, researchers found no differences existed between African Americans and Whites in gender and education. However, African Americans reported adherence to cultural reasons for providing care
42 and females in this group were more likely to provide care (Dilworth Anderson, et a l , 2005). African American caregivers reported less stress in caring for an elder with dementia, although their White counterparts had higher family income and tended to b e older (M=72.2 for Whites vs. M=55.2 for African Ameri cans; p < .0001) (Stevens et al , 2004). In their study of Mexican Americans and W hites Min and Barrion 2009, reported that 45% of the Mexican Americans would turn to informal caregivers or helper as c ompared to only 17% W hites who preferred either a spouse or children for future care needs. Montoro Rodriguez and Gallagher Thompson, 2009 reported ethnicity to exert a statistically significant direct influence on the lower level of burden reported by Lat ina caregivers than non 0.36). Therefore, literature on African American and Hispanic caregivers suggests it is important to evaluate and assess how they cope with stress effectively in specific situations. Few studies have exami ned Asian caregivers. Researchers conducting a multiethnic study of family caregivers (African American, Asian Americans, Latino, and Anglo European American) studied how ethnically diverse populations view dementia (i.e., in medical versus non medical te rms) (Hinton, Franz, Yeo, & Levkoff, 2005). cultural Chinese adult caregivers, who were born abroad but currently lived in the US (Hseueh, Phillips, Cheng, & Pico, 2005). Caregivers in the study who had lived in the US for a mean of 19 years (range from 2 to 58 years) were mostly women (70%) and had annual incomes that ranged from $40,000 to $149,000 (84%). Rewards in the caregiver role were the primary focus of the scale. Results showed that Chinese car egivers in the study felt that
43 US , several important aspects of caregiving emerged . Caregivers reported a considerable degree of social support, including family, friends and neighbors which helped with emotional and financial wellbeing (Limpanichkul and Magilvy, 2004). Preparedness of Caregiving Caregiver preparedness is defined as how ready caregivers believe they are for the tasks and stresses of caregiving (Archbold, Stewart, Greenlick, and Harvath, 1990, 1992; Rusinak and Murphy, 1995). Preparedness has an anticipatory connotation in that potential caregivers can assess their prepar edness before taking on the caregiving role ( Schumacher, Stewart, and Archbold, 2008). The research on the levels of preparedness of the caregivers is limited. Eight in ten respondents in Johnson and Johnson, 2013 survey of 1,018 adults reported being very prepared to either spend time visits and tests. 44% felt very prepared for the activities including bathing, dressing, and toileting but very few were prepared for more difficult tasks of caregiving. Grant (2012) reported that lower burden scores were significantly associated with more positive perceptions of caregiver preparedness at both 2 and 5 weeks ( p < .05). Studies ( Silver , Wellman , Galindo Ciocon , & Johnson , 2004) have reported low p reparedness for caregiving scores (mean=1.72, maximum=4.0) which were positively correlated with caregiv er competence ( p <.001 ) and self rated caregiver effectiveness ( p= .004 ). Preparedness was also negatively correlated with health care use ( p =.03) among the family caregivers who provided home enteral nutrition caregiving. Preparedness affects the psychologi cal health of the caregiver. In a study conducted by Scherbring (2002), the researcher reported for every one unit increase in the preparedness score, the
44 burden score decreased 0.853 units. Burden was found to decline, on average about 17% for every one u nit increase in preparedness. It has been documented that caregivers must be prepared adequately for their responsibilities as a means of controlling burden (Scherbring, 2002). In addition, a Taiwanese study, Shyu et al , 2010 reported that higher prepared ness was associated with higher caregiving rewards and better mental health. Schumacher, Stewart and Archbold, 2007 reported in their study of family caregivers of patients receiving treatment for cancer, that high preparedness protected caregivers from ad verse outcomes when demand was high. But when preparedness was low, caregivers were at greater risk for negative outcomes and mood disturbance. Schumacher, Stewart and Archbold , 20 07 also reported that preparedness was associated more strongly with mood disturbance outcomes than with th e caregiving specific variables of difficulty and strain among the family caregivers. I n a mixed methods study by Giarelli, McCorkle and Monturo, 2003 used Preparedness for husba , 1990) is a self report questionnaire that measures four perspectives of domain specific preparedness: physical needs, emotional needs, resources, and stress. Wives in the intervention and control gro of the physical and emotional needs of their husbands at baseline. These findings were similar to what Scherbring (2002) also reported. But 54% of wives reported needs to help the qualitative study based on grounded theory by Silva Smith, 2007 five dimensions of restructuring life were identified in the interview data; including daily life, management o f
45 multiple roles, and relationship with the stroke survivor, future hopes , and plans, and time for self, all these indirectly pointed out the process of getting prepared for the caregiver role. When asked what type of assistance they would most appreciate, most caregivers indicated that they needed assistance with housework (Van den Berg, Brouwer, Exel, and Koopmanschap, 2004). Attitude towards older population An extensive literature review focused on studying the attitudes of young adults especially colle ge students towards the older adults. Majority of the studies reported have been conducted in medical and social work field including nursing, physical therapy, social work major students. Attitudes have been traditionally defined as a psychological tenden cy that is expressed by evaluating a particular entity with some degree of favor or disfavor (Eagly a and Chaiken, 1993, p. 1).Hogg and Vaughan, 2005 defined attitude as "a relatively enduring organization of beliefs, feelings, and behavioral tendencies tow ards socially significant objects, groups, events or symbols . " Kogan 1961, defined attitudes towards elderly as the beliefs and feelings that individuals have towards old people. Ageism (Butler , 1969) refers to a kind of discrimination, similar to racism and sexism directed towards elderly people. Historically, the researchers primarily focused on studying attitude towards older population. Tuckman and Lorge, 1952, 1953 developed comprehensive instrument to assess misconceptions and stereotype about older people. They found people most likely agreed that old people are conservative and set in their ways and least likely to agree that old people are inattentive to cleanliness. Kite and Wagner, reported automatic ageism among younger and older adults and foun d more association of old and unpleasant stimuli rather than old and pleasant.
46 Gellis, Shermand , & Lawrance (2003) reported first year graduate social work independenc e and optimism. They also reported male and younger age students being less favorable towards older person but previous experience with older people did not predict attitudes toward older people. In contrast, Tomko and Munley, 2013 and Jody and Patrick, 20 13 in their study with counseling psychologists reported men scoring more positive attitude and gender as a significant predictor of global attitudes towards elderly. Similarly, Nochajski, Waldrop, Davis, Fabiano , & Goldberg, 2009 reported female dental st udents having more negative attitudes towards older adults than males. Whereas in a Sub Sahara African study the researchers found majority of medical and nursing students having positive attitude towards the elderly and found no difference between males a nd females (Zverev and Yuriy, 2013). Narayan, 2008 and SAIF , 2004 reported more positive attitudes towards older adults, with older women being rated significantly more positive than older males in the sample of university undergraduate students. In an intervention study, on attitudes about aging and gender among young, middle age and older college based students (Laditka, Fischer, Laditka , & Segal, 2004), the sample for the study included junior, senior, graduate students and members of an elder hostel organization on campus. The participants were divided into three age groups consisting 20 34 years old as young adults, 35 59 years old as middle age adults and 60 years an d older were classified as the older adults. The study reported no statistical difference in attitude based on the majors but the gender of the respondents had a significant difference towards the gender of the target group i.e ., older adults.
47 Older raters had more positive attitudes towards older targets compared with younger or middle age raters. The literature supports various variables account for a positive attitude towards older adults among college students including contact with older adults, healt h majors including psychology, medicine, nursing, dental, students who had gerontology as an elective course and female college students tend to have a more positive attitude towards older adults (Maurer et al, 2006 ; Funderburk, Damron Rodriguez, S torms & Solomon, 2013 ; Gonzales and Morrow Howell, 2009 ; Swanlund and Kujath, 2012 ; Lee, 2009). Theory of Planned Behavior and Attitude towards older adults. The Theory of Reasoned Action (TRA) and Theory of Planned Behavior (TPB) focus on the determinants of lik elihood of performing a specific behavior including beliefs, attitude, intentions and perceived control (Ajzen and Fishbein , 1980 ). TRA and TPB assume attitude, subjective norm and perceived control influences intentions which are the best predictors of ac tual behavior (Glanz, Rimer and Vishwanath, 2008). Established on the attitude measurement theory TRA was developed by Fishbein, 1967 to understand the attitude and intentions towards behavior and not only towards objects as previous attitude theorists. TR A asserts on attitude towards behavior and subjective intentions. Ajzen 1991, identified the individual control and ability over behavior and added the construct of perceived be havioral control to TRA thus creating TPB. The of perceived self efficacy , i.e ., ability to perform a behavior ( perceived behavioral control).Inves tigations have shown that individual behavior is
48 strongly influenced by their Self efficacy beliefs to influence choice of activities, preparation for an activity, input effort, as well as thought patterns and emotional reactions (Bandura, 1982, 1991). Aiz en, 2002 p.668 specified the term perceived The construct of self efficacy belief or perceived behavioral control within the general framework of TPB explains the relations among beliefs, attitudes, intentions, and behavior. Fishbein and Aizen, 2010 p.155 include availability of information, skills, opportunities and other resources required to perform the behavior as well as possible barriers or obstacles that they may have to ove rcome into the perceived behavioral control Individuals with a higher sense of efficacy would hold an optimistic view in a given situation and would react with much less distress, and thus have a higher likelihood of fully applying their potential skills. Therefore, they are more likely to succeed and gain satisfaction from their experiences (Bandura, 2001). Those people with a higher sense of efficacy have strengthened resiliency and reduced vulnerability to negative consequences (e.g. suffering from depre ssion and feelings of burden) in challenging situations, and, thus, have a more positive perception of their quality of life and psychological well being in general. Social psychological well being in two ways. First, the members of the social network could directly contribute to the level of caregiver satisfaction (e.g. a sense of accomplishment, pride) through their acknowledgement of his/her contribution in caregiving efforts social networks may indirectly contribute to caregiver well being through establishing and perform effectively as family caregivers (Shirai, Koerner & Kenyony, 2009).
49 In their studies , Ajzen , 1988, and She ppard, Hartwick, and Washaw, 1988 , explained that behaviors can be predicted accurately, when they pose no serious problems of control. Conceptually, TPB includes three independent determinants of intention. First, the attitude toward the behavior, that re fers to the degree to which a person has a favorable or unfavorable evaluation or appraisal of the behavior in question. Second, subjective norm; refers to the perceived social pressure to perform or not to perform the behavior. Third, the degree of percei ved behavioral control; the perceived ease or difficulty of performing the behavior and reflects past experience as well as anticipated impediments and obstacles. As a general rule, the perceived behavioral control is determined by more favorable attitude and subjective norm (A j zen, 1991). Studies have established the role of personal experiences, exposure to older adults and societal influence on college students in development of positive attitude towards older adults (Lovell, 2006 ; McKinlay and Cowan , 20 03 ; and Nochajski , et al, 2009). Over the years, various studies validated the relationship between intentions, attitude, subjective norms and perceived behavioral control. Positive attitude towards older adults is likely to inculcate favorable beliefs, fe elings, behavior and strong intentions to care for them among young adults (Lee, 2009). McKinlay and Cowan, 2003 reported generally positive intentions towards and attitudes about, working with older patients among student nurses. The hierarchical analyses of the results reported mainly the attitudes predicted the intention and, although small subjective norms but played a patients. Participants reported a moderately hi gh level of control over their behavior
50 towards older patients, but their perceptions of behavioral control did not predict people in a dedicated unit had no impact on attitude but, attitude was affected by participants other experience of working with older people. Positive attitude towards older people has been reported to be related to more experience and completion of geriatric courses in various studies (Cottle and Glover, 2007 ; Swanlund and Kujath, 2012 ; and Wurtele and Maruyama, 2012). According to Nochajski, Waldrop, Davis, Fabiana, and Goldberg, 2009 p.96, formation of attitude reflects a feedback look including beliefs, attitudes, intentions and behaviors. Attitudes ma y influence the formation of new beliefs, and performance of particular behavior which may lead to new beliefs and in turn influence attitudes. They also reported reciprocal interaction between attitudes and beliefs in development of professional behavior and practice patterns among dental students. The researchers in their longitudinal survey involving comparison of dental students in years one through four, indicated significant difference in attitudes towards older adults in different cohorts and indicat ed the positive influence of academic experiences on general attitude towards older people (Nochajski , et al , 2009). Behavioral intentions, regarded as necessary precursor to behavior. Similarly, positive feelings accompany positive beliefs and result in positive behaviors (A j zen and Fishbein, 1980). Lee ( 2009 ) supported the movement to induce positive feelings and intentions towards older adults among younger generation. The positive attitude towards older people prevents them from being isolated and mis treated. Students who had never lived with an older adult scored low on their knowledge of aging phenomena.
51 As in the original theory of reasoned action, a central factor in the theory of behavior. Intentions are assumed to capture the motivational factors that influence a behavior; they are indications of how hard people are willing to try, of how much of an effort they are planning to exert, in order to perform the behavior. As a general rule, the stronger the intention to engage in a behavior, the more likely should be its performance (Fishbein and Aizen , 2010). In summary, it is important to assess multiple factors to understand the involvement and intentions of young adults to provide care to their older relatives. These factors include growing burden on young adults to provide care, their attitude towards older adults, race/ethnicity of the caregiver, and preparedness to provide care. There exists paucity in literature that identifies the role of young adults especially those enrolled in some college or university. This population faces unique challenges in balancing their academic achievement and taking care of their sick or old relative. Even if at present many of these young people are not responsible for any of their relatives but given statistics of growing older population this young generation will at some time in their future be responsible to help and care for their elderly relatives. The present research identifies that the le vel of preparedness for caregiving that reduces the burden and in fact helps in providing better caregiving services. If we assess the preparedness of the present college going generation health professionals can tailor the programs according to the level of preparedness and this future population of caregivers will be better prepared and equipped to take the challenge. The research also shows that culture and ethnicity has an exponential impact on acquiring a role of caregiver. For all
52 cultural groups (i.e ., African Americans, Latino, and Asians), it is important for formal care providers as well as health professionals to acknowledge how individual groups and families frame the disease (biomedical versus folk models), how prepared and confident they are to take the challenge which could potentially influence the well being and care for the care recipient as well as health of caregiver himself.
53 F igure 2 1. Theory of Planned Behav ior (Source: Aizen, 1991)
54 CHAPTER 3 METHODS The study examined the attitude of college students towards older relatives, and adults , and their preparedness levels to provide care to their older relatives. C hapter 3 describes the methodology used in this s tudy, which includes the research design, research variables, instruments, the pilot study, and the final study. Research Design The study used a cross sectional survey research design to explore preparedness of college students as informal caregivers and their attitude s towards their older relatives and other older adults . With this design, a standardized protocol with standardized procedures can be administered to a group of participants that require a reasonable amount of time. Likewise, data can be anal yzed uniformly and objectively (McDermott and Sarvela, 1999). Research Variables The study included CPS and RASDS as the dependent (outcome) variables, ethnicity, academic classification, SES (Socio Economic Status) , gender, age , and major were the indepe ndent variables in the study. Other variables in the study included interactions, quality of experiences with their older relatives , their intentions to serve as informal caregivers , perceptions , and confidence to provide informal caregiving in future, the level of current help they provided their elder relatives with instrumental activities of daily living, activities of daily living and medical task in the past 12 months. P articipants The study participants were 18 years and older, full time undergraduate and graduate students enrolled in a large public land grant, sea grant, and space grant
55 research southeastern university. 50,000 students enrolled in the university represented academic and ethnical diversity . According to the U niversity of Florida office of institutional planning and research, 2013 t here were more number of females enrolled in the university (56%), and nearly half of the students enrolled identified themselves as whites (56%), only 15% were Hispanics and 7% each identified as Asians and B lacks during the Fall 2013 semester . Majority of the students were undergraduates (76%) and reported their age s between 18 22 years old, whereas graduate students age range was between 22 32 years. The university offered more than 250 majors with many enro lled in engineering, health science, computer science, English, finance, nursing, psychology, law, and agriculture majors respectively. Three on campus large classes were identified to participate in the study based on their representation of general coll ege population in terms of age, gender, class, and academic majors. The classes included were Health and Medical Terminology (HMT), Anatomy, and Personal and Family health (PFH). S tudents included represented over 50 different majors including law, nursing , biochemistry, engineering, health education, chemistry, biology , applied physiology and kinesiology, and education. Pilot data were collected from Health and Medical Terminology class during the Spring 2013 semester, and the final data were collected fro m students enrolled in HMT and Anatomy classes during Summer 2013 and from students enrolled in HMT and PFH classes during Fall 2013 semester, respectively. Instruments Instruments for the study were selected by conducting an extensive literature review of instruments previously used by researchers to examine preparedness, and attitude of young adults. The protocol for this study included two standardized
56 instruments: Caregiving Preparedness Scale ( Archbold, Stewart, Greenlick, & Harvath, 1990 ), and, Caregi ver Profile Information. Although, online survey programs support the bipolar questions but as in the original RASD scale the numbers 1 7 could not be displayed between the choices and it would be difficult for the participants to understand the original s cale thus the reliability issue, which was the reason a paper pencil format was used in its original format instead of the online survey. The final paper pencil survey included the original scales and other questions. Caregiving Preparedness Scale After e xtensively reviewing the literature, this scale was deemed most appropriate to measure preparedness among people currently involved in caregiving as well as who are still not providing any care. The instrument was created originally for caregivers of older adults with an acute exacerbation of chronic illness, prior to transitions to any other formal care facility . The scale was designed specifically to measure how well caregivers believed they were prepared for multiple domains of caregiving. This is 8 item scale with an open ended question where participants can specify areas in which they feel unprepared to provide care for. Responses are rated on a 5 point scale with scores ranging from 0 (not at all prepared) to 4 (very well prepared). The scale is score d by calculating the mean of all items answered with a score range of 0 to 4. The higher the score the more prepared the caregiver feels for caregiving; the lower the score the less prepared the caregiver feels. Internal consistency for the scale has been reported as moderate to high with alphas of 0.88 to 0.93 reported (Carter et al , 1998; Hudson and Haym an White, 2006). Archbold et al , 1990 reported construct and content validity between caregiver worry and lack of resources. Available as an open source on the internet, the scale was used in its original paper pencil format.
57 Refined Aging Semantic Differential scale A standard, global measure of attitude towards any behavior, concept or object is an evaluative semantic differential (Osgood, Suci and Tan nenbaum, 1957).In most applications of the theory of planned behavior evaluations for attitudes, are usually assumed to form a bipolar continuum, from a negative evaluation on one end to a positive evaluation on the other. Several semantic differential sca les to measure attitudes have been reported in the literature. Literature reports, the scales developed in 1950s lack their reliability and validity in the present multi cultural and modern society. Therefore, the refined version of Aging Semantic Differen tial scale (RASD) was chosen over the Aging Semantic Differential scale (Rosencrantz and McNevin, 1969). The original ASD consists of 32 items utilizing 7 point Likert scale with 1 representing most positive and 7 most negative. Overall attitude score is c alculated adding the 32 responses with a range score between 32 and 224. The original scale did not report retest procedures thus no measures of reliability and validity were estimated. Although the independent reliabili ty and validity measures obtained from other studies using the scale have been reported (Polizzi and Steitz, 1998 ; Polizzi and Millikin, 2002,). The RASD is similar to the original scale but includes 24 pairs of bipolar adjectives instead of 32 and can be used to record attitudes towards older adults in general. Each item consists of polar adjectives opposite in meaning with positive adjective on left side and corresponding negative on the right side. The lower score corresponds to a positive attitude and a score of 128 is considered neutral. The RASD scale found no difference between the attitudes towards older men or women. The participants mark along a seven point continuum at the point that
58 represents a spontaneous judgment about the person being rated . The score range of 24 168 for RASD, the scores are calculated similar to the original ASD where score of 96 indicates neutral attitudes and scores less than 96 indicate positive attitudes towards son values (.97) and test retest reliability (.81 .84). The studies using the scale reported .97 (Ladit ka, Fischer, Ladikta , & Segal 2004 ; Narayan , 2008 ; Chase, 2010 ; Henry, Ozier and Johnson, 2011 ; Tomko and Munley, 2013). Due to the paucity in the literature identifying attitudes towards older relatives in particular, researcher decided to use RASD twice in the instrument. The first one asked students to think about their older relatives including grandparents, aunts and uncles and answer the attitudes scale. Whereas the second RASD was included towards the end of the survey, which reported attitudes towar ds unrelated older adults. General Profile Information A general profile was developed to obtain demographic information about s tudents -s uch as age, gender, marital status, race/ethnicity, income level, enrollment status, and academic major. Items relat ed to providing any care to their elderly relatives, their interaction and quality of experience were included to assess the extent of care students provided to their older relatives provide. Items based on the theory of planned behavior were developed i ncluding the subjective perceived behavioral control to take care of their older relatives (Francis et al, 2004). Additional profile items included use of smartphone
59 and tablets and other resources to access health related informa tion for their older relatives. Expert Review (Face validity) Two faculty members and one Ph.D candidate in the department of health education and behavior, and another Ph.D . candidate in the College of Education reviewed the survey drafts during the Fall 2012 semester . They were asked to review the survey draft and suggest if the instrument looks to measure what it is supposed to. After the suggestions form the experts some questions were revised and another was added to measure the construct of the theor y. Pilot Study One The present study was the first attempt by the researcher to understand the attitude s and preparedness of informal caregiving to their older relatives among general college population. The CPS has never been used with the college populat ion, and there is limited literature reporting the use of RASD with general college population besides medical and nursing majors. Also, the researcher developed the scales to test the subjective beliefs, perceived behavioral control and intentions which h ave never been used in any previous studies, hence to test the reliability and validity of the scales pilot test was conducted using a representative population. Participant Recruitment A random sample of 25 undergraduate and graduate students enrolled i n the university were contacted. A paper pencil survey method was used and participants were asked to complete the entire instrument after they agreed to the consent form. Pilot data were used to determine face validity, identify formatting and grammatical
60 errors, and assess language clarity, skipped questions, and amount of time required to complete the survey. Procedure A draft version of the study protocol including a script for prospective parti cipants, the CPS, RASD, and demographic p rofile Informatio n was prepared. Students were also asked to assess the instrument for readability, comprehension, and cultural sensitivity and offered comments or suggestions about the structure and questions of the instrument using open ended evaluation. Participants wer e encouraged to pen their comments near any items they deemed inappropriate or not applicable. After the completion of survey the participants were asked about their suggestions and comments on the items they found difficult to understand or respond. Data from this pilot test were not included for analysis. Pilot study Two The comments and data from the pilot study one were inconclusive weather the students viewed older adults and older relatives similarly. Hence it was decided to include the RADS twice in the final survey in order to understand the attitude differences towards older relatives and older adults. Suggested changes were made to the instrument and were prepared for an extensive pilot study two. The study protocol was university internal review board. Participant Recruitment During the Spring semester 2013 , 350 students enrolled in the large on campus class of HMT were administered the survey before they took their mid term exam in class .
61 Procedure T he surveys were di stributed after a brief introduction to the study was given by the researcher and their rights as approved by IRB protocol were read. Students were explained about the two attitude scales in the survey, first one about their attitudes towards older relativ es and the second was about the attitudes towards older adults. Surveys were collected after the end of the class and were placed separately from the consent forms. Data Analysis The data from pilot study were analyzed for descriptive, frequency statistic s, and the alpha. Incomplete surveys were not included in the final analysis. A total of 306 completed surveys were used for analysis of which n=213 were females and n=93 males. Majority of the respondents reported their ages between 18 22 year s (93.2%) and were J unior s ( 33.66%) , and Sophomore s (27.45%), in the college (Table 3 1) . Majority of the stu dents identified themselves as W hite n=171 (56.25%), and there equal number of students identified themselves as Asians n=47 (15.46%), African Amer icans n=46 (15.00%) and Spanish n=40 (13.2%). The reliability coefficient for each scale calculated was =0.906 for CPS, =0.972 for RASD, subjective beliefs =0.851, and perceived behavioral control =0.905. Final Study After the pilot study two, in order to measure all the constructs of TPB, another scale measuring intentions of the college students to pro vide informal care to their older relatives was included in the final instrument. The revised study protocol was submitted to the University of Florida Institutional Review Board (IRB) for approval of the data collection. The pilot study procedure s were re plicated to recruit final participants for the
62 study. Students enrolled in three different classes including HMT , PFH, and Anatomy were recruited during the S ummer , 2013 and the F all , 2013 semester for the final data collection. Participant Recruitment Th e final data were collected from large on campus classes selected based on their representation of typical college population including class size , gender , class, and majors. Beginning in S ummer 2013, 1 0 0 students each in two different classes (HMT, and An atomy ) were provided with the instrument and consent form during their class time. Later, in the Fall semester 2013 , other class es ( HMT, and PFH ) with 100 and 450 students each were recruited to complete surveys during class time. Procedures All partici pants received a description of study procedures and information regarding their rights as a participant, and complete confidentiality before they actually start taking the survey. Participants were informed that participation was strictly voluntarily and they could discontinue answering questions at any time during the process without penalty. Only the researcher had access to results and no identification information was collected. The surveys were distributed in the class and later collected after the c ompletion. The consent forms were removed from the survey and placed in a separate file. One of the professors wanted to track the students who participated hence they were asked to write their university id on the consent form. To maintain the anonymity t he consent forms were removed from the survey and placed in different files. Two e xtra points were added to their final exam by the professors as an incentive to promote response rate (Dillman, Smyth , & Christian, 2009) for p articipation.
63 Data Analysis The data from only completed surveys were included for final data analysis. Data obtained from volunteer participants were recorded in Microsoft Excel TM spread sheet by the volunteer research assistants under the supervision of the primary researcher. The da ta were then analyzed using SPSS 21statistical software. The study included two dependent variables (RASD and CPS) and several independent variables (age, SES, gender, race, college majors, and amount of interaction with older adults). The list of majors w as dummy coded into two categories of 1) health ( Applied Physiology and K inesiology, H ealth E ducation and B ehavior, and N ursing ) and 2) non health ( Biology, C hemistry, L aw, P sychology ). After determining that the data set was approximately normally distri buted, descriptive statistics were calculated to determine baseline frequency rates. Univariate analyses can be used to present primary statistical information and to assess patterns within a data set (Peck, Olsen and Devore, 2008). In this study, frequenc y distributions and descriptive statistics were calculated to obtain baseline information about frequency of gender, race/ethnicity, mean preparedness scores, RASD score, intentions to provide care in future, frequency of different caregiving activities th ey are currently providing, ownership of smartphone and I pad or tablets, assessing mobile technology for applications to help taking care of older relatives. These descriptive statistics were used to determine a general profile of the caregiver sample for the study. Multivariate analyses were conducted including one way ANOVA to assess if previous caregiving activities impact the preparedness scores. Multiple regression with equation Y=a + b 1 X 1 + b 2 X 2 + b 3 X 3 was conducted to answer the research questions 3, 4, 5, and 6 that were to assess any relationship between demographics and
64 preparedness scores, and quality of experience as well as relationship between preparedness and attitudes s cores . In the regression equation; a= constant, b 1 is the s lope (Beta co efficient) for X 1 , X 1 = First independent variable that is explaining the variance in Y , b 2 = the Slope (Beta coefficient) for X 2 , X 2 = Second independent variable that is explaining the variance in Y , b 3 = the Slope (Beta coefficient) for X 3 , X 3 = t hird inde pendent variable that is explaining the variance in Y. The data set was investigated to satisfy the assumptions of the multiple regression analyses including ; (a) missing values , (b) presence of outliers, (c) normality, (d) line arity, and (e) homoscedastic ity. Visual inspection of histograms and Normal Quantile Quantil e (Q Q) plots for the intention score s ; attitude and perception score variables indicated approximately normal distributions. For regression analyses The demographic variables were coded as; ( a) Ethnicity (coded into four dichotomous variables of White, Black, Asian, Hispanic, and multiracial); (b) Gender, coded as 1 = female, 2 = male; (c) Class, coded as 1=Freshman, 2=Sophomore, 3=Junior, 4=Senior , and 5= Graduate student; (d) Married, coded as 1= married, and 2= not married; (e) Major, coded as 1= Health, and 2=Non Health; age and SES were entered as continuous variables . Case wise diagnostics were selected in SPSS to check for standardized residues and any outl iers with more than 3 standard ized residues were manually removed before final regression analysis. The Hierarchical regression (HR) was conducted to test the research question 7 that was to assess relationship between Theory of Planned behavior constructs and intentions of students to serve as informal caregivers ; Theory of planned behavior constructs while controlling the demographic variables such as age, race, gender, marriage status, SES, and academic major. HR has been designed to test specific
65 theory based hypotheses as noted by (Cohen, 2001 ; pp.523 524 and Wampold and Freund (1987, p.377). Data w ere checked for normality, outliers, and multicolleniarity before the regression analysis. Analyses for all research questions were tested at a .05 Summary The C hapter 3 provides details of the implementation methodology about research design, research variables, instruments, pilot study and final study. The survey was developed to assess the attitude and pr eparedness levels of college students to take care of their older relatives. Two standardized instruments were used along with the questions based on theory of planned behavior were developed. Large pilot test data were used to establish reliability of the items developed and instruments included in the survey. Pilot test reported high values of alpha for the survey items which established the reliability of the items to be included in the final survey. Pilot data collection procedures were repli cated to collect final data. The data set was checked for ap proximately normally distribution and to satisfy the assumptions of the multiple regression analyses . D escriptive statistics were calculated to det ermine baseline frequency rates and multiple regr essions was conducted to assess any relationship between various independent and dependent variables identified in the study.
66 Table 3 1. Demographic Distribution of Pilot test Sample Population Class Rank f % Freshman 58 19.4 Sophomore 84 27.45 Junior 103 33.66 Senior 41 12.39 Graduate 15 4.90 Married Yes 5 1.6 No 298 97.7 Gender Female 213 69.61 Male 93 30.40 Age 18 22 285 93.20 23 30 18 5.88 31 40 2 0.06 Estimated combined Annual Household income Less than 25,000 112 38.62 $2500 1 $75,000 51 17.60 $75,001 125,000 71 24.48 More than 125,001 56 19.31 Ethnicity Asian Indian 47 15.46 Black/African American 46 15.00 Spanish/Hispanic/ Latino 40 13.20 White/Caucasian 171 56.25 Table 3 2 . Pilot Survey Attitude towards Older Re latives Scores and distribution Item f % Mean SD 95% CI Attitude Relative 56.35 24.11 54.05 58.65 Positive <96 286 93.4 Neutral =96 5 1.63 Negative >96 15 4.9
67 Table 3 3 . Pilot Survey Attitude towards Older Adults Scores and distributi on Item f % Mean SD 95% CI Attitude Adult 64.14 21.70 62.07 66.21 Positive <96 285 93.13 Neutral =96 4 1.3 Negative >96 17 5.55 Table 3 4 . Pilot Survey Preparedness Scores and distribution Item f % Mean SD 95% CI Preparedness Score 16. 644 6.98 15.98 17.30 Not at all Prepared 23 7.5 Somewhat prepared 74 24.18 Not too prepared 106 34.64 Well prepared 90 29.41 Very well Prepared 13 4.2 Table 3 5 . Reliability analysis of sub scales Item alpha Value RASDS 0 .975 PCS 0.9 08 Perceived behavioral control 0.905 Subjective Norms 0.847
68 CHAPTER 4 RESULTS The purpose of this study was to determine the caregiving preparedness level and attitude of college students towards their older relatives and determine wheth er Theory of planned behavior influenced their intentions to take the role of caregivers in future. C hapter 4 presents the results and is organized into demographics characteristics, role as caregiver, attitudes, preparedness for informal caregiving and s ubjective norms sections . A total of 750 surveys were collected of which 72 2 completed the survey and were included in the final analysis. No pilot test data were included in the final analysis. Demographic Characteristics Table 4 1 displays summary of st udy participants according to their age, class, ethnicity, marital status, gender and socio economic status. Majority of the participants in the study were females (n=526, 73.9%), and reported being not married (n=704, 98.9). There were 65 freshmen (9.1%), 278 sophomores (39 .0 %), 216 j uniors (30.3%), 136 seniors (19.1%) and 17 graduate (2.4%) students who completed the survey. Reported m ean age of the respondents calculated was 20. 2 years, SD=3.3 with a 95% confidence interval between 19.9 20.4 years (Table 4 2) . Majority of the respondents identified themselves as white (n= 371, 56 .1 %), some identified themselves as Hispanic (n=96, 14.5%). There were almost equal number of Asians (n= 71 , 10.7 %), and African Americans (n=68, 10.3%) and n= 55 ( 8.3 % ) identifi ed themselves as multiracial . One third (n=224, 33.6%) of the respondents reported their estimated annual household income less than $25,000. About 12% (n=79) reported their annual household income within the $25 , 001 $50,000 range . Some of the students rep orted their income within the range of $75 ,001 100,000 (n=88, 13.2%), $100,001 125,000 (n=88, 13.2%) , and
69 $50,001 $75,000 (n=93, 13.9%). S tudents also (n=95, 14.2%) reported their annu al income more than $ 125,001. The college majors were recoded into two different categories of health and non health respectively. Biology, chemistry, law, psychology were grouped under the non health majors category. Whereas , Applied Physiology and Kinesiology, Health Education and B ehavior, and N ursing were coded as health majors. There were almost equal number of students enrolled in health (n=338, 49.3%) and non health (n=346, 50.6%) majors. Role as Caregivers Table 4 3 reports the caregiving activities of the students in the past 12 months and majority of the respondents (n= 480, 66.5%) had never provided unpaid care to any of their older relatives in the past but most of them reported being somewhat likely or very likely (56 .1 %) to be responsible for their older relatives in the future (Table 4 4) . A majority of the respo ndents reported planning taking care of their mother (n=586, 81.2%), and father (n=534, 74%) in future. The study participants reported also being responsible for their grandmother (n= 296, 41%) along w ith grandfather (n=175, 24%), a unt (106, 14.7%), mothe r in law (n= 98, 13.6%), f ather in law (n=94, 13%), u ncle (n=90, 12.5%) and few reported being responsible for their step parents (n=50, 6.9%), other relatives (n=24, 3.3%) and great grandparents (n=14, 1.9%) in their future (Table 4 5) . Students were aske d if they have assisted any of their older relatives with activities of daily living or instrumental activities of daily living or in any other way in the past 12 months . It was important to ask them these questions to identify if they are currently or rec ently involved in providing care to their relatives which might impact their attitude and
70 preparedness levels. The results indicate many of the respondents never assisted their older relatives with instrumental activities of daily living (n=298, 41.6%), ac tivities of daily living (n=425, 59.5%) and other activities (n=452, 62.6%) in the past 12 months. For the instrumental activities of daily living (Table4 6) most reported helping with house work such as dishes and laundry (n=307, 42.9 %), Transportation (dr iving, helping arrange for transportation, or accompanying on public transit) (n=262,36.7%) , about one third helped with grocery shopping (n=232,32.4%), one fourth helped with preparing meals (n=183,25.6 % ) , giving me dications/pills (n=142, 19.8%) and a f e w of the respondents also reported managing the finances (n=46,6.4%) for their older relatives. When asked about helping with any activities of daily living (Table 4 7 ) , about o ne third of the students reported they ( 33.33%) , and hel ped with walking (n=228 , 31.9%). Some also reported helping their older relatives with climbing stairs (n= 151, 24.07%), and getting in and out of beds or chairs (n=142, 21.30%). Very few helped with Feeding (n= 69, 9.87%), getting dressed (n= 69, 8.64%), toileting and diapers ( n=27, 4.63%) and bathing (n=30, 4.2%). Few of the respondents had assisted their relatives in finding health information on line (n=91, 12.7%), went to a medical appointment with them (n=140, 19.6%),explained side effects of a medication (n=79, 11.0%), hel ped them understand instructions on how to take medications (n=98,13.6%), helped them in understanding written information them (n=60, 8.4%) (Table4 8 )
71 The survey instrument also included items about use of technology by the students to pr ovide caregiving (Table 4 9).Most of the students own a smartphone (n=659, 92.6%) and reported being very receptive and somewhat receptive to use their smartphone for applications helpful to take care of their OR (n=602, 84.7%) . Similarly, students reported being very receptive to use their Ipad/Tablet (n=323, 45.6%) for applications helpful in providing informal caregiving to their OR. Quality of Experience s and Interactions with OR Quality o f experience and interactions with their OR are identified as critical in literature for determining the attitudes. Hence, the survey included items about the quality of experiences students had with their OR and OA as well as the amount of interaction the y had in the past 12 months with their OR. Most of the students reported positive and very positive experiences with their OR (n=612, 84.8%) (Table 4 10) as well as OA (n=485, 68.7%) (Table 4 11). Many students reported having few interactions (n=215, 29.9 %) or intermittent contact several times a year (n=241, 33.5%) with their OR . Very few had a significant contact or lived in the same household with their OR (n=72, 10%) or had frequent contact on regular basis (n=54, 7.5%). Thirty seven students reported that their OR were not alive (Table 4 12) . There was a significant correlation between the interactions with OR and quality of experiences with them (t=0.365, p<0.0001). A standard multiple regression was used to test if demographic variables (gender , age, SES, ethnicity, class , and major ) , quality of experiences with OA, and interactions with OR significantly predicted quality of experiences with OR. Tests for multicollinearity indicated that a very low level of multicollinearity was present ( VIF< 1.142 ). T he results of the regression are presented in T able 4 13 indicate that and the variables explained
72 24. 9 % of the variance. (R = 0.499 , F ( 9 ,6 12 ) = 22.606 , p < .0 001 ) . It was found that ethnicity 0.115 , t = 3.253, p = 0.0 01 ) (1=White, 2= African American , 3=Hispanic, 4=Asian, 5=Multiracial), quality of experiences with OA 0 . 327 , t = 9.140 , p <0.0001 ), and interactions with OR 0 . 292 , t = 8.082 , p <0.0001 ), significantly predicted the quality of experiences between the students and their OR (Table4 14) . The regression equation based on the results for Quality of experiences with OR= 2.94+0.026(class) 0.163 (married) 0.053 (gender ) _ 0.001 (age) +0.17 (income ) + 0.012(major) 0.024 (ethnic ity ) + 0.273 (Q.Exp. OA ) + 0.159 (interaction with OR) To further explore the relationship of ethnicity and quality of experiences analysis of variance was conducted to identify differences among different ethnic groups the results of ANOVA are presented in T able 4 1 5 and indicate that there was a significant difference in quality of experiences among the ethnic groups (F (4,683) = 6.467, p<0.0001). However, further post hoc analysis of Scheffe could not identify any significant differences between the ethnic groups and quality of experiences of the students with their OR. Attitude s The descriptive results are presented in T able 4 1 6 , and indicate that the majority of the respondents (n= 644, 90.2%) scored less than 96 on the RASDS, thus a positive attitude t owards their older relat ives with a mean score of 56.19, SD= 26.41 , and 95% CI between 53.19 57.17. Similarly, the majority (n=626, 87.3%) scored less than 96 and reported a positive attitude towards OA with a mean score of 66.72 , SD= 24.15 , and 95% CI bet ween 64.45 68.06 . The bivariate analysis determined a significant relationship (p<0.001) between the two scores with a variance of 0.645 . Based on the study results we reject the null hypotheses for research question one, because the
73 mean score for the RA SD is not equal to 96 but lower thus indicating positive attitude towards OR . A multiple regression was performed to test the hypothesis of association between demographic characteristics ( age, SES, gender, ethnicity, majors, marriage ) , attitudes towards O A, amount of interaction with OR , past informal caregiving, quality of experience with OR and attitude s of college students towards their OR . Tests for multicollinearity indicated very low level of multicollinearity ( VIF<1.99) . As a group demographi cs vari ables did not contribute significantly and accounted for only 0.6% of the variance in attitude (F (7,617 ) = 0.531, p=0.812 ) (Table 4 1 7 ) . Whereas amount of interaction, past informal caregiving, attitudes towards OA , and quality of ex periences with OR acco unted for 56.4% of the variance in attitudes (F (11,613) =72.133, p<0.0001 . Attitude towards OA . 628 , t = 21.75 , p < .00 0 1 ), and quality of experiences with OR ( 0.245 , t = 8. 151 , p < 0 .00 0 1 ) significantly predicted attitudes towards OR (Table 4 1 8 ) . The negative values implies that as the quality of experience increases by one standard deviation attitude score will decrease by 0.245.( low quality of experiences with older relatives tend to develop a negative attitude towards them ) (high RASDS score= negative attitude). Interactions with OR and providing informal care in the past 12 month s did not predict the attitudes towards OR. Therefore, model for predicting attitude towards OR is a linear combination of, quality of experience with OR and attitude towards OA (R = 0 .720, R 2 = 0 .518, F (10,625) = 67.275, p < 0 .001). The regression equati on based on the results for attitudes towards OR= 61.979 0. 448 (class) 12.159 (married ) + 0. 573 (gender ) + 0.009 (age) 0.395
74 (income) + 1.903(major ) + 0.02 7 (ethnicity ) + 1.502 (previous caregiving ) + 0.679 (attitudes towards OA) 7.670 (Q.Exp. OA ) + 0. 380 (inter action with OR) Preparedness to Take Care Of Older Relatives In Future Consistent with the proposed method, responses to the categories agree and strongly agree were summed and divided by 8 to calculate the mean preparedness score (Table 4 1 9 ) . Partic ipan ts scored low on the scale with M = 1 .8 58 7 , SD=0.975 , and 95% CI between 1.787 1.930 . Based on the score range of CPS m any of the students reported being not too prepared (n=198, 27.4%) as informal caregivers for their older relatives, lower percentage repor ted being well prepared (n=165, 22.9%), not at all prepared (n=100, 13.9%), and very well prepared (n=38, 5.3%). Most of the students (n=221, 30.6%) felt somewhat prepared for the future role. The detailed CPS responses are presented in T able 4 20 . Most o f the students reported not at all, somewhat, and not too well prepared for the stress of caregiving (n= 496, 69.0%), setting up services (n=495, 68.8%), get help and information from health care system (n=464, 64.5%) , take care of their OR emotional needs (n= 457, 63.5%), respond to and handle emergencies (n=445, 61.8%), make caregiving activities pleasant for themselves and their OR (n=438, 61.0%),and take care of their OR physical needs (n=4 83, 57.2%). Overall n=482, 67% students reported being not at al l, somewhat, and not too well prepared to care for their OR. One way ANOVA was conducted to compare the effect of previous caregiving activities including ADL, IADL and others on the preparedness scores. The results are presented in T able 4 2 1 and indicate a significant effect of previously provided IADL (F=24.130, P<0.0001), ADL (F=32.361, p<0.0001) and other activities (F=23.792, p<0.0001) in the past 12 months on the preparedness scores of the students.
75 A multiple linear regression was performed t o test any association between the demographic variables ( age, SES, gender, ethnicity, majors, marriage ) , past informal caregiving, amount of interaction , perceived behavioral control for taking care, and quality of experience with OR. Tests for multicollinearity indicated that a very low level of multicollinearity was present ( VIF< 1.191 ). Results are presented in T able 4 2 2 and report a s tatistically significant proportion of variance (45.9%, p<0.0001) was explained by the model including past informal caregivin g (Yes=1, No=2) , amount of interaction , perceived behavioral control for taking care, and quality of experience with OR while controlling for demographic variables. Standardized regression coefficient results (Table 4 2 3 ) showed that perceived behavior al control for taking care was strongly 0 .6 31 , t = 20.542 , p < 0 .0 001).Also, past informal caregiving ( 0 .0 9 0 , t = 2 . 95 7 , p < 0 .05 ) , and quality of experiences with OR ( 0 .0 90 , t = 2. 8 7 2 , p < .05 ) , had s maller but statis tically significant association with preparedness for caregiving. The negative for past informal caregiving implies that as the students report not having provided informal care to any of their OR in the past 12 months increas es by one std. deviation, the ir prepared ness as informal caregiver decreases by 0.090 SD . The refore, the model for predicting preparedness to take care of OR is a linear combination of, quality of experience with OR , perceived behavioral control, and hav ing provided informal care in the past (R = .6 87 , R 2 = .4 73 , F (11,622) = 50.026 , p < .00 0 1) and the regression equation included preparedness as informal caregiver = 1.873+ 0. 005(class)+0.091 (married)+0. 004 (gender)+0. 027 (age)+ 0. 02 5 (income) + 0.032 (majo r) 0.0 07 (ethnicity)
76 0.186 (previous caregiving)+0. 108 ( Qlty.Exp with OR ) 7.670 (Q.Exp. OA ) + 0. 017 (interaction with OR ) + 0.087 (perceived behavioral control) Relationship between Attitudes towards OR and Preparedness for Caregiving Table 4 2 4 shows the results of association between the attitude and preparedness score. The model explained only 4.6 % variance in attitude towards OR based on the preparedness scores (R = . 215 , R 2 = . 046 , F ( 1 , 700 ) = 33.962 , p < .0 001 ) . The significant negative standardized regression coefficient 0.215 , t = 5.828 , p <0.0001) (Table 4 2 5 ) implies that as the preparedness to take care of the older relatives SD increases by one, students attitude scores drop by 0.215 SD (low RASDS score=positive attitudes) . The multiple regression equation explained attitudes towards OR=65.674 0.698(preparedness score) Theory of Planned Behavior Constructs Perceived Behavioral Control PBC is one of the constructs of TPB which is closely associated with self efficacy or confidence to adopt or change a behavior. Many respondents agree and strongly agree that the y are confident of assisting their OR with IADL ( n =486, 68.5%), make caregiving activities pleasant (n=422, 59.4%), handle emergencies (n=397, 56.0%), get help and information from he alth care system (n=397, 56.0%), setting up services (n=393, 55.4%), take care of their emotional needs (n=383, 53.9%), managing the stress associated with caregiving (n=332, 46.8%), ADL (N=308, 43.4%) (Table 4 2 6 ) . About half of the students 389 (54.8%) r eported they were overall prepared for informal caregiving .
77 Subjective Norms SN is one of the constructs of TPB that includes how individuals perceive other people important to them think about the behavior. Many respondents agree and strongly agree that their family expects (47%), their culture (46%), religion (34%), an obligation (51%) and important for their own personal fulfillment (74%) to take care of their older relatives (Table 4 2 7 ) . Intentions Table 4 2 8 presents the frequency analysis of th e intentions of the students to provide informal care to their OR. About three fourth of the students reported that they somewhat likely and very likely intend to handle emergencies (n=544, 76.7%) and seek help and information from health care system (n=52 6, 74.1%). Many intend to set up services (n=513, 72.3%) , cater to emotional needs (n=497, 70.0%), and assist of their OR with IADL (n=471, 66.4%) and ADL (n=361, 50.8%). Theory of Planned Behavior To e xplore the constructs of TPB as predict ors of students intentions as informal caregivers for their older relatives in future, a hierarchical multiple regression analysis was performed with the independent demographic variables ( (a) Ethnicity (coded into four dichotomous variables of 1= White, 2= Black, 3= Asi an, 4= Hispanic, and 5= multiracial); (b) Gender, coded as 1 = female, 2 = male; (c) Class, coded as 1=Freshman, 2=Sophomore, 3=Junior, 4=Senior , and 5= Graduate student; (d) Married, coded as 1= married, and 2= not married; (e) Major, coded as 1= Health, a nd 2=Non Health; age and SES were entered as continuous variables ) . The data set was investigated to satisfy the assumptions of the multiple regression analyses including ; missing values , presence of outliers , normality, linearity , and homoscedasticity. V isual
78 inspection of histograms and Normal Quantile Quantile (Q Q) plots for the intentions score; attitude and perception score variables indicated approximately normal distributions. Controls variables (demographics) were entered into the model on the fir st step of the regression followed by attitude towards OR scores, perception scores on the third step, and perceived behavioral control scores were entered into the model on the fourth step. Table 4 2 9 shows the results of hierarchal m ultiple regressions . The demographic variables explained only 1.9% of the variance in intentions. Attitude towards older relatives explained 8.5% variance, subjective norms about informal caregiving contributed additional 41.9% variance and c onfidence to take care explained 53 .7 % of variance in the intention scores when we controlled for demographics. It was found that a ttitude towards OR ( 0 . 126, t= 4.439, p< 0.000 1 with one SD increase in attitude scores results in decrease of 0.126 SD in the intentions ), subjective norms 388 , t =11.628, p< 0.000 1 ) and perceived behavioral control 0 .412, t=12.370 p< 0 .000 1 ) significantly predicted intentions of the students to take care of their older relatives in future (Table 4 30 ) . The values imply that with an increase of one SD of subjective norms and perceived behavioral control the intentions to serve as infor mal caregiver increases by 0.388 and 0.412 respectively. The full model that included attitude towards OR , subjective norms about informal caregiving and perceived behavioral control to serve as informal caregiver was a significant improvement from step o ne (F (10, 602) = 69.733,p<0.0001) , which was the controls only, model and the regression equation explained Intentions to serve as informal caregivers for their OR= 1 1. 090+ 0. 117 (class) 1 . 2 49 (married) 0. 405
79 (gender)+0. 012 (age) 0.055 (income) 0 . 163(majo r) 0.0 38 (ethnicity) 0. 024 (attitudes towards O R ) +0.421 ( subjective norms )+0. 2 80 ( perceived behavioral control ) . We reject the null hypothesis and conclude that the constructs of theory of planned behavior had a statistically significant association with the intentions to provide informal care to the older relatives beyond the control variables .
80 Table 4 1 . Distribution of Participants by Class, Marriage, gender, SES and Major. Item f % Class Freshman 65 9.1 Sophomore 278 39 Junior 216 30.3 Senior 136 19.1 Graduate 17 2.4 Total 712 Married Yes 8 1.1 No 704 98.9 Total 712 Gender Female 526 73.9 Male 186 26.1 Total 712 Estimated combined Annual Household income Less than 25,000 224 33.6 $25001 $50,000 79 11.8 $50,001 $75,000 93 13.9 $75,001 100,000 88 13.2 $100,001 125,000 88 13.2 More than 125,001 95 14.2 Total 667 33.6 Ethnicity Asian 71 10.7 Black/African American 68 10.3 Spanish/Hispanic/ Latino 96 14.5 White/Caucasian 371 56.1 Multi Race 55 8.3 T otal 661 Major Health 338 49.3 Non Health 346 50.6 Total 684
81 Table 4 2. Age Variable Item Mean SD 95% Conf. Interval Age 20.187 3.31 19.943 20.43 Table 4 3 . Frequency Anal ysis Results for Provided Unpaid Care in P a st 12 M onths Item f % Yes 241 33.5 No 480 66.5 Total 712 Note: Twelve students did not report providing unpaid care in past 12 months. Valid percentages are reported Tabl e 4 4 . Frequency Analysis Results for L ikely Responsible For Older R elatives Item f % Very u nlikely 109 15.1 Somewhat Unlikely 124 17.2 Undecided 84 11.6 Somewhat Likely 221 30.6 Very Likely 184 25.5 Total 722 Note: Two students did not report likelihood of being responsible for their older relatives. Valid perc entages are reported Table 4 5 . Frequency Analysis Results for Family M ember s Need to T ake Ca re Item f % Mother 586 81.2 Grandfather 175 24.2 Great Grandparents 14 1.9 Father 534 74 Mother in law 98 13.6 Step Parents 50 6.9 Aunt 106 14.7 Grandmother 296 41 Father in law 94 13 Uncle 90 12.5
82 Table 4 6. Frequency Analys is Results for Providing Instrumental Activities of Daily Living Item f % Giving medications/pills 142 19.8 Manage finances 46 6.4 Grocery shopping 232 32.4 House work such as dishes, laundry 307 42.9 Preparing meals 183 25.6 Transportation (dr iving, helping arrange for transportation) 263 36.7 Arranging or supervising paid services (nurses,, Meals on Wheels) 34 4.7 None 298 41.6 Table 4 7 . Frequency Analysis Results for Providing Activities of Daily L iving Item f % Bathing 30 4.2 Ge tting dressed 69 9.7 Feeding 69 9.6 Getting in and out of beds or chairs 142 19.9 Help with toileting 38 5.3 Dealing with incontinence or diapers 27 3.8 Walking 228 31.9 Climbing stairs 151 21.1 None 425 59.5 Table 4 8.Frequency Analysis R esults for Providing Other Activities Item f % Made a medical appointment for him or her 60 8.4 Went with him or her to a medical appointment 140 19.6 Helped him or her in understanding written information from 140 19.6 Acted as a translator at a medical or social service visit 108 15.1 Helped with filling out a medical or insurance form 68 9.5 Helped him or her to understand the instructions on how to take a medication 98 13.6 Explained the side effects of a medica tion 79 11 Gone online to find health information for him or her 91 12.7 None 452 62.6
83 Table 4 9. Frequency Analysis Results for Use of Technology for Caregiving Item f % Own Smartphone Yes 659 92.6 No 53 7.4 Total 712 Own an I pad/Tabl et Yes 269 37.8 no 443 62.2 Total 712 Receptive to use smartphone for applications helpful to take care of their older relatives Very Receptive 394 55.4 Somewhat receptive 208 29.3 A little receptive 69 9.7 Not receptive 40 5.6 Total 711 Receptive to use I pad/Tablet for applications helpful to take care of their older relatives Very Receptive 323 45.6 Somewhat receptive 204 28.8 A little receptive 72 10.2 Not receptive 109 15.4 Total 708 Table 4 10 . Frequency Analysis Result s for Quality of experiences with Older R elatives Item f % Negative 11 1.5 Very Negative 7 1 Neutral 91 12.6 Positive 298 41.3 Very positive 314 43.5 Total 724
84 Table 4 11 . Frequency Analysis Results for Quality of experiences with O lder Adults Item f % Negative 22 3.1 Very Negative 7 1 Neutral 197 27.3 Positive 382 53 Very positive 113 15.7 Very Negative 7 1 Total 706 Note: Eighteen students did not report quality of their experiences with older adults. Valid percentages are reported Table 4 12 . Frequency Analysis Results for Interaction with older relatives Item f % They are Not alive 37 5.1 Frequent contact on regular basis 54 7.5 Little or no contact 101 14 Few Interactions 215 29.9 Intermittent contact several times a year 241 33.5 Significant contact/lived in same household 72 10 Total 720 Note: Four students did not report frequency of interaction with older relatives. Valid percentages are reported Table 4 13 . Summa ry of Multiple Regression Analysis of Independent Variables Predicting Quality of Experience with OR R R 2 R 2 F Sig. Interaction with OR .499 . 249 . 238 22.606 .0 00* * *Significant at the p<0.05 level, **Significant at the p<0.0001 level
85 Table 4 14 . Summary of Multiple Regression Analysis of Independent Variables Predicting Quality of Experience with OR B SE B t Sig Model 1 (Constant) 2.940 .525 5.600 .000 Class .026 .027 .036 .961 .337 Married .163 .222 .026 .734 .463 Gender .053 .057 .034 .938 .349 Age .001 .007 .007 .194 .846 Income .017 .014 .044 1.229 .220 Major .012 .050 .009 .2 43 .808 Ethnicity .024 .007 .115 3.253 .001 ** QEXP.A .273 .030 .327 9.140 .000 ** interact ion .159 .020 .292 8.082 .000 ** Table 4 1 5 . ANOVA of Quality of Experience with OR with different ethnic groups f Mean Std. Deviation Std. Error F Sig White 364 4.41 .677 .035 6.467 0.000 African American 67 4.04 .747 .091 Hispanic 94 4.33 .739 .076 Asian 109 4.12 .690 .066 Multiracial 54 4.30 .690 .094 Total 688 4.31 .707 .027 Table 4 1 6 . Analysis Results for Attitudes towards O lder Relatives and Older Adults Item f % Mean SD 95% CI Attitude towards older relatives (f=709) 56.19 26.412 53.19 57.17 Positive <96 644 90.2 Neutral =96 25 3.5 Negative >96 45 6.3 Attitude towards older adults (f=717) 66.72 24.146 64.4 5 68.06 Positive <96 626 87.3 Neutral =96 21 2.9 Negative >96 70 9.8
86 Table 4 1 7 . Summary of Multiple Regression Analysis of Independent Variables with Attitudes towards Older Relatives R R 2 R 2 F Sig. Model 1 Age, Class, Ethnicity, Major, Married, Income .077 .006 .006 .531 .812 Model 2 Age, Class, Ethnicity, Major, Married, Income, Attitude towards OA , Provided unpaid care, interaction with OR and Quality of Experience with OR. .751 .56 4 .558 72.133 .000 ** **Significant at the p<0.0001 level Table 4 1 8 . Multiple Regression Analysis of Independent Variables with Attitudes t owards Older Relatives B SE B t Sig Model 1 (Constant) 64.262 21.103 3.045 .002 Class .341 1.140 .013 .2 99 .765 Married 4.719 9.376 .021 .503 .615 Gender 2.517 2.364 .044 1.065 .287 Age .134 .316 .018 .425 .671 Income .515 .572 .037 .900 .368 Major 1.476 2.106 .029 .701 .484 Ethnicity .176 .308 .023 .571 .568 Model 2 (Constant) 61.979 1 5.482 4.003 .000 Class .448 .761 .017 .588 .556 Married 12.159 6.243 .053 1.948 .052 * Gender .573 1.583 .010 .362 .717 Age .009 .210 .001 .043 .966 Income .395 .384 .028 1.029 .304 Major 1.903 1.400 .037 1.359 .175 Ethnicity .027 .2 05 .004 .130 .896 Unp.Care 1.502 1.476 .028 1.018 .309 Atti. OA .679 .031 .628 21.754 .000 ** Interaction .380 .587 .019 .647 .518 QExp.OR 7.670 .941 .245 8.151 .000 ** *Significant at the p<0.05 level, **Significant at the p<0.0001 level
87 Table 4 1 9 . Analysis Results for Preparedness Score N =722 Item f % Mean SD 95% CI Preparedness Score 1.8 5 8 0 . 975 1.787 1.930 Not at all Prepared 100 13.9 Somewhat prepared 221 30.6 Not too prepared 198 27.4 Well prepared 165 22.9 Very well Prepared 38 5.3 Total 722
88 Table 4 20 . Frequency Analysis Results for Preparedness for Caregiving Not at all Prepared f (%) Somewhat Prepared f (%) Not too well Prepared f (%) Pretty well Prepared f (%) Very well Prepare d f (%) How well are yo u prepared to take care of your older family member's physical needs 114 (15.9) 221 (20.7) 148 (20.6) 180 (25.0) 53 (7.4) How well are you prepared to take care of your older family member's emotional needs 70 (9.7) 208 (28.9) 179 (24.9) 193 (26.8) 65 ( 9.0) How well prepared do you think you are to find out about and set up services for him or her? 116 (16.1) 175 (24.3) 204 (28.4) 167 (23.2) 53 (7.4) How well prepared do you think you are for the stress of caregiving 141 (19.6) 168 (23.4) 187 (26.0) 171 (23.8) 48 (6.7) How well prepared do you think you are to make caregiving activities pleasant for both you and your family member? 94 (13.1) 204 (28.4) 140 (19.5) 222 (30.9) 55 (7.6) How well prepared do you think you are to respond to and handle em ergencies that involve him or her? 83 (11.5) 180 (25.0) 182 (25.3) 196 (27.3) 71 (9.9) How well prepared do you think you are to get help and information you need from the health care system? 114 (15.9) 185 (25.7) 165 (22.9) 182 (25.3) 69 (9.6) Overal l, How well prepared do you think you are to care for your older family member? 77 (10.7) 212 (29.5) 193 (26.8) 179 (24.9) 54 (7.5)
89 Table 4 2 1. Summary of One way ANOVA of Preparedness Scores with previous caregiving activities Item f % Mean SE F Sig IADL 24. 787 .000 ** yes 41 8 58.34 2.008 . 046 No 29 6 41.65 1.654 . 056 Total 71 4 ADL 32.210 .000 ** yes 288 40.50 2.104 0.053 No 42 4 59.49 1.689 0.047 Total 71 2 Other yes 263 36.93 2.098 . 059 26.086 .000 ** No 4 50 63.0 6 1.718 . 044 Total 71 3 *Significant at the p<0.05 level, **Significant at the p<0.0001 level Table 4 2 2 . Summary of Multiple Regression Analysis of Independent Variables with Preparedness Scores R R 2 F Sig. Model 1 Age, Class, Ethnicity, Major, Married, Income .134 .018 .007 1.608 .1 30 Model 2 Unp aid Care, Qexp.OR, Per. Beh.Control , interaction with OR .687 .473 .463 50.026 .000 ** *Significant at the p<0.05 level, **Significant at the p <0.0001 level
90 Table 4 2 3 . Hierarchical Regression Analysis of Independent Variables with Preparedness Scores B SEB t Sig Model1 (Constant) 2.075 1.119 1.854 .064 Class .074 .055 .073 1.337 .182 Married .467 .384 .054 1.217 .224 Gender .0 55 .090 .025 .617 .538 Age .020 .032 .037 .643 .520 Income .032 .022 .060 1.476 .140 Major .076 .080 .039 .953 .341 Ethnicity .001 .012 .003 .085 .932 Model 2 (Constant) 1.873 .860 2.177 .030 Class .005 .041 .005 .115 .908 Married .091 .283 .010 .320 .749 Gender .004 .067 .002 .067 .947 Age .027 .023 .050 1.173 .241 Income .025 .016 .047 1.544 .123 Major .032 .059 .016 .541 .589 Ethnicity .007 .009 .024 .827 .408 Unpaid Care .186 .063 .090 2.957 .003 * Interaction OR .017 .025 .023 .705 .481 Q.Exp.OR .108 .038 .090 2.872 .004 * Perc.Beh. Control .087 .004 .631 20.542 .000 ** *Significant at the p<0.05 level, **Significant at the p<0.0001 level Table 4 2 4 . Summary of Linear Regression Analysis of Attitudes towards OR with Preparedness to take care (f=7 22 ) Model R R 2 F Sig. 1 .215 a .046 .045 33.962 .000 ** *Significant at the p<0.05 level, **Significant at the p<0.0001 level Table 4 2 5 . Linear Regression Analysis of Attitude Scores with Preparedness Scores B SEB t Sig (Constant) 65.674 2.027 32.399 .00 0 ** Preparedness score .698 .120 .215 5.828 .000 ** *Significant at the p<0.05 level, **Significant at the p<0.0001 level
91 Table 4 2 6 . Frequency Analysis Results for Perceived Behavioral Control for Caregiving I feel confident of assisting my older relatives in the future with Strongly Disagree f (%) Disagree f (%) Neither Agree nor Disagree f (%) Agree f (%) Strongly Agree f (%) IADL 26 (3.7) 64 (9.0) 134 (18.9) 379 (53.4) 107 (15.1) ADL 49 (6.9) 158 (22.3) 195 (27.5) 249 (35.1) 59 (8.3) Emotional needs 25 (3.5) 112 (15.8) 190 (26.8) 300 (42.3) 83 (11.6) Set up services 29 (4.1) 115 (16.2) 172 (24.3) 309 (43.6) 84 (11.8) Manage the stress 39 (5.5) 121 (17.1) 217 (30.6) 269 (37.9) 63 (8.9) Make care giving activities pleasant 20 (2. 8) 77 (10.8) 191 (26.9) 345 (48.6) 77 (10.8) Handle emergencies 32 (4.5) 95 (13.4) 185 (26.1) 300 (42.3) 97 (13.7) Information from health care system 39 (5.5) 111 (15.4) 171 (23.7) 300 (42.3) 97 (13.7) Over all I feel confident 31 (4.4) 84 (11.8) 20 6 (29.0) 319 (44.9) 70 (9.9)
92 Table 4 27 . Frequency Analysis Results for Subjective Norms about Caregiving Items Strongly Disagree N (%) Disagree N (%) Neither Agree nor Disagree N (%) Agree N (%) Strongly Agree N (%) My family expects me to take care of my OR 62 (8.7) 118 (16.6) 226 (31.7) 208 (29.2) 98 (13.8) In my culture, It is responsibility of young adults to take care of OR 57 (8) 105 (14.7) 205 (28.8) 216 (30.3) 129 (18.1) In my religion, It is responsibility of young adults to take car e of OR 59 (8.3) 109 (15.4) 279 (39.4) 181 (25.5) 81 (11.4) It is an obligation for me to take care of my OR 56 (7.8) 91 (12.8) 229 (32.2) 231 (32.5) 104 (14.6) It is important for my own Personal Fulfillment to take care of my OR 17 (2.4) 57 (8) 150 (21.1) 300 (42.2) 187 (26.3) Table 4 2 8 . Frequency Analysis Results for Intentions about providing care to Older I intend to assist my older relatives Very Unlikely f (%) Somewhat Unlikely f (%) Undecide d f (%) Somewhat Likely f (%) Very Like ly f (%) IADL 31 (4.4) 49 (6.9) 159 (22.4) 337 (47.5) 134 (18.9) ADL 28 (3.9) 102 (14.4) 219 (20.8) 262 (36.9) 99 (13.9) Emotional needs 20 (2.8) 37 (5.2) 156 (21.6) 367 (51.7) 130 (18.3) Set up services 19 (2.7) 38 (5.4) 140 (19.7) 362 (51.0) 151 (21.3) Handle emergencies 14 (2.0) 32 (4.5) 119 (16.8) 373 (52.6) 171 (24.1) Information from the health care system 21 (3.0) 34 (4.8) 129 (18.2) 369 (52.0) 157 (22.1)
93 Table 4 2 9 . Summary of Hi erarchical Regression Analysis of Theory of Planned Beha vior Constructs with Intentions to provide care R R 2 R 2 F Sig . Model 1 Age, Class, Ethnicity, Major, Married, Income .139 a .019 .008 1.707 .104 Model 2 Attitude Relative .292 b .085 .073 7.011 .000 ** Model 3 Perception .647 c .419 .410 48.303 .00 0 ** Model 4 Perc. Beh. Control .733 d .537 .529 69.733 .000 ** *Significant at the p<0.05 level, **Significant at the p<0.0001 level
94 Table 4 30 . Hi erarchical Regression Analysis of Theory of Planned Behavior Constructs with Intentions to Provide care B SEB t Sig Model1 (Constant) 27.684 4.168 6.642 .000 Class .266 .213 .053 1.247 .213 Married 3.246 1.858 .072 1.747 .081 Gender .670 .444 .062 1.509 .132 Age .055 .059 .041 .941 .347 Income .027 .107 .010 .248 .804 Major .091 .393 .010 .232 .816 Ethnicity .089 .058 .063 1.542 .124 Model 2 (Constant) 30.405 4.051 7.506 .000 Class .249 .206 .050 1.209 .227 Married 3.270 1.797 .073 1.820 .069 Gender .567 .429 .053 1.321 .187 Age .049 .057 .036 .871 .384 Income .049 .104 .019 .473 .636 Major .169 .380 .018 .445 .657 Ethnicity .097 .056 .068 1.725 .085 Attitude OR .049 .007 .257 6.581 .000 ** Model 3 (Constant) 17.077 3.309 5.161 .000 Class .355 .164 .071 2.160 .031 Married 1.742 1.435 .039 1.214 .225 Gender .522 .343 .049 1.523 .128 Age .014 .045 .010 .308 .758 Income .044 .083 .017 .530 .596 Major .116 .304 .012 .383 .702 Ethnicity .082 .046 .058 1.801 .072 Attitude OR .037 .006 .191 6.113 .000 ** Sub.Norms .649 .035 .598 18 .616 .000 ** Model 4 (Constant) 11.090 2.997 3.701 .000 Class .117 .148 .024 .791 .429 Married 1.249 1.283 .028 .973 .331 Gender .405 .306 .038 1.321 .187 Age .012 .040 .009 .299 .765 Income .055 .074 .021 .747 .456 Major .163 .271 .017 .600 .549 Ethnicity .038 .041 .027 .936 .350 Attitude OR .024 .005 .126 4.439 .000 **
95 Table 4 30. Continued B SEB t Sig Sub.Norms .421 .036 .388 11.628 .000 ** Perc. Beh. Control .280 .023 .412 12.370 .000 ** *Significant at the p< 0.05 level, **Significant at the p<0.0001 level
96 Figure 4 1 . Normal P P Plot of Regression Standardized Residual of Attitude towards older adults Score Figure 4 2 . Normal P P Plot of Regression Standardized Residual of Preparedness Score
97 Figure 4 3 . Normal P P Plot of Regression Standardized Residual of Intentions Score Figure 4 4 Means Plot between Preparedness Mean and Provided IADL in past 12 months
98 Figure 4 5 . Means Plot between Preparedness Mean and Provided ADL in past 12 months Figure 4 6 . Means Plot between Preparedness Mean and Provided Other Activities of Caregiving in past 12 months
99 CHAPTER 5 DISCUSSION This study used a cross sectional survey design that included RASDS and PCS besides scales based on TPB constructs, and demographi c information. The study assessed the attitude s of college students towards their older relatives and levels of preparedness to serve as informal caregivers, a group that has, to date, received little attention in the informal caregiving literature. This r esearch also examined the relationship of age, gender, SES, ethnicity, major, and marriage to attitudes and preparedness scores. Lastly the study investigated the influence of TPB constructs (attitudes, subjective norms and perceived behavioral control) on the intentions of students to provide informal care to their older relatives. Findings of the study disclosed a positive attitude of students towards their older relatives but lower levels of preparedness to serve as informal caregivers. This study also revealed that the constructs of the TPB influenced the intentions of college students to serve as informal caregivers. As yet, few studies have investigated attitudes of typical college population towards older relatives and none has been reported to asses s the preparedness for informal caregiving among the college population. The study included two pilot studies and the final administration of a paper pencil survey. The pilot studies were used only to test the reliability and validity of the scales used an d whether there was any difference between the attitudes towards older adults and older relatives. Pilot test responses were used to refine and improve the survey instrument for use in the final implementation. The main purpose of this chapter is to discus s the results for the current study in view with previous literature and presents strengths and
100 limitations of the study and provides future research recommendations and study conclusions. Study Population and Previous Caregiving Activities The study re cr uited students enrolled in three large on campus classes which were representative of the university enrolled population based on their age, gender, SES, major and ethnicity. For a representative sample d ata were collected over one academic calendar beginn ing Spring semester for pilot test, and final data were collected over the Summer and Fall semesters within a year. The average age of the students was comparable with other studies that included college students (Harwood et al, 2005; Chase 2011; Swanlund and K ujath, 2012) . The study included fewer male participants than females and more participants identified themselves as white , typical with many studies those have included gender and ethnic discrepancies in their studies that involved college population (Harwood et al, 2005, Narayan, 2008; & , Hawkins 2004) . Also, demographics of the participants included in the study were representative of the university population which reported higher enrollment of females, whites , and undergraduates during the study y ear (University office of institutional planning and research, 2013). The study adds to the literature by identifying one third of the study participants as informal caregivers, who reported that they have provided unpaid care to their OR in the past 12 m onths , which is lower than a national study by Johnson and Johnson, 2013 which reported a n estimate of 120 million adult Americans (57%) are either providing or have provided in informal care in the past, to their OR or friends. Other studies with adolesce nts and college population have also reported higher number of their participants as either providing or have provided informal care to their OR in past
101 ( Hamil, 2012 (68%), and Baus, Dysart Gale , & Haven, 2005 (83.8%) . Although not current active informal caregivers but many students did report their intentions for being somewhat likely and very likely (56%) responsible of their OR in future which is consistent with the results reported by Hamil , 2012 (59.3%) but lower than the study by Johnson and Johnso n, 2013 who reported t wo third of the population (66%) reported very likely (43%) or somewhat likely (23%) will need to provide care to someone in the future , and 34% reported having talked with their families about providing care to them in future . Many o f the participants identified their parents and grandparents as the OR they will need to take care in future similar to Dellmann Jenkins, Blankemeyer & Pinkard (2000) who reported majority of grandchildren between the ages of 18 35 years (76%) acquired the role of caregiving. According to Pew Research Center, 2010 a n estimated 83 % of Americans say they would feel very obligated to provide assistance to their parent in a time of need which echoes our study results where 68% agreed and strongly agreed that it was important for their personal fulfillment to take care of their OR . The study results align with the qualitative study conducted by Sweden Ali, Ahlstrom, Rot , & Skarsater (2012) who reported young adults (16 24 years) were ready as informal caregivers t o their OR in future . The students selected various caregiving activities they have assisted with and m ore number reported providing assistance with IADL s such as housework, preparing meals, transportation, which are less complex than ADLs and other acti vities of caregiving consistent with findings of Baus, Dysart Gale, & Haven (2005) , Hamill (2012) , and Dellmann Jenkins, Blankemeyer, & Pinkard (2000) . These results may attribute to the fact that college students generally are not the primary caregivers a nd
102 may assist with simple activities of transportation or preparing a meal . Consistent with Ryn et al 2011, study that confident 71% ( n = 472) about providing physical care and emotional needs ( 46%, n = 312) , our study population also reported higher confidence to provide assistance with IADLs and emotional needs as well. Given the technological advancement and increased use of smartphones, ipad and tablets by young generation, the study also exp lored the receptiveness of the college students to use the smart technology as an assistance to provide informal caregiving. Most of the students were very receptive and somewhat receptive to use applications for informal caregiving on their smartphones, I pads and tablets. This provides an opportunity for the educators and app developers to collaborate and develop applications for informal caregiving. Attitudes towards Older Relatives Attitudes represent the feelings of an individual towards any person or o bject and OA and their OR . The RASDS yielded a high reliability consistent with other studies who recruited medical major students ( C ronbach's alpha=0.91, Henry et al, 2011 ; and Chase, 20 11), couns elling psychologists students ( alpha=0.95, Tomko and Munley, 2012, alpha=0.94, Laditka, Fischer, Laditka , & Segal, 2004 . The study participants reported a positive attitude towards their OR as well as OA . These findings echo those of earlier stud ies who identified the attitudes of nursing, nutrition, and medical major students ( Henry et al, 2011; Narayan, 2008 , G onzales and M o rrow Howell, 2009 ; Chase, 2011 ; and Yuriy, 2013 ) . Contrary to our study Swanlund and Kujath, 2012 , reported negative attitu des of nursing students towards older adults. The significant difference between the scores of
103 attitudes towards OA and OR suggest that college students tend to have more positive attitude towards their own OR than other OA. Most of the attitude studies am ong college students in the literature have studied effect of academic intervention on the attitude (Nochajski et al, 2009 ; Bernard et al, 2003 ; and Jensen and Winifred, 2004 ) but rarely there have been studies that have studied the impact of other behavio rs and perceptions on attitudes. Our study identified attitude towards OA and quality of experience with OR associated significantly with the attitude towards OR. Contrary to t he study of adolescents by Harwood et al, 2005 who noted that quality of contact and interaction significantly predicted attitudes , o ur study did not report interaction or demographic variables as predictor of attitudes towards OR . A positive relationship between attitudes and age, gender, and major has been reported in the literature but this relationship is not consistently upheld. W hile our study consistent with Zverev, 2013 and Narayan, 2008 did not identify any gender differences in the attitude towards older relatives, some studies identified men having a less positive attitude t owards older population (Rupp et al, 2005; Lee , 2009 ; Gellis , et al, 2003) while others reported females having a less positive attitude towards elderly (Tomko and Munley, 2012; Nochajski , et al, 2009). In a study condu cted by Tomko and Munley, 2012, age and gender together accounted for a significant variance in the attitude but identified only gender as a significant predictor (t= 2.38, p=0.018). and Brookover, 2002; Lee, 2009 ; and Nochajski, 2009 also reported no association between age and att itude which is consistent with our findings but Laditka et al, 2009 did report a positive attitude with increase in age. O ur study did not report any association between class and attitude which is contrary to other studies (Nochajski,
104 2009 ; Gellis et al, 2003; Swanlund and Kujath, 2012) who reported a positive association between the attitudes and as the students progressed in class. Study also intended to explore any differences between health and nob health majors but n o significant differences were foun d between attitudes and major as noted in the literature (Laditka, Fischer, Laditka , & Segal, 2004) . Other constructs in the study including interaction and quality of experiences have been hypothesized to be positively associated with attitudes towards OR . The study results suggest that higher quality of experience with OR rather than more interaction with them may lead to positive attitudes. Consistent with our study results, other studies have established relationship between attitudes and having frequen t or occasional contact with older adults and high quality experience with older relatives ( Funderbunk, Damron Rodriguez, Storms , & Solomon, 2006 ; Harwood et al 2005 ; and Voogt, Mickus, Santiago, & Herman, 2008) as a significant predictor of positive attit udes . Lovell, 2 006 ; , McKinlay and Cowna, 2003 ; Nochajski et al, 2009 , Lee, Reuben and Ferrell, 2005 ; and McKinlay and Cowan, 2003 also reported personal experiences of medical students and student nurses had a significant association with their attitudes towards their older patients. Similar to our study Voogt, Mickus, Santiago, & Brookover, 2002 also reported that amount of interaction with OR was not a predictor of attitudes. On the contrary, Lee 2009, observed a positive asso ciation between interaction and attitudes but not between quality of experiences and attitudes . Positive attitude towards older people has been reported to be related to more experience and completion of geriatric courses in various studies as well (Cottl e and Glover, 2007 ; Swanlund and Kujath, 2012 ; Wurtele and Maruyama, 2012).
105 A growing number of college students and graduates will be needed to provide informal care to their older relatives due to economic downturn and growing number of elderly hence it is quiet essential to assess their attitudes towards the older population which influences the quality of care provided an in return impacts health of both caregivers as well as care receivers . Preparedness to take care of older relatives in future An ext ensive literature has identified the physical, mental and emotional effects of caregiving on the overall health of the caregivers as well as care receivers (Cannuscio et al , 2004 ; Chritakis and Allison, 2006 ; Fredman, Cauley, Hochberg, Ensrud, & Doros, 20 10 ; Norton et al , 2010 ; Haley, Roth, Howard, & Safford, 2010 ; Sparrengerger et al , 2009 ) . Other literature has also identified preparedness for caregiving as critical determinant of quality of care to the elderly as well as essential for overall well bei ng of the caregiver ( Scherbring, 2002 ; Shyu et al , 2010 ; and Schumacher, Stewart and Archbold, 2007 ). The preparedness of the college students to serve as informal caregivers for their older relatives was assessed using the CPS. A lthough , used for the firs t time among the college population , CPS yielded a high reliability which adds to the body of literature which has used this scale extensively among active caregivers ( alpha = 0.85, Ducharme, 2011 ) The study identified previous informal caregiv ing experience, quality of experience with older relatives and perceived behavioral control to provide informal care influenced the preparedness scores. As noted earlier the scale has never been used among the population which identifies as future caregiv ers, however, the study results are comparable with the literature that identified preparedness for caregiving among active caregivers. The mean preparedness score of the study participants (1.858) lower than the studies that
106 reported mean preparedness sco re for active caregivers (Scherbring, 2002, and Ducharme et al, 2011), but was comparable (Mean= 1.80, SD = 0.70) with the study that identified future caregiving preparedness (Sorensen, Wenster , & Roggman, 2002) and higher than the active caregivers in th e study by Silver et al, 2004 (M = 1.72, SD= 0.77) . A voluminous literature included the factors affecting preparedness of caregivers. The liner multiple regression analysis in this study reported a significant association between the preparedness scores an d having provided informal care in the past , quality of experience and perceived behavioral control that was contrary with the findings reported by Silver et al , 2004 who did not find any relationship between low preparedness scores and providing caregivin g tasks but noted that greater competence as caregiver was significantly associated with greater overall preparedness. Although Henriksson and Arestedt, 2013 identified females to be better prepared as caregivers but our study could not establish a relatio nship between preparedness and any other demographic variables. The relationship between having provided informal caregiving in the past had a positive impact on the preparedness scores and the students who have provided IADLs, IDL and other activities sco red significantly higher that the students who reported not providing informal care in the past. About one third of the study participants reported feeling prepared or pretty wel l prepared for the caregiving activities including physical, and emotional nee ds . Our study also noted that low preparedness for caregiving had a negative correlation with positive attitude and hence better preparedness to serve as informal caregivers may influence the attitude towards OR. Constructs of Theory of Planned Behavior Th e study incorporated TPB constructs; attitudes, perceived behavioral control and subjective norms to explore intentions of college students for providing informal
107 care to their OR. Participants generally had stronger intentions to serve as informal caregiv ers in line with McKinlay and Cow an , 2003 towards working with older patients. Our study echoes the results of various studies that validate the relationship between intentions, attitude, subjective norms and perceived be havioral control. Our study partially confirmed the results of McKinlay and Cowan, 2003 who conducted hierarchical analyses and reported mainly the attitudes, predicted the intention s, and subjective norms had small but significant association , but behavio ral control was not significantly associated with intentions . Consistent with Lee 2009, hierarchal regression results of our study reported that positive attitude, subjective norms and perceived behavioral control are positively associated with intentions to provide informal caregiving. Besides reporting a positive attitude, our participants also reported high levels of confidence to serve as informal caregivers. Thus assuming a strengthened resiliency and reduced vulnerability to negative consequences of s erving as informal caregiver even though they lack preparedness for the role. Lower percentage reported influence /pressure of family, culture and, religion on their perceptions to serve as informal caregiver and majority perceived the role as important f or their own personal fulfillment and reported over all high intention scores to serve as informal caregiver to their OR. As intentions are a central factor in the TPB that are assumed to capture the motivational factors that influence a behavior; they are indications of how hard people are willing to try, of how much of an effort they are planning to exert, in order to perform the behavior. As a general rule, the stronger the intention to engage in a behavior, the more likely should be its performance (Fis hbein
108 and Aizen 2010). Thus, the findings of our study show that in the present context, TPB Our study aligns with the provisions , and opportunities , the new health care reform law the Patient Protection and Affordable Care Act includes for informal family caregivers. The law advances efforts to better prepare family caregivers to perform their care tasks and enhances opportunities to expand home and community based s ervices and provide better support to caregiving families. The law explicitly mentions the term The study also supports the earlier evidence of more family caregivers assisting OR than in past ( Doty, 20 10; Houser, Gibson, Redfoot , & AARP, 2011 ) . Although the literature has frequently reported the burden and stress of caregiving Hogs t el, Curry and Walker ( 2005 ) have identified the benefits of informal family caregiving as resolving past hurts and conflict s, celebrating small things, developing personal strength and aging readiness and experiencing the . T hese can motivate young adults to get more involved with their older relatives, develop heal thy relationship and attitudes , and pr ovide care to the older generation . Implications and Future Research As there are no t many previous studies that identify college students as informal caregivers and recognize their preparedness for the role it is anticipated that this study will provide b asis for further exploration. One of the salient findings of the study is that TPB can be used to explore the intentions of informal caregiving and thus has implications of including broader population in terms of gender, age , and ethnicity. The results re port that as the preparedness to take care of the older relatives increases students report a positive attitude towards their OR. Therefore , there is an opportunity
109 among academic and health professionals to better prepare this group in order to develop be tter attitudes and in turn improve their intentions to provide informal care to their OR in future. The low preparedness scores has the potential to be of practical utility to the academic professionals in context of planning curriculum , interventions and study materials for the typical college population to help them prepare for the role of informal caregiver. The study results have implications for health educators, patient educators, and health care providers to involve and educate this young adult popul ation in providing care to older population . A future qualitative interview research will give detailed information about the topics college students identify in order to provide informal care to their OR. An extensive study including larger sample size a nd equal number of females and males is recommended to further understand any gender differences between attitudes and preparedness. Also, a lthough the study results did not have any significant association with the five different ethnic groups but a furth er analysis with just two groups including W hites and N on W hites will be interesting. Although currently, college students are not involved in informal caregiving but this population is the future workforce as well who will face the challenge of balancing work and their personal responsibilities hence providing them with information and resources early on will impact their future stress as well as burden levels. Recommendations The study is pioneer in the field by identifying preparedness of college student s for informal caregiving. The study results can form the basis for future qualitative research role. Multiple site studies are recommended to understand the prepared ness for
110 informal caregiving in a larger population. The study also presents a scope for developing intervention studies with small lessons to prepare the students for the challenges and later assessing its impact. Additionally, the study expanded the popu lation to assess attitudes of typical college students. An extensive literature has reported education intervention studies to improve attitudes of medical/health major students towards older population, which now can be extended to the typical college pop ulation as well. This study echoes the recommendations of Lee 2009, who supported the movement to induce positive feelings and intentions towards older adults among younger generation. The positive attitude towards older people prevents them from being iso lated and mistreated. Similarly, academics as well as health professionals can promote perceived behavioral control that has a strong association with intentions and preparedness for informal caregiving among the student population by providing support and information. The study also underscores the relevance of quality of experiences with attitude and preparedness which can be improved by efforts of family and other members of the society . Conclusions The study was set to explore the attitudes of college s tudents towards their older relatives and assess their preparedness for the role of informal caregivers. The study also sought to know whether the theory of planned behavior could predict the intentions of the college students to provide informal care to t heir older relatives in future. Although the college students reported a positive attitude towards their older generation but they scored low on their preparedness to take care of them. The theory of planned behavior constructs including attitude, subjecti ve norms, and perceived behavioral control contributed towards the intentions to serve as informal caregivers by the college
111 students. The study identified no differences in attitudes towards older population based on gender, class, SES, age, and major. Th e quality of experiences with older relatives contributed towards better preparedness as informal caregivers as well as better attitudes towards older relatives. High preparedness scores were also associated with perceived behavioral control. The study res ults have implications for health educators, patient educators, and health care providers to involve and educate this young adult population in providing care to older population The results of the study indicate not many college students are providing ass istance with ADL, IADL or other activities related with caregiving to their older relatives but have a positive attitude towards them. This has implications for the geriatrics health care providers be informed about the attitudes and role of young populat ion and develop strategies to assist this particular group in taking better care of the older generation in future. In conclusion, it must be noted that the study reported her e has explored the attitudes, preparedness and intentions of the college students and makes no attempt to determine the extent to which intentions are translated into actual informal caregiving behavior, and how they serve as caregivers, therefore further research is recommended to measure actual informal caregiving behavior in the future.
112 APPENDIX A RELIABILITY ANALYSIS TABLES Table A 1 Attitude towards older relatives: Item Total Statistics item Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Squared Multiple Correlation Cronbach's Alpha if Item Deleted Cheerful 53.86 642.199 .784 .781 .972 Pleasant 53.94 642.836 .833 .842 .972 Friendly 54.06 644.825 .848 .845 .972 Kind 54.14 644.967 .846 .859 .972 Sweet 54.03 641.012 .860 .855 .972 Nice 54.08 643.390 .842 .823 .972 Tolerant 53.44 636.837 .731 .673 .973 Cooperative 53.48 636.267 .781 .745 .972 Fair 53.73 639.447 .815 .721 .972 Grateful 53.95 637.596 .826 .734 .972 Unselfish 53.87 639.253 .806 .750 .972 Considerate 53.90 6 39.367 .818 .786 .972 Patient 53.40 632.752 .758 .673 .972 Positive 53.72 634.086 .834 .762 .972 Calm 53.62 638.459 .764 .642 .972 Thoughtful 54.01 642.034 .840 .771 .972 Humble 53.93 641.164 .809 .696 .972 Frugal 53.11 663.856 .306 .172 .977 Flexib le 53.31 637.199 .715 .612 .973 Good 54.09 643.735 .824 .753 .972 Hopeful 53.75 637.865 .806 .812 .972 Optimistic 53.67 635.688 .786 .801 .972 Trustful 54.07 640.056 .813 .736 .972 Safe 54.19 651.735 .712 .630 .973 Table A 2 Reliability Analysis fo r Caregiver Preparedness Scale item Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Squared Multiple Correlation Alpha if Item Deleted Physical needs 13.20 46.383 .764 .624 .920 Emotional needs 13.0 1 48.227 .681 .516 .926 Set up services 13.16 46.622 .766 .607 .920 Handle stress 13.23 46.607 .746 .585 .921 Pleasant 13.06 46.211 .788 .643 .918 Handle ER 12.99 46.721 .761 .607 .920 Information 13.11 46.865 .712 .573 .924 Overall 13.09 46.207 .845 .723 .914
113 Table A 3 Reliability Analysis for Intentions Scale Item Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Squared Multiple Correlation Cronbach's Alpha if Item Deleted IDL 18.81 16.619 .799 .684 .92 6 ADL 19.08 16.848 .737 .623 .935 Emotional care 18.73 17.085 .830 .693 .922 Set up services 18.68 16.914 .843 .761 .920 Handle ER 18.58 17.425 .811 .722 .925 Info from health system 18.65 16.799 .859 .794 .918 Table A 4 Reliability Analysis for Sub jective Norms Scale item Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Squared Multiple Correlation Cronbach's Alpha if Item Deleted Family expectations 13.68 12.564 .722 .529 .827 Culture 13.55 12.276 .742 .6 26 .821 Religion 13.74 13.020 .710 .579 .830 Obligation 13.57 12.843 .706 .508 .831 Personal fulfillment 13.08 14.625 .548 .324 .867 Table A 5 Reliability Analysis for Perceived Behavioral control Item Scale Mean if Item Deleted Scale Variance if It em Deleted Corrected Item Total Correlation Squared Multiple Correlation Cronbach's Alpha if Item Deleted IDL 27.14 42.548 .667 .531 .922 ADL 27.65 41.125 .686 .554 .921 Emotional care 27.38 42.075 .669 .470 .922 Set up services 27.38 41.236 .721 .598 .918 Stress 27.53 40.569 .779 .657 .915 Pleasant 27.27 41.599 .784 .629 .915 Handle ER 27.34 41.116 .726 .574 .918 Info from health system 27.40 40.917 .716 .595 .919 Overall 27.37 40.357 .853 .744 .910
114 APPENDIX B INSTITUTIONAL REVIEW BOARD SUMMER 2013 SUBMISSION FORM
117 APPENDIX C CONSENT FORM You are invited to participate in this anonymous survey . The study aims to assess the attitude of college students towards older relatives and their preparedness levels to take care of their older rel atives. Completing the survey is voluntary. There are no anticipated risks for completing the survey and there are no direct benefits. However, through your participation, we will be able to understand attitudes and preparation of college students to ta ke care of their older relatives. You will receive two extra points on your final exam grade as a compensation for your time. If you are not comfortable answering a question, just leave it blank. The survey will take about 10 15 minutes to complete. The survey is anonymous and any identifying info rmation including your name or UF ID, will not be collected. If you have any questions about this study, please contact the principal researcher, Gungeet Joshi, Department of Health Education and Behavior, FLG 65, (352) 294 1815 , or contact the University of Florida's Institutional Review Board at IRB02 Office, Box 112250, University of Florida, Gainesville, FL 32611 2250 (352) 392 0433. Please indicate your acceptance to participate. I agree, Signature ________________________________________ I disagree, Signature ______________________________________
118 APPENDIX D SURVEY FORM
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140 BIOGRAPHICAL SKETCH Origin ally from northern state of Punjab, India Gungeet Joshi came to U.S in 2006. She earned her undergraduate degree in Home Science in 2002, Master of Science in Food and Nutrition 2004, and Bachelor of Education in 2006 from Punjab Agricultural University, I ndia. She is also trained as dietician and has completed observer ship at a leading post graduate Institute of medical research in India. After she moved to Gainesville, Florida, Gungeet worked to receive her Master of Science degree in Health Education an d Behavior and also received her certification as Health Education specialist in 2011 from University of Florida. As a master student she worked as graduate research assistant and was involved in various research projects. Gungeet continued in the same dep artment as doctoral student and was teaching assistant for the Medical Terminology course offered by the department. Gungeet successfully A ttitude towards, and caregiving preparedness for, their older relatives among college students Ph.D. degree in August 2014. Her areas of research include ; Asian Indian student population in the US , informal caregivers and survey developme nt. Gungeet plans to continue working in academia and research in informal caregiving.