CC BY
34
Perspectives of Science & Education
International Scientific Electronic Journal ISSN 2307-2334 (Online)
Available: https://pnojournal.wordpress.com/2022-2/22-04/ Accepted: 12 May 2022 Published: 31 August 2022
Ki-Nam Lee, Yun-Jeong Kim
The moderating effect of resilience on the effect of the caregiving burden of primary caregivers on depression: targeting primary caregivers of elderly people who use a day care center
Introduction. As family caregiving for the elderly was reaching its limit due to the continuing increase in the elderly population, day care can be said to be an intermediate stage between home care and facility care, and a system that responds well to Korea's welfare policy for the elderly, which advocates aging in place and integrated community care. Therefore, the purpose of this study is to understand the moderating effect of resilience on the effects of the caregiving burden of primary caregivers of elderly people who use day care centers on depression.
Study participants and methods. The participants in this study were 304 primary caregiver of elderly people who use a day care center. 76.0% of the 304 were woman, 57.9% were middle-aged people aged 50 to 64, 41.8% of them were high school graduates. Frequency analysis, t-test, and one-way ANOVA were performed using SPSS Win 24.0, and moderating effect analysis was performed using SPSS PROCESS MACRO 3.5.4 version (Model 1).
Results. The higher the independent variable, i.e., the higher the caregiving burden, the higher the depression (Coefficient=.374, p=.000), and the higher the resilience, the lower the depression (Coefficient=-.174, p=.000). The effect value of the interaction term of the dependency burden and resilience was significant as -.270 (p=.001). The F value of the model was significant as 33.667 (p=.000), and the explanatory power was 25.1%. Also as interaction terms are added. The amount of change in R2 was significant as .031 (p=.001), and the moderating effect of resilience was verified
Practical significance. It was revealed that self-esteem and basic job skills are important to improve the job-search skills of middle-aged adults. Therefore, in order to support customized career design at the national level, it is suggested that vocational education programs should include not only certification courses, but also content for improving basic vocational competency and counseling for improving self-esteem.
Keywords: moderating effect, resilience, caregiving burden, depression, day care center
For Reference:
Lee, K.-N., & Kim, Y.-J. (2022). The moderating effect of resilience on the effect of the caregiving burden of primary caregivers on depression: targeting primary caregivers of elderly people who use a day care center. Perspektivy nauki i obrazovania - Perspectives of Science and Education, 58 (4), 508521 doi: 10.32744/pse.2022.3.30
Introduction
ith the rapid aging rate in Korea, the cost of caregiving its elderly population is rapidly increasing as well. As of 2022, the total caregiving population ratio is 40.8, the elderly caregiving population ratio is 24.6, and 100 people aged 15 to
64 have to caregiving 24.6 elderly people aged 65 or older [1]. As family caregiving for the elderly was reaching its limit due to the continuing increase in the elderly population, the long-term care insurance system for the elderly was introduced in 2008, thus shifting from a model of family caregiving to one of social caregiving. In Korea's long-term care insurance system for the elderly, typical outcomes include home care, facility care for admission to facilities, and day care for institutions during the day.
The conceptual bases of Korea's welfare policy for the elderly are aging in place and integrated community care. Aging in place refers to living in the same community one has lived their entire life in old age [2], and community integration care refers to a situation in which the local community provides integrated and systematic services to the elderly [3]. Day care can be said to be an intermediate stage between home care and facility care, and a system that responds well to Korea's welfare policy for the elderly, which advocates aging in place and integrated community care.
A Day Care Center is a facility that cares for and protects the elderly in need of care during the day, and that provides structured programs such as cognitive activity programs tailored to the elderly and dietary nutrition management programs [4-6]. This concept was introduced in Moscow in 1920 to address the shortage of facilities to hospitalize psychiatric patients, and the United States first launched the Elderly Day Care Project at Hudson Day Center in New York in 1954 [7]. Since 1970, as the concept of the day care project has expanded to chronically ill patients, the types and services of daytime protection have been diversifying [7; 8]. Currently, day care centers in Korea represent a positive alternative to family caregiving in elderly care [9]. As of August 2021, the number of elderly people receiving long-term care and using day care centers is increasing rapidly, with a total of 4,738 such locations [10]. Therefore, it is likely that the use of day care centers in Korea will become a form of universal caregiving beyond positive alternatives in the future.
On the other hand, caring for the elderly in need of long-term care leads to a burden involved with providing such caregiving among family caregivers (hereinafter referred to as primary caregivers) [11]. Caregiving burden is a concept that collectively refers to the physical, psychological, and socioeconomic burdens experienced while caring for patients [12; 13], and it is also defined as the difficulties arising from the elderly's physical dependence, problem behavior, and lack of awareness [14]. However, one of the factors that particularly affects the caregiving burden is that family caregivers must continually live with the elderly with dementia or chronic diseases to whom they are providing caregiving [15; 16].
Primary caregivers who have such daily lives experience negative emotions such as decreased interest in daily life, tension, burden, frustration, anxiety, etc. [17]. This caregiving burden serves as a cause of depression among primary caregivers [17] because the social isolation involved in providing such caregiving increases depression [16]. Therefore, the use of day care centers for the elderly gives caregivers time to rest during the day. The use of day care centers for the elderly reduces fatigue and depression while also increasing life satisfaction among caregivers [15; 18].
This study focuses on resilience as a variable that can control the effect that the caregiving burden of caregivers has on depression. Resilience is the psychological ability to overcome and successfully recover from stress and crisis situations [19] and to overcome difficulties in life and adapt to such difficulties [20; 21]. People with high resilience show the characteristics of reduced stress, anxiety, and depression by seeking help from their family and friends [22]. Higher resilience has been shown to be associated with lower depression [23; 24], lower rates of negative emotions such as suicide and depression in middle-aged women [25], and higher quality of life [26].
In this way, as higher resilience is expected to reduce the depression felt by primary caregivers as a result of their caregiving burden, it is possible to predict the buffering effect of resilience, that is, the moderating effect. Fergus and Zimmerman [27] called resilience a protective factor that buffers against and reduces the effects of risk factors for negative outcomes. Resilience is the ability to utilize pro-social attitudes and social resources to overcome crises [28], the ability to overcome adversity and stress, and the ability to effectively utilize internal and external resources [29]. In other words, resilience, which is the ability to recover ones original functioning following stressful situations or trauma, is expected to control the impact of the caregiving burden on depression; this is because, when faced with trials that can generally lead to depression, people with high resilience can use such trials as an opportunity to cultivate growth and crisis coping skills.
However, the prior studies examining primary caregivers of elderly people using day care centers have not revealed this process. As was previously suggested, the use of day care center has been shown to reduce the caregiving burden of care givers and provide conditions for more concentrated economic and social activities [15; 18]. However, some critics argue that while the caregiving burden was reduced while the elderly people were using the day care center and visiting care services, it was not reduced outside that time [30].
In other words, although the elderly's use of the day care center did reduce the caregiving burden for the caregiver, there was a substantial caregiving burden remaining which could still result in depression; in this situation, resilience is expected to control for any associated effects of this remaining burden, but the related studies have thus far been insufficient. Accordingly, there is a need for research examining this point due to the lack of efforts to mediate the relationship between the caregiving burden and depression of elderly caregivers using day care centers.
Therefore, the purpose of this study is to understand the moderating effect of resilience on the effects of the caregiving burden of primary caregivers of elderly people who use day care centers on depression. The specific research questions are as follows: first, what are the characteristics of care for the elderly and the use of day care centers? Second, are there differences in the caregiving burden, depression, and resilience depending on the care characteristics and the use of day care? Third, does resilience have a moderating effect on the effect of the caregiving burden of caregivers on depression?
Method
1 Research Model
Figure 1 presents a depiction of the conceptual model of this study, which was based on the assumption that resilience would have a moderating effect on the effect of the caregiving burden of primary caregivers on depression.
Figurel Research Model
2 Research subjects and data collection procedures
The subjects of this study are primary caregivers of elderly people who use a day care center. To administer the survey, the heads of 30 day care centers in Korea were asked to conduct 10 to 15 surveys per institution. Each institution asked primary caregivers of elderly people to respond to the questionnaire when visiting the elderly's home for the remittance service of the elderly who use the day care center, and the responses were collected a week later. For those who did not live with the primary caregivers, the elderly who used the day care center were asked to have the caregivers respond to the survey. Initially, 320 copies were distributed and 313 copies were collected, of which 304 copies were used for analysis after excluding nine copies that were not responded to by the caregivers.
3 Measuring tools
The instrument of caregiving burden was developed by Montgomery et al. [31], and the subjective burden scale was used among the tools translated by Oh [32]. In this scale, there are 12 questions in total, and these are each responded to on a 5-point Likert scale (1=not at all, 5=very much so). Two of the 12 questions were reverse-coded, "I am a person who needs my parents (spouse)" and "I enjoy being with my parents (spouse)", where higher scores reflected higher caregiving burdens. In terms of reliability, this scale showed a Cronbach's alpha value of .817 in this study.
For depression, a scale that was developed by Radloff [33] was used by translating the Center for Epidemiological Studies Depression (CES-D), abbreviated by Kohout, Berkman, Evans, and Cornoni-Huntley [34], from the Korean Welfare Panel [35]. In total, 11 questions were measured as "1=very rare (1 day a week or less), 2=sometimes (2-3 days a week), 3=sometimes (3-4 days a week), and 4=mostly so (5 days a week or more). Higher scores indicated higher depression. In terms of reliability, this scale showed a Cronbach's alpha value of .839 in this study.
For resilience, the Korean Version of the Connor-Davidson Resilience Scale (CD-RISC) scale developed by Connor and Davidson [36] was adapted and validated by Back et al. [37]. There are 25 questions in total, and they are responded to on a 5-point Likert scale (1=not at all, 5=very much so). Higher scores indicate higher resilience. In terms of reliability, this scale showed a Cronbach's alpha value of .940 in this study.
Care characteristics were measured by the relationship between the elderly and the primary caregivers, whether they lived together, intimacy between family members, motivation for care, and care period; these factors were selected by referring to previous
studies. The use of the day care center was also measured by referring to previous studies, such as recommendation for use, motivation for use, period of use, satisfaction among the elderly, satisfaction of caregivers, and changes in health and family relations after using the day care center.
4 Characteristics of the caregiver
In terms of the socio-demographic characteristics of the primary caregivers surveyed in this study, 76.0% of the 304 were women and 24.0% were men, thus showing approximately three times more women. In terms of the age of the primary caregivers, 57.9% were middle-aged people aged 50 to 64, and in terms of education, 41.8% of them were high school graduates. The absolute majority (82.6%) had spouses, and the most common response was that both the health and economic conditions of the respondent were normal.
5 Analysis Method
Frequency analysis, t-test, and one-way ANOVA were performed using SPSS Win 24.0, and moderating effect analysis was performed using SPSS PROCESS MACRO 3.5.4 version. For the moderating effect, Model 1 of PROCESS macro proposed by Hayes [38] was used. Bootstrapping was designated 5,000 times, and a 95% confidence interval was set. Further, independent variables such as caregiving burden and regulating variables such as resilience were analyzed through mean centering.
Results
1 Care characteristics and day care usage status
Table 1 shows the characteristics of the primary caregivers. Regarding the relationships between the elderly people and their caregivers, 65.1% were adult children of the elderly, such as sons/daughters, while 26.0% were daughters-in-law/son-in-law. The smallest group at 8.9% was that made up of spouses of the elderly. In terms of whether the elderly and primary caregivers lived together, 63.8% of the primary caregivers lived together with the elderly as they supported them. Regarding family intimacy, 50.7% of responses were "good" and 46.4% were "normal," and it was quite high with an average score of 2.48 points out of 3. The most common motivation for caring was "no choice" at 42.8%, followed in order by 21.4% with "living together from marriage" and 12.2% with "old parents want," indicating that it was most often a situation-based choice rather than voluntary care. Finally, the average care period was 8.96 years, and 20.1% responded more than 10 years, thus showing that the elderly caregiving period is also prolonged due to the increase in average life expectancy.
Table 1
Characteristics of Caregivers <N=304>
N % M(SD)
Relationship between the elderly person and their primary caregiver Spouse 27 8.9 -
Son/Daughter 198 65.1
Daughter-in-law/son-in-law 79 26.0
Co-residence of elderly person and primary caregiver Living together 194 63.8 -
Living separately 110 36.2
Intimacy With Family Member Bad 9 3.0 2.48(.557)
Normal 141 46.4
Good 154 50.7
Motivation for Caring Living together since marriage 65 21.4 -
There's no choice 130 42.8
Elderly wanted it 37 12.2
Etc. 72 23.7
Care period Less than 2 years 91 29.9 8.96(11.515)
More than 2 to less than 5 years. 82 27.0
More than 5 to less than 10 years. 70 23.0
More than 10 years 61 20.1
Table 2 shows the use of day care centers among the elderly. In terms of who recommended the use of the day care center, it was "children" in 52.3% of cases and "medical personnel and people around them" in 38.5% of cases. Regarding the motivation of the use of the day care center, 52% responded "no one else to take care of them" and 34.2% responded that the "care time burden" made it difficult for families to take care of the elderly. Regarding the period of use, 28.3% reported more than one year to less than two years, and the average was 1.88 years. Satisfaction with the use of day care centers was very high, with values of 2.77 out of 3 points for the elderly and 2.82 out of 3 points for the primary caregivers.
Further, changes in the health of the elderly and changes in the relationship between family members after using the day care center - which can be seen as the effectiveness of using the day care center - were examined. Health change for the elderly showed positive results with 71.7% reporting "improvement" and 24.7% reporting "similar", and when looking at changes in family relations, 69.1% reported "improvement" and 28.6% reported "similar".
Table 2
Status of using the Day Care Center <N=304>
N % M(SD) M(SD)
Recommendation Elderly and spouses 28 9.2 -
Child 159 52.3
Medical personnel and acquaintance 117 38.5
Motivation for Use No one to take care of 158 52.0 -
Burden of Caring time 104 34.2
Improving cognitive skills 42 13.8
Period of Use Less than a year 68 22.4 1.88(1.892)
More than a year or less 86 28.3
More than 2 to 3 years 65 21.4
Over 3 years 85 28.0
Satisfaction of the elderly Unsatisfactory 15 4.9 2.77(.526)
Regular 40 13.2
Satisfaction 249 81.9
Use satisfaction of the primary caregiver Unsatisfactory 9 3.0 2.82(.456)
Regular 37 12.2
Satisfaction 258 84.9
Health change for the elderly Get Worse 11 3.6 2.68(.539)
Similar 75 24.7
Get Better 218 71.7
Changes in family relationships Get Worse 7 2.3 2.67(.518)
Similar 87 28.6
Get Better 210 69.1
2 Differences in caregiving burden, depression, and resilience according to the characteristics of care and the use of the day care center
2.1 Differences in caregiving burden, depression, and resilience according to care characteristics
Looking at the differences in caregiving burden according to the characteristics of care, the relationship between the elderly person and their primary caregiver, family intimacy, motivation for care, and care period were all significant (Table 3).
When the primary caregiver was a "spouse", the caregiving burden was higher than when they were a "son/daughter" (F=3.595, p<.01). Meanwhile, the most common responses for family intimacy were in the order of "bad", "normal", and "good" (F=38.172, p<).001). In addition, Scheffe's post-verification was not significant depending on the motivation for care; therefore, focusing on the average value, the caregiving burden was high when 'living together' and 'because there was no choice' from marriage, followed by elderly wanted it' and 'other' (F=3.369, p<.05). In addition, the caregiving burden was higher in the case of "more than 10 years" than it was in the case of "less than 2 years" (F=6.283, p<.001). However, there was no significant difference in the caregiving burden depending on whether the elderly and the primary caregivers lived together.
Regarding the differences in depression according to care characteristics, there were significant differences according to the relationship between the elderly people and their caregivers and according to family intimacy (Table 3). the average primary caregiver who was a "spouse" was more depressed than a "son/daughter" (F=4.070, p<.01), and family intimacy was more associated with higher depression in "bad" and "normal" than it was in "good" (F=23.442, p<.001). However, there were no significant differences in depression according to cohabitation, motivation for care, or care period.
Looking at the differences in resilience according to care characteristics, the only significant difference was seen in family intimacy (Table 3). Family intimacy was higher in resilience in "good" than in "bad" (F=11.834, p<.01). However, the differences in depression according to the elderly-primary caregiver relationship, cohabitation, motivation for care, and care period were not significant.
Table 3
Differences in caregiving burden, depression, and resilience according to care
characteristics <N=304>
N M S.D t/F Scheffe
The relationship between the elderly person and Spouse 27 2.73 .560 b
Son/Daughter 198 2.45 .581 3.595* a
their primary caregiver Daughter-in-law/Son-in-law 79 2.59 .583 ab
Intimacy With Family Member Bad 9 3.15 .322 c
Normal 141 2.74 .494 38.172*** b
Good 154 2.26 .558 a
Living together since marriage 65 2.59 .528 a
Caregiving Burden Motivation for Caring There's no choice 130 2.59 .556 3.369* a
Elderly wanted it 37 2.34 .676 a
Etc. 72 2.39 .606 a
Less than 2 years 91 2.33 .651 a
More than 2 to less than 5 years 82 2.49 .507 ab
Care Period 6.283***
More than 5 to less than 10 years 70 2.59 .543 ab
More than 10 years 61 2.72 .552 b
The relationship between the elderly person and Spouse 27 2.13 .465 b
Son/Daughter 198 1.87 .518 4.070* a
Depression their primary caregiver Daughter-in-law/Son-in-law 79 1.81 .483 a
Bad 9 2.49 .386 b
Intimacy With Family Member Normal 141 2.02 .512 23.442*** b
Good 154 1.71 .445 a
Intimacy With Family Member Bad 9 3.10 .487 a
Resilience Normal 141 3.35 .497 11.834** ab
Good 154 3.62 .543 b
*p<.05, ***p<.001
Footnote) Only meaningful results are presented in the table
2.2 Differences in the caregiving burden, depression, and resilience according to the state of use of the day care center during the week
There were no significant variables in the differences in caregiving burden according to the use of the day care center. Next, regarding the difference in depression according to the use of the day care center, the differences according to the elderly's satisfaction with use, the use satisfaction of the primary caregivers, the elderly's health change, and the family relationship change were all significant (Table 4). The elderly who were "unsatisfied" with the use of the day care center were more depressed than those who reported "normal" and "good" (F=5.395, p<.01) The feeling of depression was in descending order of "discontent", "normal", and "satisfaction" with the day care center (F=5.145, p<.01). In addition, the elderly had depression in descending order of "worsening", "similar", and "improvement" after using the day care center (F=4.112, p<.05), and the cases for which the family relationship changed to "deterioration" after using the day care center showed higher depression than "similar" and "improvement" (F=5.498, p<.01). However,
the differences according to the recommendation, motivation, and period of use of the day care center were not significant.
Regarding the difference in resilience according to the use of the day care center, only the difference according to the change in family relations was significant (Table 4). After using the day care center, family relationships were more resilient than those that showed a change from "improvement" and "similar" into "worsening" (F=4.440, p<).01). However, there were no significant differences according to the recommended use of the day care center, motivation for use, duration of use, satisfaction of the elderly, satisfaction of use of the primary caregiver, or changes in health of the elderly.
Table 4
Differences in depression according to the use of the day care center <N=304>
N M S.D t/F Scheffe
Unsatisfactory 15 2.27 .555 b
Satisfaction of the elderly Normal 40 1.95 .473 5.395** a
Satisfaction 249 1.84 .504 a
Use satisfaction of the primary caregiver Unsatisfactory 9 2.09 .758 5.145** a
Normal 37 2.10 .541 a
Depression Satisfaction 258 1.84 .487 a
Health change for the elderly Get worse 11 2.11 .515 4.112* a
Similar 75 1.99 .561 a
Get better 218 1.83 .484 a
Get worse 7 2.48 .435 5.498** b
Changes in family relationships Similar 87 1.90 .535 a
Get better 210 1.85 .491 a
Changes in family relationships Get worse 7 2.91 .585 4.440** a
Resilience Similar 87 3.45 .472 b
Get worse 210 3.51 .555 b
*p<.05, **p<.01
Footnote) Only meaningful results are presented in the table.
3 The moderating effect of resilience on the effect of the caregiving burden on depression
The correlation between variables was examined before analyzing the moderating effect of resilience on the effect of caregiving burden on depression. The higher the caregiving burden, the higher the depression, and the higher the resilience, the lower the depression. In addition, the higher the resilience, the lower the caregiving burden. Regarding the correlation coefficient r, there was no multicollinearity between variables from .285 to .438.
After analyzing whether resilience regulates the relationship between the caregiving burden and depression of primary care giver, the results showed that the higher the independent variable, i.e., the higher the caregiving burden, the higher the depression (Coefficient=.374, p=.000), and the higher the resilience, the lower the depression (Coefficient=-.174, p=.000). In addition, the effect value of the interaction term of the dependency burden and resilience was significant as -.270 (p=.001). The F value of the
model was significant as 33.667 (p=.000), and the explanatory power was 25.1%. Also as interaction terms are added. The amount of change in R2 was significant as .031 (p=.001), and the moderating effect of resilience was verified (Table 5).
Since the moderating effect of resilience was statistically significant, Figure 2 shows the results of visualizing the moderating effect to confirm its form. To confirm the pattern of significant interaction, the slope was examined by dividing the participants in terms of resilience into a low group, a middle group, and a high group. Looking at the conditional effect of the caregiving burden according to resilience in Figure 2 and Table 5, the moderating effect of resilience is more clearly revealed in the effect of the caregiving burden on primary caregivers on depression. First, looking at the conditional effects of Table 5, all three conditions (M, M±SD) of resilience were significant. Further, as shown in Figure 2, depression is low regardless of resilience when the caregiving burden is low. However, as the caregiving burden increases, the difference in depression between the high, intermediate, and low groups of resilience increases. In other words, the group with low resilience shows a sharp increase in depression as the caregiving burden increases, while the group with high resilience shows a gentle increase in depression even if the caregiving burden increases. In other words, it was found that the group with high resilience was less affected by the caregiving burden on depression. Finally, according to Johnson-Newman analysis, a lighting analysis method, the conditional effect of caregiving burden according to resilience was significant in 94.74% of all primary caregivers.
Table 5
The moderating effect of resilience on the effect of caregiving burden on depression <N=304>
Dependent variable: Depression
Variable Coeffect SE t P LLCI* ULCI**
A constant 1.855 .026 70.443 .000 1.803 1.906
Caregiving Burden .374 .047 8.029 .000 .282 .466
Resilience -.178 .049 -3.539 .000 -.276 -.081
Caregiving burden x Resilience -.270 .076 -3.539 .001 -.420 -.120
R2=.251, F=33.667 p=.000
R2 increase according to interaction
Interaction Term R2 F P
Caregiving burden x Resilience .031 12.526 .001
Conditional effect of caregiving burden according to resilience
Resilience Effect se t P LLCI* ULCI**
-.539(M-1SD) .520 .069 7.569 .000 .385 .655
.000(M) .374 .047 8.029 .000 .282 .466
.539(M+1SD) .228 .055 4.163 .000 .121 .336
*LLCI=boot lower limit value within 95% confidence interval of indirect effect **ULCI=boot upper limit value within 95% confidence interval of indirect effect
Figure 2 Moderating effect of resilience on the effect of the caregiving burden on
depression
Discussion and Conclusion
The purpose of this study was to elucidate the moderating effect of resilience on the effect of the caregiving burdening elderly primary caregivers using a day care center on depression. The discussion summarizing the main research results is as follows.
First, Korean primary caregivers use the day care center because elderly care is difficult, so it can be seen as a result of their children's choice. Both the elderly and the primary caregiver showed high satisfaction with the use of the day care center, which solves these difficulties, and both the elderly's health and family relationships showed positive changes after using the day care center. Therefore, the results of this study indicate that the purpose [39] of the long-term care insurance system for the elderly was achieved to promote health and stabilize living for the elderly, and to reduce the caregiving burden for dependents. Further, the use of day care centers has reduced the caregiving burden for the elderly, reduced depression, increased understanding, and provided favorable conditions for caregivers to concentrate more on their own economic and social activities. Therefore, there is a need for a plan to expand the use of day care centers for the elderly in Korea.
Second, regarding the caregiving burden of primary caregiver, the caregiving burden was high when the spouse provided caregiving, when the family intimacy was poor, when the care period was longer than 10 years, and when the family relationship deteriorated after using the day care center. In the case of caregiving being provided by the spouse [42], the longer the caregiving period [43], the higher the caregiving burden, which is consistent with the findings of previous studies.
Next, regarding the depression of the primary caregiver, depression was high when the spouse was the one providing caregiving, when family intimacy was poor, when the elderly person and the primary caregiver were dissatisfied with the use of the day care center, and when the elderly's health and family relationship deteriorated. This is consistent with a study by [15] showing that when a spouse is the one providing caregiving, depression is high [16], and the use of a day care center has lowered the depression of primary care givers.
Finally, in terms of the resilience of primary caregivers, the resilience was high when family intimacy was good and when family relations improved after using the day care center. This is consistent with the results of previous studies showing that the resilience was high in the presence of children or spouses [44].
The results of this study lead to two implications: One is that if the spouse is the primary caregiver, then the caregiving burden and depression is high. This result is interpreted to mean that the spouse would have provided long-term care while living with the elderly, that the spouse would also be physically ill with old age, and that the elderly have higher depression than other age groups. The other is the importance of family relations; if family intimacy is poor or family relations are perceived as unfavorable, then resilience will also be low. Resilience is the ability to effectively utilize internal and external resources to overcome adversity and stress [29], and the ability to utilize social resources [28]; in this context, the results reveal that family relationships are the most important social resources in caregiving the elderly. Therefore, it is necessary to include a plan to improve family relationships among the programs of the day care center.
Third, the moderating effect of resilience was verified in the effect of the caregiving burden on depression. The group with low resilience showed a sharp increase in depression as the caregiving burden increased, but the group with high resilience showed a gentle increase in depression even when the caregiving burden increased. This can be seen to mean that the group with high resilience receives less negative influence from the caregiving burden on depression. This is consistent with previous studies that directly or indirectly proposed a moderating effect of resilience on the effect of the caregiving burden on depression. Therefore, it is necessary to strengthen resilience to reduce the caregiving burden and depression among the elderly who use day care centers.
REFERENCES
1. Statistics Korea. (2020). Future population projection (as of 2020), Statistics Korea. Available at: http://www.mdex. go.kr/unify/idx-info.do?idxCd=4228#quick_02(2022. 2. 14)
2. Wiles J. L., Leibing A., Guberman N., Reeve J., Allen R. E. The meaning of "aging in place" to older people. The Gerontologist, 2012, vol. 52, no. 3, pp. 357-366. DOI: 10.1093/geront/gnr098
3. Moon K. J., Shin Y. R., Kim C. S. A Study on Policy Implications and Critical Review of autonomous Region's ordinance related to Community Care. Journal of Regional Studies, 2020, vol. 28, no. 4, pp. 189-224. DOI: 10.31324/ JRS.2020.12.28.4.189
4. Baumgarten M., Lebel P., Laprise H., Leclerc C., Quinn C. Adult day care for the frail elderly: outcomes, satisfaction, and cost. Journal of aging and Health, 2002, vol. 14, no. 2, pp. 237-259. DOI: 10.1177/089826430201400204
5. Hunter S. Adult day care: Promoting quality of life for the elderly. Journal of Gerontological Nursing, 1992, vol. 18, no. 2, pp. 17-20. DOI: 10.3928/0098-9134-19920201-06
6. McCann J. J., Hebert L. E., Li Y., Wolinsky F. D., Gilley D. W., Aggarwal N. T., Miller J. M., Evans D. A. The effect of adult day care services on time to nursing home placement in older adults with Alzheimer's disease. Gerontologist, 2005, vol. 45, no. 6, pp. 754-63. DOI: 10.1093/geront/45.6.754
7. Nadash P. Adult day centers: everything you wanted to know but were afraid to ask. Caring Magazine, 2003, vol. 22, no. 8, pp. 6-8. Available at: https://europepmc.org/article/med/14556371(2022. 2. 24)
8. Warren S., Kerr J. R., Smith D., Schalm C. The impact of adult day programs on family caregivers of elderly relatives. Journal of Community Health Nursing, 2003, vol. 20, no. 4, pp. 209-221. DOI: 10.1207/S15327655JCHN2004_02
9. Seo H. B. An Exploratory Study of Interpreting Social Use of Streets for Elder's Independence based on the Baltes Theory of Human Development and the Concept of Territoriality. Journal of the Korean Housing Association, 2020, vol. 3, no. 1, pp. 1-10. DOI: 10.6107/JKHA.2020.31.1.001
10. National Health Insurance Service (2021). December 2021 Status of Long-Term Care Institutions by City, Gun and Gu. National Health Insurance Service. Available at: https://www.longtermcare.or.kr/npbs/d/m/000/moveBoardV iew?menuId=npe0000000950&bKey=B0019&zoomSize= (accessed 24 February 2022)
11. Mo S. H., Choi S. Y. Changes in the caregiving burden for families using long-term care services for the elderly. Critical Social Policy, 2013, vol. 40, no. 8. pp. 7-31. Available at: https://www.dbpia.co.kr/Journal/articleDetaiPno
deId=N0DE02250162 (accessed 6 March 2022)
12. Zarit S. H., Reever K. E., Bach-Peterson J. Relatives of the impaired elderly: correlates of feelings of burden. The Gerontologist, 1980, vol. 20, no. 6, pp. 649-655. DOI: 10.1093/geront/20.6.649
13. Grano C., Lucidi F., Violani C. The relationship between caregiving self-efficacy and depressive symptoms in family caregivers of patients with Alzheimer disease: a longitudinal study. International Psychogeriatrics, 2017, vol. 29, no. 7, pp. 1095-1103. DOI: 10.1017/S1041610217000059
14. Kim Y. J. Verification of the Effectiveness of Caregiving Model on Caregiving Stress. Korean Association of Family Relations, 2006, vol. 11, no. 1, pp. 79-101. Available at: http://www.riss.kr.library.hanseo.ac.kr:8000/ link?id=A75020943 (2022. 3. 6)
15. Lee Y. W., Park K. H., Seong Y. S. A study on changes of primary Caregivers' fatigue, depression and life satisfaction by using dementia day care service. Korean Journal of Adult Nursing, 2008, vol. 20, no. 3, pp. 443-451.
16. Available at: https://www.kci.go.kr/kciportal/ci/sereArticleSearch/ciSereArtiView.kci?sereArticleSearchBean. artiId=ART001259884 (accessed 6 March 2022)
17. Jo J. H., Kim B. S., Jang. S. M. Major Depressive Disorder in Family Caregivers of Patients with Dementia. Korean. Society of Biologoical Therapies in Psychiatry. 2019, vol. 25, no. 2, pp. 95-100. DOI: 10.22802/jksbtp.2019.25.2.95
18. Park S.Y., Park M. H. Effects of Family caregiving Programs for Caregivers of People with Dementia Caregiving Burden, Depression, and Stress. Korean Society of Nursing Science, 2015, vol. 45, no. 5, pp. 627-640. DOI: 10.4040/ jkan.2015.45.5.627
19. Dijkstra A., Sipsma D., Dassen T. Predictors of care dependency in Alzheimer's disease after a two-year period. Internaltional Journal of Nursing Study, 1999, vol. 36, no. 6, pp. 487-495. DOI: 10.1111/1467-8624.00164
20. Luthar S. S., Cicchetti D., Becker B. The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 2000, vol. 71, no. 3, pp. 543-562. DOI: 10.1111/1467-8624.00164
21. Carver C. S. Resilience and thriving: Issues, models, and linkages. Journal of Social Issues, 1998, 54, pp. 245-266. Available at: https://www.public.asu.edu/~iacmao/PGS191/resilience%20reading%20%232.pdf (accessed 6 March 2022)
22. Reivich K., Shatte A. (2002). The resilience factor: Seven essential skills for overcoming life's inevitable obstacles. NY: Broad way Books. Available at: https://psycnet.apa.org/record/2002-18688-000 (accessed 6 March 2022)
23. Resnick B. Resilience in older adults. Topics in Geriatric Rehabilitation, 2014, vol. 30, no. 3, pp. 155-163. DOI: 10.1097/TGR.0000000000000024.
24. Min E. S. Relationship between stress, depression, and resilience of middle-aged women. Journal of the Korea Entertainment Industry Association, 2017, vol. 11, no. 4, pp. 199-207. DOI: 10.21184/jkeia.2017.06.11.4.199
25. Yoon H. S., Yeom S. R. The Mediating Effects of Resilience on Depression and Suicidal Ideation of Older Adults in Korea. Korean Society of Gerontological Social Welfare. Korean Journal of Gerontological Social Welfare, 2017, vol. 72, no. 1, pp. 233-255. DOI: 10.21194/kjgsw.72.1.201703.233
26. Jung M. K., Lee K. M. A path analysis of stress, depression, optimism, and resilience in the elderly. Journal of the Korean Gerontological Society, 2010, vol. 30, no. 2, pp. 629-642. Available at: https://www.kci.go.kr/kciportal/ci/ sereArticleSearch/ciSereArtiView.kci?sereArticleSearchBean.artiId=ART001448142 (accessed 6 March 2022)
27. Nam B. H., Shin J. S. The effect of the characteristics of the elderly on the quality of life -Resilience and participation in social activities as a mediating effect. Korean Society for Social Welfare Management, 2016, vol. 3, no. 1, pp. 279-301. Available at: http://www.riss.kr.library.hanseo.ac.kr:8000/link?id=T14510279 (accessed 6 March 2022)
28. Fergust S., Zimmerman M. A. Adolescent resilience a framework for understanding healthy development in the face of risk. Annual. Review of Public Health, 2005, 26, pp. 399-419. DOI: 10.1146/annurev.publhealth.26.021304.144357
29. Lamond A. J., Depp C. A., Allison M., Langer R., Reichstadt J., Moore D. J., Ganiats T. G., Golshan S., Jeste D. V. Measurement and predictors of resilience among community-dwelling older women. Journal of Psychiatric research, 2008, vol. 43, no. 2, pp. 148-154. DOI: 10.1016/j.jpsychires.2008.03.007
30. Waters E., Sroufe L. A. Social Competence as a Developmental Construct. Developmental Review, 1983, 3, pp. 7997. DOI: 10.1016/0273-2297(83)90010-2
31. Lee H. K., Choc B., Lee H. A Study on Caregiver's Burden and Family Cohesion among Family Primary Caregivers. Family and Cultural, 2018, vol. 30, no. 2, pp. 78-104, DOI: 10.21478/family.30.2.201806.003
32. Montgomery R., Gonyea J., Hooyman N. Caregiving and experience of subjective and objective burden. Family relations, 1985, vol. 34, no. 1, pp. 19-26. DOI: 10.2307/583753
33. Oh S. H. (A) Relationship between burden and stress of family members of intensive care unit patient. Clinical Nursing Research Journal, 2004, no. 7, pp. 111-114. Available at: https://www.dbpia.co.kr/journal/articleDetaiPn odeId=NODE02324078 (accessed 6 March 2022)
34. Radloff L. S. The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1977, no. 1, pp. 385-401. DOI: 10.1177/014662167700100306
35. Kohout F. J., Berkman L. F., Evans D. A., Cornoni-Huntley J. Two Shorter Forms of the CES-D Depression Symptoms Index. J of aging and health, 1993, vol. 5, no. 2, pp. 179-193. DOI: 10.1177/089826439300500202
36. Korea Welfare Panel (2021). Available at: https://www.koweps.re.kr (accessed 6 March 2022).
37. Connor K. M., Davison J. R. Development of a new resilience scale: The Connor-Davidson resilience scale (CD-RISC). Depression and Anxiety, 2003, vol. 18, no. 2, pp. 76-82. DOI: 10.1002/da.10113
38. Baek H. S., Lee K. U., Joo E. J., Lee M. Y., Choi K. S. Reliability and validity of the Korean version of the Connor-Davidson Resilience Scale (K-CD-RISC). Eulji University Master's thesis, 2010, DOI: 10.4306/pi.2010.7.2.109
39. Hayes A. F. Partial, conditional, and moderated moderated mediation: Quantification, inference, and interpretation. Communication monographs, 2018, vol. 85, no. 1, pp. 4-40. DOI: 10.1080/03637751.2017.1352100
40. Long-Term Care Insurance Act for the Elderly. Available at: https://www.law.go.kr (accessed 6 March 2022)
41. Kim H. S., Lee Y. W., Park J. S., Jeon J. W., Ahn J. Y. Comparison of Cognitive Function, Depression, Activities of Daily Living and Postural Balance of Persons using Dementia Day Care Centers and Non-users. Journal of Geriatric Nursing, 2020, vol. 22, no. 1, pp. 22-33. DOI: 10.17079/jkgn.2020.22.1.22
42. Choi I. H., Kim E. J., Chung S. Y., Yang N. J. A study on the effect of long-term care insurance system for the elderly on families. Korean Women's Policy Research, 2011. Available at: https://scholar.dkyobobook.co.kr/searchDetail. laf?barcode=4010023866905 (accessed 6 March 2022)
43. Barber C. E., Fisher B. L., Pasley B. K. Family care of Alheimer's disease patients: Predictors of subjective and objecive burden. Family Perspective, 1990, vol. 24, no. 30, pp. 283-309. DOI: 10.1177.073346489501400203
44. Im M. Y., Kim Y. J. Supporting stress for eacy type of supporting the aged with dementia - Comparison of the stress by supporters at home and supporters in the nursing home. Korean Journal of Gerontological Social Welfare, 2006, 34, pp. 163-189.
45. Available at: https://www.kci.go.kr/kciportal/ci/sereArticleSearch/ciSereArtiView.kci?sereArticleSearchBean. artiId=ART001035615 (accessed 6 March 2022)
46. Lee Y. K., Jung M. H. The Effect of Family Resilience on Depression and Suicide Ideation of the elderly. Korean Journal of Gerontological Social Welfare, 2013, vol. 61, pp. 111-134. DOI: 10.21194/kjgsw.61.201309. 111
Information about the authors
Ki-Nam Lee
(South Korea, Seosan city) Master of Counseling, Doctor Course student Department of the Elderly Welfare Hanseo University E-mail: [email protected] ORCID ID: 0000-0002-8505-6729
Yun-Jeong Kim
(South Korea, Seosan city) Doctor of Humanities, Professor Department of Health, Counseling and Welfare Hanseo University E-mail: twoyun21@hanmailnet ORCID ID: 0000-0001-7707-8330
