Quality of Life Research 12 (Suppl. 1): 33–41, 2003.

33
Ó 2003 Kluwer Academic Publishers. Printed in the Netherlands.

Family burden and quality of life

Esther Sales
University of Pittsburgh, School of Social Work, Pittsburgh, PA, USA (E-mail: sales@pitt.edu)

Accepted in revised form 9 February 2002

Abstract

Providing care to family members dealing with chronic illness may result in feelings of burden or strain for
caregivers that can diminish their quality of life. This article examines objective and subjective dimensions
of family burden, and the extent to which illness characteristics and contextual variables have been found to
contribute to caregiver stress for different chronic illnesses. After discussing some of the problems in the
conceptualization and measurement of caregiving burden, it suggests several important directions for future
research, including further clarification of generic versus specific factors affecting caregiver burden, greater
understanding of contextual variables, the impact of other roles, and examining changes in caregiving
demands over the illness course.

Key words: Caregivers, Family burden, Quality of life

The impact of a chronic illness on other members
of the family, especially those who are most re-
sponsible for caregiving, can vary greatly. In gen-
eral, chronic illnesses that involve high caregiving
demands and long-term dependencies cause more
strains for family caregivers [1]. Within this con-
text, several societal factors may be seen as po-
tentially contributing to the strain for family
members of those with chronic illness. First, the
extended life spans for both the chronically ill and
their families may increase the time span within
which care is needed and provided by other family
members. Second, smaller family sizes and greater
geographical separation may exacerbate the
problems of family members in providing needed
care. Third, changes in the health care, such as
deinstitutionalization and managed care, have re-
turned more chronically ill family members to the
community. Fourth, technological advances in
outpatient medical care require patients and their
families to engage in more complex care tasks.
Finally, the increased complexities of navigating
the rapidly changing health care system, including
difficulties in obtaining information, managing
bills and payment requests, and negotiating the
system generally, add to the strain of family
caregivers in our current health care environment
[2].
Emergence of a caregiver strain perspective
Despite societal changes that may intensify the
burdens of caregivers, recognition of family care-
giving strains associated with chronic illness is far
from universal. Most discussions of family care-
giving strains reside in illness-specific medical lite-
rature. For some illnesses there has been extensive
consideration of caregiver strains, while other
medical problems have had very limited discussion
of this issue. Looking across illness categories, it
appears that each medical arena may follow a
similar path of discovery regarding the psychoso-
cial impact of chronic illness on patients and their
families. This path begins with an exclusively
medical focus, which may be followed by the fol-
lowing two additional stages. The first stage rec-
ognizes that the family may be a key medical ally
serving as a source of tangible and emotional
support during the patient’s treatment course and
34
recovery. Here the emphasis is on a family’s po-
tential contributions for facilitating the patient’s
medical treatment course. A second stage, which
occurs for only some illnesses, focuses on the
family members’ own problems in dealing with the
patient’s illness, as well as the physical and mental
health consequences for family caregivers. This
refocusing on the family impact of illness demands
a fundamental change in perspective. Medical
practitioners may find this switch especially diffi-
cult, since their training has focused most on the
primary patient. Thus, it may not be surprising
that ancillary fields such as social work and nurs-
ing, which have had a long tradition of dealing
with families in hospital settings, have been
quicker to recognize the stresses and burdens cre-
ated for families.
Two medical problem areas have contributed
most extensively to our understanding of family
burdens associated with chronic illness. These
arenas focus on families of severely mentally ill
adults, mainly persons with schizophrenia [3–7]
and families with impaired elders, mainly Alzhei-
mer’s patients [8–12]. In contrast, the caregiving
literature on cancer and cardiovascular problems,
the most common chronic illnesses of adulthood,
are far less extensive. Although a few cancer re-
searchers had begun to recognize the powerful
emotional and physical demands on families pre-
cipitated by this life changing disease in the 1970s,
the cardiovascular research arena lagged notice-
ably behind, with little discussion of family impact
until the 1980s and a paucity of empirical research
until around 1990 [1].
Why is the family caregiving literature most
comprehensive for Alzheimer’s patients and for
adults with severe mental illness? Four common-
alities between these disorders suggests some of the
factors that may focus attention on the burdens of
caregivers rather than on the patients themselves:
(1) both are long-term caregiving situations which
offer minimal hope that patients will get better,
and strong possibilities that they could get worse.
Consequently, family members often remain in a
caregiving role for substantial periods of their
lives, living with uncertainty regarding the pa-
tient’s future, but with the likelihood of care de-
mands increasing over time; (2) both disorders
place extremely high physical and emotional care
demands on the caregiver; (3) both illnesses man-
ifest in major cognitive and emotional disruptions
of normal behaviors; and (4) both populations are
viewed as lacking the competence needed to take
care of their own lives. Since they are not seen as
capable of self-maintenance, the medical system is
forced to rely on caregivers as the competent care
overseers maintaining medical care regimens and
avoiding more costly institutional care options.
Dimensions of family burden
The burdens of families associated with a patient’s
illness can take many forms. Thus, it is not sur-
prising that the concept of family burden is viewed
as multidimensional. These potential difficulties
include the direct care needs generated by the ill-
ness, disruption of normal household routines and
roles, financial concerns relating to medical costs
and income loss, and emotional stresses triggered
by the illness. Family burden is typically defined as
consisting of all the difficulties and challenges ex-
perienced by families as a consequence of some-
one’s illness. Researchers more or less agree that
there are two central dimensions, objective and
subjective burdens, that comprise the family burden
concept [9, 10]. However, there is less agreement
about the conceptual definition of burden, and how
best to classify the various components [13].
Table 1 presents components of objective and
subjective burdens that are identified and mea-
sured by researchers. I have organized these com-
ponents based on Schene et al.’s [14] examination
of 21 measures of family caregiving burden in se-
vere mental illness as well as Braithwaite’s [15]
discussion. The numbers in parentheses are Schene
et al.’s tallies of the number of instruments in-
cluding each component, and may be seen as
representing the degree of consensus among re-
searchers regarding each component’s centrality to
the concepts of objective and subjective burden.
The following review of literature relating to each
component of caregiving burden reflects the cate-
gories used in this table.
Objective burden
In general, the direct care tasks stemming from the
illness are viewed as objective. These include ‘all

Table 1. Dimensions assessed by 21 family or caregiver burden
instruments for severely mentally ill adults [14]
I. Objective burden
A. Direct tasks of care
Helping patient with ADLs (13)
Supervising the patient (13)
B. Indirect tasks
C. Dealing with the emotional needs of patient
Encouraging the patient (9)
D Effects of caregiving on other aspects of life
Family interaction (16)
Family routine (19)
Leisure (18)
Work/employment (15)
Mental health (15)
Physical health (10)
Social network (16)
Others outside household (12)
Children (13)
Financial consequences (17)
II. Subjective burden
Personal reactions to caregiving
Distress (18)
Stigma (14)
Worrying (19)
Shame (10)
Guilt (10)
those things that the caregiver and/or his or her
family has to do (helping, supervising, controlling,
paying, etc.), experiences (disturbed family and/or
social relations), or is not allowed to do any longer
(hobbies, clubs, career, work) as a consequence of
the caregiving task’ [14, p. 308]. Alternatively,
objective burden can be defined as ‘the time and
effort required of one person to attend to the needs
of another’ [1, p. 51]. Although these definitions
seem fairly specific, most measures of objective
burden rely on a family member’s self-report of the
extent of their caregiving activities, which may be
far from objective.
A few researchers have recognized this problem
and have attempted to develop more objective
categories. Poulshock and Deimling [11] view
burden as a consequence of impairment (in socia-
bility, disruptive behavior, cognitive incapacity,
activities of daily living (ADL) impairment) with
different consequences for different impairments.
For example, if the patient is disruptive, the care-
giver’s social activities are likely to be more lim-
ited. Others have attempted to identify the types of
burdens associated with specific illnesses. Exam-
ining the literature on the impact of schizophrenia
35
on families, Maurin and Boyd [16] found the fol-
lowing five objective burden dimensions identified
across studies: (1) disturbed family relations pro-
voked by mental disorders, (2) financial costs
linked to these difficulties, (3) poor social perfor-
mance of person with mental disorder, (4) assis-
tance in ADL provided to the person, and (5)
problem behavior exhibited by the person. More
recently, Lefley [17] presented a more compre-
hensive list of 10 objective burdens for families of
the mentally ill, consisting of: (1) patient economic
dependence, (2) disruption of daily routines, (3)
behavioral management, (4) times and energy de-
mands required to negotiate the mental health
system, (5) confusing or humiliating interactions
with service providers, (6) financial costs of illness,
(7) deprivation of needs of other family members,
(8) curtailment of social activities, (9) impaired
relations with outside world, and (10) inability to
find satisfactory care settings. Although the de-
lineation of burden categories varies greatly across
research studies, it is possible to identify the fol-
lowing dimensions that appear to crosscut mea-
sures.
Dimensions of objective burden
The direct tasks of care
These tasks are most commonly measured by the
time needed to help patients with ADLs and su-
pervising the patient, which can vary greatly by ill-
ness or phase of illness. For instance, Stommel et al.
[18] calculated that caregivers spend 51/2 hours per
day providing for the care needs of cancer patients.
The care needs of other diseases, especially many
chronic conditions, may be more modest, with pa-
tients able to oversee much of their own needs and
regimen. Thus, many patients needing dialysis may
need help driving to their clinic or in maintaining
their diets, while cardiovascular patients may need
to monitor diet and exercise, with much less time
demands on their family. In addition to the com-
mon inclusion of help with ADLs and supervision
of the patient, Marsh and Johnson [2] have more
recently suggested that this category should include
the time that families may expend dealing with the
health care system in order to obtain needed re-
sources.
36
Indirect tasks of care
This category consists of other household tasks
that are taken over by family members, such as
cooking, financial management, which had been
previously performed by the patient. These new
responsibilities may require learning new skills,
and invariably add to the time demands of care-
givers. Such necessary changes in established role
patterns can be very stressful and disruptive for
family members [13].
Dealing with emotional needs of patient
Family members may need to devote time to lis-
tening to the patient’s concerns and dealing with
their distress. Providing support and encourage-
ment to the patient is an indicator that is often
included in family burden measures.
Effects of caregiving on other life roles
In some ways, the impact of caregiving on other
central life roles may be its most pervasive and
pernicious consequence. The degree to which
caregiving demands truncate or create conflict in
other role sectors may vary, but most researchers
attempt to measure the broad range of impact
commonly felt. These include changes in family
interactions, family routines, leisure, work, social
network involvement, contacts with others outside
the household, as well as the financial conse-
quences of illness. These role ramifications are
most commonly viewed as additional objective
consequences of caregiving [16, 17], although
Braithwaite [15] places them in the subjective
burden category.
Subjective burden
Subjective burden is defined as the distress expe-
rienced by the caregiver in dealing the objective
stressors described above [9, 10, 13]. Maurin and
Boyd [16] view subjective burden as the emotional
costs to the family resulting from the patient’s
disorder. In the case of mental illness, these costs
include feeling trapped, being confined to the
house, becoming isolated from others, feeling re-
sponsible for others, and emotional reactions to-
ward other’s behavior. Generally, these felt
emotional strains have included indicators of
worrying, distress, stigma, shame, and guilt.
Marsh and Johnson [2] suggest that grief and loss,
chronic strain, the emotional roller coaster of the
illness course, and empathic pain are additional
sources of distress. It should also be recognized
that caregivers frequently feel the need to conceal
these feelings from the patient, which itself may
exert another emotional cost. Inasmuch as care-
giving has such broad emotional ripple effects, it is
not surprising that many caregiving burden mea-
sures include more items dealing with subjective
strains than objective strains. However, it should
be noted that many indicators of subjective bur-
den, such as worrying, feeling stress, or guilt, also
may be viewed as indicators of depression, which
is frequently examined as a consequence of care-
giving burden, but may contribute to scores of
subjective burden.
Issues in the conceptualization and measurement
of caregiving burden
Schene et al.’s [14] review of measures of caregiv-
ing burden identified the following commonalities:
(1) most are multidimensional; (2) measure both
objective and subjective burden; (3) are comprised
of only negative items; (4) are administered on a
single occasion; (5) are a composite of various di-
mensions, most commonly, actual care demands,
added domestic tasks, readjustments in other role
demands, and emotional reactions of caregiver;
and (6) are administered only to the primary
caregiver, despite the recognition that all family
members are impacted by the patient’s illness.
Schene et al. [13] found an upsurge in measures
of caregiver burden in the early 1990s, with 15 of
the 21 measures they examined appearing during
this period. However, despite these continuing ef-
forts, no standard instrument has emerged that
can be used across illness groups.
Ambiguities in the conceptual meaning of subjective
burden
There are some apparent contradictions in the
operationalization of the concept of subjective

burden. Many measures either blend or fail to
distinguish objective and subjective aspects of
burden, or conflate subjective burden, measured
as the emotional response to caregiving demands,
with its psychosocial sequelae [11, 13]. Thus,
Braithwaite [15] views the impact of caregiving on
other role sectors as subjective, while many others
consider it objective. She suggests that this fuzzi-
ness is responsible for the inconsistent patterns of
findings between demands of caregiving and bur-
den. A stronger relationship between objective
and subjective burden may be found when sub-
Figure 1. Variables found to be related to caregiver stress by illness [1, p. 212].
37
jective burden includes interference with other role
aspects of life, whereas a weaker relationship may
be found between objective and subjective burden
if the definition of subjective burden is limited to
affective reactions and emotional well-being.
Generic vs. specific burdens of illnesses
Generally, discussions of family caregiving strains
are still problem specific, with little cross-commu-
nication between researchers examining specific
38
illness groups. Thus, a reader cannot determine
which issues are population specific, and which
may be general across illness groups. Biegel et al.’s
synthesis [1] of findings spanning different chronic
illnesses suggested that there were a number of
common variables affecting burden across illness
categories. These are presented in Figure 1 [1, p.
212]. This figure reveals that the level of demands,
types of demands, and trajectory of an illness ap-
pear to affect caregiver distress across a broad
range of chronic illnesses. For example, cognitive
and affective impairment that change a patient’s
behavior, no matter what their etiology, are more
difficult than physical impairments for family
members. Also, when there is more uncertainty
there could be more anxiety. In contrast, some
variables seem influential for specific illnesses.
Thus, shame and stigma are common burdens
mentioned for mental illness, but may not be major
stress sources for other illnesses. Even within dis-
ease categories, there can be many differences in
disease course. Thus, brain cancer appears to be the
most emotionally difficult malignancy for family
members [19]. Alzheimer patients and those with
retardation may need more physical care, and
parents of children with emotional problems were
found to have more worries about their child’s
future than any other category of subjective burden
[20], whereas studies of parents of severely mentally
ill adults have found higher objective strain.
This issue is closely linked to whether tailored vs.
generic measures are more desirable for research.
Generic measures allow cross-disease comparisons,
but omit what may be specific challenges that may
impact on both the objective and subjective bur-
dens of a particular illness. In contrast, illness-
specific measures may identify problems unique to
an illness, such as stigma in mental illness, or out-
come uncertainty in cancer, but provide noncom-
parable data for cross-illness comparisons.
Greater emphasis on the contextual variables
impacting on family reactions
Many current studies fail to examine the ways in
which other attributes of the caregiver may affect
their felt burden. Yet life circumstances and de-
mographic characteristics such as socio-economic
status, ethnicity, age, gender, family stage and
composition, may be central to caregiver burden
[16, 17, 19, 21].
The impact of other roles and responsibilities
of the caregiver
Pearlin [22, 23] has investigated the role implica-
tions of life stressors, including family illness. He
suggests that concepts such as role captivity, which
is viewed as being placed in a role involuntarily
and unwillingly, and role overload, help us to
understand many dilemmas of caregiving [22]. He
also acknowledges the impact of caregivers’ coping
and social support resources on their ability to
deal with caregiving demands.
Need to more fully capture the concept of
family burden
As mentioned earlier, the measurement of care-
giving burden has not really examined the family
as a system, but most commonly has obtained data
solely from the primary caregiver [1, 13]. A sys-
tems perspective would emphasize the examination
of family issues and adaptations, relationships,
role and task restructuring, inasmuch as chronic
illness requires major role realignments as the new
role of caregiver is added and pre-existing role
allocations for patient may need to be reassigned
[17, 23, 24]. For example, the American Cancer
Society [25] reported that 35% of families reported
that there had been role changes in families due to
the patient’s illness.
Research on family caregiving assumes that illness
demands are static
However, in many illnesses, there are changes in
patient care needs and illness trajectory over time
that create different demands on the caregiver [1,
13, 26]. The challenges for families when dealing
with newly diagnosed illness, or during an acute
health crisis, are different from those accompany-
ing a chronic long-term condition. We usually
collect data on family burden when patients are in
contact with health care system. These cross-sec-
tional data make it impossible to assess whether

Table 2. Stage-specific problems experienced by families of
adult cancer patients [26, 27]
I. Initial illness phases
A. Diagnostic phase
1. Managing emotional tensions
2. Concealment of feelings – anxiety, fear for future
3. Feelings of isolation
B. Hospitalization
1. Managing emotional tensions
2. Feeling excluded from the focus of care
3. Communicating with staff-serving as patient advocate and
mediator
4. Role overload
5. Fatigue and exhaustion
6. Concealment of feelings – anxiety, fear, exhaustion,
resentment
II. Adaptation phases
A. Posthospital phase
1. Adjusting to changes in roles and life styles
2. Meeting the needs of well family members
3. Living with uncertainty
4. Feelings of inadequacy regarding needed caregiving skills
B. Adjuvant treatment phase
1. Recapitulation of initial illness phases (I), plus
2. Dealing with side effects of treatment
C. Recurrence
Recapitulation of diagnostic phase (IA) reactions
III. Terminal phase
1. Communicating about death
2. Providing care and support to dying family member
3. Dealing with feelings of separation and loss
4. Role overload
5. Concealing of feelings
6. Feelings of isolation
7. Fatigue and exhaustion
8. Feelings of inadequacy regarding needed skills
the felt burden of caregivers change over time, or if
there is an adaptation or fatigue factor in caregiver
reactions. In addition, it seems possible that the
burden may be greatest for families when they are
in least contact with health care system. For ex-
ample, most research on cancer patients and their
families occurs at diagnostic and treatment stages,
rather than at subsequent phases prior to the ter-
minal period. But little is known about family
burden during the often extensive period between
adjuvant treatment and terminal phase. Table 2,
taken from Sales [26] and derived from Northouse
[27], suggests the many differences in family de-
mands associated with different illness phases. In
the diagnostic phase, common family difficulties
include managing their emotions while concealing
them from the patient. Once the patient is hospi-
39
talized, family members often feel role overload as
they shuttle between home, work and hospital.
They also have to establish ways of communicat-
ing with health care providers. In the posthospital
phase other challenges emerge, including family
role adjustments, and learning new caregiving
skills. Finally, there are unique difficulties and
challenges associated with the terminal phase, in-
cluding communicating with the patient about
death, and dealing with feelings of loss. These
shifts in family demands and concerns undermine
our static views of family burden and the cross-
sectional research designs that undergird them,
clearly suggesting that much of our empirical
findings may distort the dynamic challenges to
caregivers at varying illness phases.
Recognition of the burdens associated with
interacting with the health care system
As Lefley [17] and Marsh and Johnson [2] have
emphasized, greater attention should be paid to the
difficulties for caregivers dealing with the health
care system in their role of mediators and advocates
for the patient. There is little discussion or research
yet that examines these caregiving demands, except
for studies of families of the mentally ill. However,
more research on the difficulties of families inter-
acting with the health care system is likely to emerge
as managed care creates new challenges to those
seeking care for their ill family members.
The burden label itself
There appears to be growing discomfort with the
term ‘burden’ in dealing with the strains of care-
giving. Burden is an aversive label, and many
family members rightfully chafe when this term is
applied to their feelings toward their loved one.
The term implies something unwanted, unrelent-
ingly negative, imposed rather than chosen, and
something a person would desire to shed. Most
family members do not consider giving care a
burden, but rather an obligation that is willingly
incurred as part of a cherished family role. We give
care to those we love because we love them, because
it’s part of our expected role, and often to recip-
rocate for their past care for us. Thus, the term
40
burden ignores the contextual, affective, historical
and relational elements of the role that may be
most central to caregivers. Because of this negative
connotation, some recent work has abandoned the
term ‘burden’. It is noteworthy, for example, that
Brannon, Heflinger and Bickman’s Burden of Care
Questionnaire, [20] developed for the Fort Bragg
study, has been retitled the Caregiver Strain
Questionnaire in their later 1997 article.
In addition, focusing on burden ignores the
positive aspects of caregiving that emphasize the
satisfactions associated with giving care [16, 17,
28]. The narrow, negative focus on burden only
emphasizes half of the equation by which its im-
pact should be understood. Recently there has
been more acknowledgment of the rewards and
satisfaction of caregiving, including feeling needed,
and having the companionship of the ill family
member.
Conclusion
This examination of the conceptual and research
literature on family burden emphasized the family
systems impact of illness across health fields, fo-
cusing on both the objective and subjective psy-
chosocial ramifications of chronic illness on other
family members. Inasmuch as family members
may be an even more central component of patient
care in the current health care environment, we
may need to be even more cognizant of the strains
they experience in their caregiving role. Thus,
discussions of the psychosocial impact of illness
should recognize the family as an integral com-
ponent of the patient care system, and be sensitive
to their needs and difficulties as well as those of the
primary patient.
References
1. Biegel D, Sales E, Schulz R. Family Caregiving in Chronic
Illness. Newbury Park, CA: Sage Publications, 1991.
2. Marsh D, Johnson D. The family experience of mental ill-
ness: Implications for intervention. Profess Psychol: Res
Pract 1997; 28(3): 229–237.
3. Clausen J, Yarrow M. Paths to the mental hospital. J Soc
Issues 1955; 11: 25–32.
4. Grad J, Sainsbury P. Mental illness and the family. Lancet
1963; 1: 544–547.
5. Greenberg JS, Greenley JR, McKee D, Brown R, Griffin-
Francell C. Mothers caring for an adult child with schizo-
phrenia. Family Relat 1993; 42: 205–211.
6. Hoenig J, Hamilton MW. The schizophrenic patient in the
community and his effect on the household. Int J Soc
Psychiatry 1966; 12: 165–176.
7. Thompson EH, Doll W. The burden of families coping with
the mentally ill: An invisible crisis. Family Relat 1982; 31:
379–388.
8. Brody EM. Women in the middle and family, help to older
people. Gerontologist 1981; 21: 471–480.
9. George L, Gwyther LP. Caregiver well-being: A multidi-
mensional examination of family caregivers of demented
adults. Gerontologist 1986; 26: 253–259.
10. Montgomery R, Gonyea J, Hooyman N. Caregiving and
the experience of subjective and objective burden. Family
Relat 1985; 34: 19–26.
11. Poulshock SW, Deimling GT. Families caring for elders in
residence: Issues in the measurement of burden. J Gerontol
1984; 39: 230–239.
12. Zarit SH, Reever KE, Bach-Peterson J. Relatives of the
impaired elderly: Correlates of feelings of burden. Geron-
tologist 1980; 20: 649–655.
13. Schene AH, Tessler RC, Gamache GM. Caregiving in se-
vere mental illness: Conceptualization and measurement.
In: Knudsen HC, Thornicroft G (eds), Mental Health
Service Evaluation, New York: Cambridge University
Press, 1996; 296–316.
14. Schene AH, Tessler RC, Gamache GM. Instruments mea-
suring family or caregiver burden in severe mental illness.
Psychiat Psychiat Epidemiol 1994; 29: 228–240.
15. Braithwaite V. Caregiving burden: Making the concept
scientifically useful and policy relevant. Res Aging 1992;
14(1): 3–27.
16. Maurin J, Boyd B. Burden of mental illness on the family:
A critical review. Arch Psychiatr Nurs 1990; 4: 99–107.
17. Lefley HP. Family Caregiving in Mental Illness. Thousand
Oaks, CA: Sage Publications, 1996.
18. Stommel M, Given C, Given B. The cost of cancer care to
families. Cancer 1993; 71: 1867–1874.
19. Sales E, Schulz R, Biegel D. Predictors of strain in families
of cancer patients: A review of the literature. J Psychosoc
Oncol 1992; 10(2): 1–26.
20. Brannon A, Heflinger C, Bickman L. The caregiver strain
questionnaire: Measuring the impact on the family of living
with a child with serious emotional disturbance. J Emot
Behav Disord 1997; 5(4): 212–222.
21. Kahana E, Biegel D, Wykle M. Family Caregiving Across
the Lifespan. Thousand Oaks, CA: Sage Publications, 1994.
22. Pearlin L. Role strains and personal stress. In: Kaplan H
(ed.), Psychosocial Stress: Trends in Theory and Research,
NY: Academic Press, 1983; 3–32.
23. Pearlin L. The sociological study of stress. J Health Soc
Behav 1989; 30: 241–256.
24. Noelker L, Townsend A. Perceived caregiving effectiveness:
The impact of parental impairment, community resources
and caregiver characteristics. In: Brubaker T (ed.), Aging,
Health, and Family, Newbury Park, CA: Sage Publications,
1987; 58–79.
 41

25. American Cancer Society. Facts and Figures, 1979. of later-life caregiving. Gerontologist 1993; 33: 542–
26. Sales E. Psychosocial impact of the phase of cancer on the 550.
family: An updated review. J Psychosoc Oncol 1991; 9(4):
1–26.
27. Northouse L. The impact of cancer on the family: An Address for correspondence: Esther Sales, University of Pitts-
overview. Int J Psychiatry Med 1984; 14: 215– burgh, School of Social Work, CL 2217F, Pittsburgh, PA
242. 15261, USA
28. Greenberg JS, Seltzer MM, Greenley JR. Aging parents of Phone: +1-412-624-6314
adults with disabilities: The gratifications and frustrations E-mail: sales@pitt.edu