Narrative synthesis element 3: Exploring relationships within and between

2.5.3.1 Self-efficacy and health-related quality of life

The effect size (r) was calculated for eight out of the eleven quantitative studies comprising a measure of health-related QoL. Of these studies, four demonstrated a statistically significant association between SE and health-related QoL domains (Table 2.1), and four studies found a weak or no association. The mean overall effect size with generic health-related QoL was 0.21, which is indicative of a small association

according to Cohen’s (1988) guidance. The mean effect size for the mental health domain was 0.31 and the physical health domain was 0.21. However, effect sizes varied considerably, possibly due to the varied measurement scales and/or caring SE domains evaluated in the studies, or reflecting the complexity of caring and other factors

involved. In addition, it was not possible to evaluate the effect size for SE judgments relating to specific caring tasks due to the small number of studies and heterogeneity in SE instruments used.

2.5.3.2 Self-efficacy and positive aspects of caring

Nine quantitative studies found that at a higher level of SE, there was a corresponding increase in positive aspects of caring, including finding meaning, satisfaction,

resilience, positive gain, and positive affect, with a mean overall effect size of 0.26. However the strength of associations varied considerably, which might be a result of the variation in positive outcome measures or the absence of a clear conceptualisation of positive aspects. For example, while Cheng et al. (2012) used the Positive Aspects of Caregiving Scale to evaluate generic positive aspects of caring, Quinn et al. (2012) specifically examined finding meaning using the Finding Meaning in Caregiving Scale. In addition, there were cultural differences between studies, for instance Cheng et al. (2012) was conducted in Hong Kong, while Fitzpatrick and Vacha-Haase (2010) was conducted in the US. There were also differences in sample characteristics between studies; Narayan et al. (2001) involved spousal carers only, while Liew et al. (2010) primarily involved son/daughter carers.

Furthermore, three studies found a weak or no association between SE and positive aspects of caring (e.g. Davis et al., 2006; Haley et al., 1987; Roud et al., 2006). Reasons for the disparity in findings might be due to the small samples used or due to differences in measurement scales, for example, Roud et al. (2006) used a measure of competence rather than SE and Haley et al. (1987) used single items to evaluate SE and these had not been previously validated.

Several themes relating to the relationship between carer SE and positive aspects of caring emerged from the conceptual mapping:

i. Peacock et al. (2010) and Sanders (2005) found SE was associated with carer ability to cope with challenging situations, such as disruptive behaviours, and

provide safe care, as well as the ability to perform a task that they thought they were not capable of completing. In turn, Peacock et al. (2010) found that mastering the complexity of caring generated satisfaction, meaning and pride. ii. Narayan et al. (2001) and Sanders (2005) highlighted the relationship between

higher carer SE and the development of new skills transferable to other contexts (e.g. personal growth). Peacock et al. (2010) found that these skills generate enrichment events such as pleasant activities/events that make a positive contribution to the caring experience and enhance sense of meaning, satisfaction, gain and wellbeing.

iii. A close association between carer role identity and SE beliefs was outlined. In particular, Simpson (2010) found that reconciliation of self-identity between different roles (e.g. parenting, employment) influenced carer SE. In addition, Skaff and Pearlin (1992) proposed that SE influences whether one will

experience a loss of sense of self (identity) as a result of caring stressors, which in turn determines carer well-being. Consistent with this proposition, Quinn et al. (2012) suggested that sense of meaning and satisfaction determine self- evaluations such as wellbeing.

However, it is important to note that studies were primarily qualitative and conducted in the US/Canada, therefore findings might not be generalisable to other populations. In addition, the Simpson (2010) article involved a case study of only two carers and therefore findings might not be generalisable, as caring experiences are extremely heterogeneous. Furthermore, Skaff and Pearlin (1992) did not specify a sample size or methods of recruitment, therefore it is not possible to determine the validity of the findings.

The limited literature makes it difficult to determine the roles of SE beliefs relating to specific caring domains in positive outcomes. Cheng et al. (2012) found task-specific SE beliefs have distinct associations with positive aspects: SE for responding to disruptive behaviours had a direct effect on positive gain, whereas SE for controlling upsetting thoughts moderated the relationship between stressors and gain. However, the study comprised a small Hong Kong sample and thus findings might not be

generalisable. In addition, Gottlieb and Rooney (2004) found instrumental, relational and self-soothing SE beliefs were related to positive affect, however the underlying mechanism was unclear and correlations were modest.

2.5.3.3 Self-efficacy and negative aspects of caring

Low SE was related to negative outcomes in caring, such as depression. SE for obtaining respite, responding to disruptive behaviours, controlling upsetting thoughts, self-soothing SE and instrumental SE were negatively associated with negative outcomes (e.g. Au et al., 2010; Gottlieb & Rooney, 2003, 2004). For example, Rabinowitz et al. (2009) found SE for responding to disruptive behaviours and for controlling upsetting thoughts exerted a direct effect on depression and SE for

responding to disruptive behaviours moderated the relationship between stressors and negative outcomes. In addition, Gottlieb and Rooney (2004) found an inverse

correlation between negative affect and instrumental SE. While Au et al. (2010) found that SE for obtaining respite, responding to disruptive behaviours and controlling upsetting thoughts were moderately negatively correlated with depression. However, it is important to note study limitations, such as studies being correlational and therefore causality cannot be established, and measurement scales of carer SE varying across studies. In addition, Gottlieb and Rooney (2004) examined the mental health component of carer QoL only.

The association between SE and negative outcomes might be driven by the protective role of SE, particularly for responding to disruptive behaviours and controlling

upsetting thoughts (described in Figure 2.3). Specifically, Au et al. (2010), Haley et al. (1987) and Rabinowitz et al. (2009) propose that SE might promote emotional

robustness, positive appraisals (and cognitive processes) and lead to reduced emotional vulnerability and negative states. These assumptions are consistent with SE Theory (Bandura, 1997) that SE can determine cognitive and affective processes. However, the role of instrumental SE and self-soothing SE in negative aspects is not clear, although self-soothing SE might improve emotional regulation.

2.5.3.4 Self-efficacy and physical health related quality of life

There is limited literature concerning the role of SE in carer physical health related QoL. However, Rabinowitz et al. (2009) proposed SE beliefs exert a protective

influence on physical health related QoL, and Au et al. (2010) and Marziali et al. (2010) found that higher SE was associated with improved physical health related QoL. More specifically, Au et al. (2010) found SE for responding to disruptive behaviours and controlling upsetting thoughts demonstrated the strongest associations with better physical health. In addition, Au et al. (2010) found that SE for controlling upsetting thoughts functioned as a mediator in the relationship between depression and physical health, with greater ability to manage negative thoughts protecting against negative emotions, and in turn impacting on perceived physical health related QoL. However, it is important to note that Marziali et al. (2010) examined generic SE only and the Au et al. (2010) study was conducted in Hong Kong, therefore findings might not be

applicable to other caring populations. Overall, there was limited evidence concerning the pathway, thus findings must be interpreted with caution.