a cross-cultural validation of coping strategies and their

Copyright 1997 byThe Cerontological Society of America

The CerontologistVol. 37, No. 4, 490-504

Coping strategies were compared among family caregivers of Alzheimer's disease patientsin Shanghai, China (n = 110) and San Diego, California (n = 139). Four coping factors werereliably consistent in both samples, supporting their widespread relevance to life adversity:

behavioral confronting, behavioral distancing/social support, cognitive confronting, andcognitive distancing. Shanghai and San Diego caregivers endorsed similar rates of coping, but

Shanghai caregivers reported fewer symptoms of depression and anxiety. Although copingstrategies were similar, cultural ideals promoting family interdependence, veneration of

elderly family members, and acceptance of traditional family roles may have reduced thepsychological impacts of caregiving in the Shanghai sample.

Key Words: Caregiver stress, Coping, Eastern cultures, China, Alzheimer's disease

A Cross-Cultural Validation of CopingStrategies and Their AssociationsWith Caregiving Distress1

William S. Shaw, BS,2 Thomas L Patterson, PhD,3

Shirley J. Semple, PhD,3 Igor Grant, MD,3

Elena S. H. Yu, PhD, MPH,4 M. y. Zhang, MD,5

Yanling He,5 and W. y. Wu, MD5

Coping has been defined by Lazarus (1993) as "on-going cognitive and behavioral efforts to managespecific external and/or internal demands that are ap-praised as taxing or exceeding the resources of theperson" (p. 19). While many studies have reportedthe importance of coping in conceptual models ofadaptation to stressful life events, there is little con-sensus among researchers regarding the partitioningof coping into factors and the association of thesefactors with mental and physical health outcomes.Central to this debate is whether a vast and variablearray of coping strategies can be trimmed or orga-nized in a way that describes fundamental human re-sponses to life stress. One method for narrowing thefield of fundamental coping factors may be to lookfor similarities in coping across diverse cultures.

Previous studies have identified from two to eightcoping factors, and these factors have had overlap-ping and inconsistent labels (Tobin, Holroyd, Rey-

This research was supported by National Institute of Mental HealthGrant No. 42840 to Igor Grant, MD, and a research award from the Samand Rose Stein Institute for Research on Aging awarded to William S.Shaw. The authors would like to acknowledge Sandy Ho and Mary RoseOlenik for their assistance in data collection and management.

2San Diego State University/University of California, San Diego JointDoctoral Program in Clinical Psychology, San Diego, CA.

'University of California, San Diego, and the Department of VeteransAffairs Medical Center, San Diego, CA. Address correspondence and re-quests for reprints to Thomas L. Patterson, PhD, Department of Psychiatry0680, University of California, San Diego, Clinical Sciences Building, 9500Gilman Drive, La Jolla, CA 92093-0680.

4San Diego State University, San Diego, CA.'Shanghai Mental Health Center, Shanghai, People's Republic of China.

nolds, & Wigal, 1989). Despite these inconsistencies,both qualitative and quantitative differences in cop-ing have repeatedly been shown to mediate rela-tionships between life stressors and health out-comes (Bolger, 1990; Folkman & Lazarus, 1988a). Themost frequently cited two-factor categorization ofcoping strategies is problem-focused versus emo-tion-focused coping. Problem-focused coping in-volves efforts to change situational variables (an ex-ternal emphasis), whereas emotion-focused copinginvolves efforts to reappraise the situation in someway (an internal emphasis) (Lazarus & Folkman,1984; Pruchno & Resch, 1989; Vitaliano et al., 1990b).This classification system is consistent with a dualis-tic model of stress adaptation wherein internal andexternal stressors are dealt with independentlyusing a different set of coping strategies for each.Based on this model, researchers have speculatedthat problem-focused coping is more beneficial inchangeable situations and emotion-focused copingis more beneficial in unchangeable situations, al-though this hypothesis has received only limited em-pirical support (Vitaliano, DeWolfe, Maiuro, Russo, &Katon, 1990a).

Even the distinction between problem-focusedand emotion-focused coping strategies has beenchallenged by some studies. Other two-factor solu-tions have identified factors labeled engagement anddisengagement coping (Tobin et al., 1989), repressionand sensitization (Cohen, 1991), and avoidant and ap-proach coping (Patterson et al., 1995). Unlike theproblem-focused/emotion-focused distinction, these

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classifications tend to stress the importance of asuppressive or avoidant coping style, the theoreticalfrontrunner of which is the psychoanalytic conceptof ego defense (Lazarus, 1993). Avoidant coping hasgenerally been associated with negative mentalhealth outcomes (Aldwin & Revenson, 1987; Patter-son et al., 1995) while approach coping appears tobe unrelated to health. Avoidant coping, however,may be adaptive in negative life circumstances thatcannot be improved (Collins, Baum, & Singer, 1983).

Beyond the general two-factor scheme, many mul-tiple factor solutions have been derived from a num-ber of coping measures. Some of the most fre-quently cited coping factors include seeking socialsupport, escape/avoidance, and positive reappraisal.The Ways of Coping-Revised (WOC-R) question-naire by Folkman and Lazarus (1985), which has beenlargely accepted and employed in stress and copingstudies, includes 67 items that have been factor-ana-lyzed to produce eight coping subscales: confrontivecoping, distancing, self-controlling, seeking socialsupport, accepting responsibility, escape-avoidance,planful problem solving, and positive reappraisal.These subscales have been the basis for many stud-ies addressing coping and chronic illness.

A common property of coping subscales is thatthey covary to a large degree, making it difficult todistinguish adaptive from maladaptive copingstyles. Individuals with high scores on planful prob-lem solving, for example, also score high on mostother subscales, even those that appear to be anti-thetical to planful problem solving (e.g., escape-avoidance). Although each of the eight subscales ofthe WOC-R is face-valid and factor-analytically sup-ported, none of these subscales is consistently pre-dictive of mental health outcomes. Therefore, theremay be fewer factors at a more basic level that arekey to understanding the role of coping in predict-ing mental health outcomes.

Few studies have examined coping cross-cultur-ally. Several U.S. studies have addressed culturalvariations among rural older adults (Bray-Preston &Mansfield, 1984), American Indians (Strong, 1984),and African Americans (Conway, 1985). Variations incoping among these subpopulations might be ex-pected, given that items in coping self-report ques-tionnaires tend to be highly culture-bound and col-loquial. For example, the WOC-R includes itemssuch as "I looked for the silver lining," "\ stood myground," and "I just let things go." Literal transla-tions of these items may not be appropriate, andtranslated items may require substantial editing orsubstitution. In addition to translation difficulties,beliefs about the efficacy of various coping strate-gies may also differ between cultures. Given themyriad of possible variability sources, it may bemore informative to look for cross-cultural similari-ties in coping rather than differences.

Caregiving for a chronically ill family memberhas been well-documented as a source of distressamong caregivers in the United States. Caregivingfor a family member with Alzheimer's disease (AD)has received considerable attention because care-

givers are usually older, and the insidious and globaldeterioration of cognitive functions in the AD pa-tient represents a tremendous burden. Caregivershave generally been shown to endorse more copingitems (Sistler, 1989), report more psychological dis-tress (Anthony-Bergstone, Zarit, & Gatz, 1988; Baum-garten et al., 1992), report poorer physical health(Pruchno & Potashnik, 1989), and show signs of re-duced immunity (Kiecolt-Glaser, Dura, Speicher,Trask, & Glaser, 1991) when compared with age-matched controls.

Recent epidemiological studies in Shanghai,China, have suggested that age-stratified prevalencerates of AD in China and the associated cognitiveand behavioral deficits are similar to those found inthe U.S. (Zhang et al., 1990). The disease-related de-mands of caring for a relative with AD, then, appearto be similar across both cultures. However, differ-ences in family size, familial roles, social support,financial burden, and availability of formal servicesmay produce differences in the caregiving experi-ence. For example, parent care from adult childrenmay be more normative in China than in the U.S.(Davis-Friedmann, 1983).

Stylistic differences in traditional Eastern andWestern cultures would suggest that coping strate-gies vary considerably. These stereotypical differ-ences are probably becoming less profound be-tween the U.S. and China, given the rapid economicand demographic changes that have occurred inChina since Communist rule began in 1949 and therecent institution of free-market reforms. Neverthe-less, the traditional Chinese attitudes of respect andconcern for older adults appear to have outlastedother ideological changes (Davis-Friedmann, 1983).Older family members are still encouraged to accepta role of passive dependency (both financial andemotional) on younger family members (Kwong &Guoxuan, 1992). Social interaction in China stressesthe importance of interpersonal harmony and familyvalues. Individuals are encouraged to share personaland emotional problems with family members (Hsu,1985) and to avoid interpersonal conflict (Lai, 1995).These beliefs contrast with the traditional Westernemphasis placed on individualism, personal inde-pendence, and assertive action.

The majority of English-language reports related toEast/West differences in coping have comparedAsian Americans to White Americans. Such studieshave suggested that Asian Americans are more inhib-ited and less socially aggressive than their WhiteAmerican counterparts (Axelson, 1985, pp. 101-102).This has led to the speculation that people in someEastern cultures may find it relatively difficult to initi-ate emotional expression, at least when comparedwith White Americans. Others have speculated thatChinese and other Eastern inhabitants believe in a"conservation of emotional energy," and that socialreserve need not be mistaken for an absence ofemotions (Huang, 1976). Based on these claims, wehypothesized that Chinese caregivers would bemore likely than U.S. caregivers to use positive reap-praisal and seek social support, and they would be

Vol. 37, No. 4,1997 491


less likely to use active problem-solving strategies.We also hypothesized that avoidant coping styleswould be associated with psychological distress inboth cultures.

The present study involved administering a trans-lated version of the WOC-R questionnaire to ADfamily caregivers in Shanghai, China, and compar-ing results to an ongoing U.S. (San Diego) study.The goals of this analysis were to identify the factorstructure of the translated version, compare thesefactors to those of the U.S. sample, and examine re-lationships between coping and health for the twosites. The intent of this cross-cultural comparisonwas to discover coping constructs that may be simi-lar across divergent cultures, thereby providingsome evidence for universal coping strategies.

Method

SubjectsThe Shanghai caregivers were 110 (47 male, 63 fe-

male) family caregivers of older demented adultsresiding in the Jing-An district of Shanghai, thelargest city in China. They were recruited from alarge-scale epidemiologic research program inves-tigating the prevalence of AD and dementia inShanghai. From a screening of cognitive impairmentin a probability sample of 5,055 older (55+) adults,the caregivers were family members responsible forhome care of individuals who had received a clini-cal diagnosis of dementia (for diagnostic criteria,see Zhang et al., 1990). From this sample, 125 fami-lies that were identified as having a family caregiverwere contacted for participation, and 110 (88%)chose to participate. Shanghai control subjectswere 110 individuals from the same survey who

were matched for gender, age, and relationship tothe caregiver, and another family member was des-ignated as the "nonpatient."

The U.S. caregiver subjects were 139 (49 male, 90female) spouses of Alzheimer's disease (AD) pa-tients residing in San Diego, California. Of the 139AD patients, 66 were screened and diagnosed byneurologists and neuropsychologists at the Uni-versity of California, San Diego (UCSD) AlzheimerDisease Research Center (ADRC). The remaining 73patient/caregiver dyads were obtained through com-munity support groups or physician referrals, withall caregivers reporting a prior physician diagnosisof "probable" or "possible" Alzheimer's disease fortheir spouse. The caregivers were responsible forhome care of the patient at the start of the study,and both caregiver and patient were willing to par-ticipate in a 5-year longitudinal study including peri-odic blood draws and psychosocial assessments.San Diego control subjects were 51 age-matchedmarried couples selected from neighborhoods so-ciodemographically matched to the San Diego care-givers. Control subjects were chosen from a groupof 150 volunteer control subjects (with spouses)available through the ADRC and other geriatric re-search centers affiliated with UCSD. From each con-trol couple, one spouse was randomly assigned as"nonpatient" and the other as "noncaregiver."

Demographic characteristics of both Shanghaiand San Diego caregivers and controls are listed inTable 1. The proportion of male caregivers was simi-lar in both the Shanghai (43%) and San Diego (35%)samples. By design, the San Diego sample includedonly spouses as caregivers. In contrast, the Shang-hai sample included children, siblings, and other re-lations, who made up 69% of the sample. For thisreason, San Diego caregivers were considerably

Table 1 . Demographic Characteristics of Caregivers and Controls

Variable Name

GenderMaleFemale

Mean age (SD)**Relationship

SpouseSon/daughterGrandson/granddaughterOther

Working statusNever workedWorked and retiredStill workingWorked in past

Mean years education (SD)**Mean monthly income (SD)**Mean years married (SD)**Mean no. of children (SD)**Mean years since diagnosis (SD)

Shanghai

Caregiversn =

476358.0

346673

5505328.7

714

2.14.4

= 110

(42.7%)(57.3%)(15.5)

(30.9%)(60.0%)(6.4%)(2.7%)

(4.5%)(45.5%)(48.2%)(1.8%)(5.2)(404)

(1.8)(3.6)

Controlsn =

525855.6

3357173

4485539.2

786

2.1

= 110

(47.3%)(52.7%)(17.9)

(30.0%)(51.8%)(15.5%)(2.7%)

(3.6%)(43.7%)(50.0%)(2.7%)(5.1)(691)

—(2.0)

Shanghai (spouses only)

Caregiversn ••

142075.1

34

428205.3

52446.93.14.1

= 34

(41.2%)(58.8%)(7.0)

(100.0%)———

(11.8%)(82.3%)(5.9%)(0.0%)(5.6)(414)

(11.6)(2.3)(2.6)

Controlsn

161775.6

33

127325.8

64752.14.1

= 33

(48.5%)(51.5%)(6.5)

(100.0%)———

(3.0%)(81.8%)(9.1%)(6.1%)(5.7)(528)(8.2)(1.9)

-

San Diego

Caregiversn =

499070.7

139

1194132114.2

7,45339.72.54.9

**f-test or chi-square significant at p < .01 (comparing Shanghai and San Diego spousal caregivers only).

492

139

(35.3%)(64.7%)(7.3)

(100.0%)

(7.9%)(67.6%)(9.4%)

(15.1%)(3.2)

(20,187)(14.0)(1.6)

(11.0)

Controlsn -

262569.8

51 I

13875

15.59,189

37.92.7

= 51

(51.0%)(49.0%)(7.3)

(100.0%)

(2.0%)(74.5%)(13.7%)(9.8%)(2.7)

(22,403)(12.8)(1.7)

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older (M = 70.8 years, SD = 73) than Shanghai care-givers (M = 58.0 years, SD = 15.5). When comparingonly spousal caregivers, however, caregivers of theShanghai group were slightly older (M = 75.1 years,SD = 7.0) than San Diego caregivers. Shanghaispousal caregivers were married longer, had morechildren, had fewer years of education, and re-ported less income (based on U.S. dollar trade stan-dard) than San Diego caregivers. Shanghai and SanDiego caregivers reported similar rates of memoryand behavior problems in the AD patient, as well assimilar commitments of caregiving time. Approxi-mately half of the caregivers in both studies (42% inShanghai, 45% in San Diego) provided more than 7hours/day in direct care of their family member withAD. Approximately one-fifth of the caregivers (16%in Shanghai, 19% in San Diego) provided nearlyconstant care (19-24 hours/day).

Procedures

Shanghai caregivers and controls completed a 1-hour test battery administered verbally by a trainedinterviewer in their homes. San Diego caregiversand controls completed a longer (2-hour) test bat-tery. Unlike the Shanghai participants, who wereadministered all measures verbally, San Diego par-ticipants completed the Ways of Coping-Revised(WOC-R) questionnaire independently and mailedthe WOC-R to the research office. A second meth-odological distinction involved the introductoryparagraph providing instructions for completion ofthe WOC-R. San Diego participants were told torefer to "conflict or disagreement with your spouse."Shanghai participants were told to refer to "a diffi-cult situation or problem in your life." This wordingchange was the result of difficulties in translating theterm "conflict" into an equivalent term in MandarinChinese. Our Chinese collaborators felt that, if liter-ally translated, this phrase would have such a nega-tive connotation that it would be insulting to partici-pants, and unusual responses would likely result.

Our Chinese collaborators also discarded manyitems because of perceived problems in translationor cultural relevance (only 34 of 67 items from theoriginal WOC-R scale were retained). Items judgedas irrelevant tended to be highly colloquial or cul-ture-bound — for example, "found new faith," "grewas a person," "took it out on others," and "had fan-tasies." Many of the items judged as inappropriatewere labeled as escape-avoidance or positive reap-praisal by Folkman and Lazarus (1988b); therefore,these two coping strategies may be difficult to de-scribe in Eastern cultures. Both Shanghai and SanDiego participants were offered no incentives forcompleting the test battery. A previous Chinesetranslation of the Hamilton Rating Scale for Depres-sion was available from the Shanghai Institute onMental Health. The Brief Symptom Inventory hadalso been previously translated (Jin et al., 1986). Allother measures were translated from English to Man-darin Chinese and back-translated by others to en-sure accurate translation. With the exception of the

revisions to the WOC-R questionnaire (describedabove), all measures were retained in their entiretyin the Chinese translation.

Measures

Patient Dementia Severity. — The Clinical De-mentia Rating (CDR) scale by Hughes and others(1982) was used to classify AD patients as healthy,questionable, mildly demented, moderately de-mented, or severely demented. The CDR was basedon caregiver ratings within six domains: memory,orientation, judgment/problem solving, communityaffairs, home/hobbies, and personal care. Internalconsistency (alpha coefficient) for the measure inthe present study was .97 for both the San Diegoand Shanghai samples of AD caregivers.

Caregiving Role. — Caregivers and controls wereasked to provide a number of details about theircaregiving role, including amount of care provided,activities requiring assistance, and respite time(Pearlin, Mullan, Semple, & Skaff, 1990). A numberof demographic background variables were also as-sessed, including age, gender, education, and in-come of the caregiver and patient.

Coping. — The Ways of Coping-Revised ques-tionnaire is a 67-item instrument which asks individ-uals to rate on a 4-point Likert scale the degree towhich they use particular strategies in dealing withconflicts or stressful situations (Folkman & Lazarus,1988b). The Shanghai version of the Ways of Copingquestionnaire is a substantially reduced form of the67-item original. A subset of items was selected byour Chinese collaborators from the Shanghai Men-tal Health Center based on ease of translation andcultural relevance. Based on their review of the 67items, 34 items were selected and six additionalitems were added, resulting in 40 items in theShanghai version of the WOC-R. Translated ver-sions are available from the authors upon request.

Mental Health. — An abbreviated form (53-itemversion) of the Hopkins Symptom Checklist (HSCL)was used to assess anxiety and depression amongparticipants. This 53-item self-report instrument, ti-tled the Brief Symptom Inventory (BSD, has beenshown to have internal consistencies from .84 to .87,and both criterion-related validity and constructvalidity have been demonstrated in psychiatric out-patients, other outpatients, and normal controls(Derogatis, Lipman, Rickels, Uhlenhuth, & Covi,1974; Derogatis & Melisaratos, 1983). The observer-rated Hamilton Rating Scale for Depression (HRSD)was also administered to participants. The HRSD is a24-item clinical instrument for assessing depressivesymptoms based on 3- or 5-point Likert scale re-sponses. The HRSD has well documented validity(Endicott et al., 1981), and it has been used exten-sively in clinical trials of antidepressant drugs.Inter-rater reliability has been found to be in therange of .80 to .91 (Hamilton, 1960,1969).

Vol. 37, No. 4,1997 493


Physical Symptoms. — The Interval Medical His-tory (IMED), a 21-item questionnaire, assessed typi-cal physical symptoms associated with each of themajor systems, as well as information on health carevisits, medications, hospitalizations, accidents, etc.The total number of symptoms reported for the pre-vious 6-month period was used as an outcome mea-sure of physical health.

Results

Factor Analysis (Shanghai)

A Principal Axis Factoring (PAF) extraction tech-nique was used to decide on the number of factorsadequate to represent the coping data from theShanghai sample. For the sake of comparison to theU.S. sample, only the 34 items translated from theoriginal WOC-R measure (of 40 total items) wereemployed. Although previous studies have sug-

gested that individuals under stress may exhibit in-creased coping, there is no extant literature to sug-gest that the underlying factor structure of copingmight vary between stressed and nonstressed pop-ulations. Therefore, all Shanghai participants (N =220) were included in the PAF computations (aquick check of this assumption revealed that at least90% of the coping items loaded on the same factorsfor both caregivers and controls). In the full analy-sis, a scree plot of eigenvalues was found to levelafter four factors. That is, although a total of eightfactors emerged with eigenvalues greater than 1.0,the latter ones did not add appreciably (less than5%) to the proportion of variance explained by thefirst four alone (49%). The first four factor solutionsproduced eigenvalues of 8.71, 338, 2.43, and 2.15.

Based on the results of the PAF extraction, anoblique rotation was performed to increase inter-pretability of the four factors. Factor loadings areshown in Table 2. The four factors were labeled

Table 2. Oblimin-Rotated Factor Loadings (Structure Matrix): Shanghai Ways of Coping Questionnaire

Abbreviated Coping Item

Factor 1: Behavioral Confronting*29. Brought the problem on myself*46. Stood my ground and fought*51. Promise to be different next time

*7. Get the person to change his mind49. Doubled my efforts9. Criticized or lectured myself5. Bargained or compromised

26. Made a plan and followed it30. Came out of experience better64. See other point of view2. Analyzed the problem

15. Looked for the silver lining3. Worked to take my mind off it

Factor 2: Cognitive Distancing*44. Made light of the situation*41. Refused to think about it*54. Keep feelings from interfering*14. Kept my feelings to myself13. Went on as if nothing happened35. Tried not to act too hastily56. Changed something about myself43. Kept others from knowing17. Expressed anger to the person

Factor 3: Cognitive Confronting*12. Sometimes just bad luck

*6. At least 1 did something*58. Wished that it would go away•53. Just accepted it

•4. Only thing to do is wait27. Accepted the next best thing40. Avoided being with people

Factor 4: Behavioral Distancing/Social Support*8. Talk to find out more about it

*45. Talk to someone about feelings*42. Ask someone for advice*22. Get professional help*31. Talk to someone who can act

Factor 1

.71 (.56)

.61 (.60)

.41 (.67)

.33 (.42)

.77 (.16)

.76 (.32)

.73 (.02)

.71 (.20)

.66 (.16)

.64 (.05)

.62 (-.03)

.43 (-.16)

.34 (-.13)

-.02 (-.00)-.08 (.14)

.31 (.13)

.00 (.00)-.17 (.11)

.39 (.27)

.17 (.37)

.26 (35)

.09 (.56)

-.00 (.02).27 (.03).32 (.29)

-.21 (.02).12 (-.09).05 (.20).09 (.29)

.10 (-.02)-.05 (.20)

.03 (.07)

.01 (-.12)

.38 (.19)

Factor Loadings**

Factor 2

-.05 (.18).06 (.01).22 (.06)

-.06 (.06)-.01 (.52)-.06 (.08)-.02 (.15)-.02 (-.02).08 (.38)

-.13 (.51).24 (.18).25 (.71).10 (.39)

.72 (.51)

.67 (.45)

.58 (.52)

.56 (.46)

.69 (.23)

.51 (.04). .50 (.18)

.37 (.20)-.29 (-.17)

-.21 (.02)-.14 (.03)

.04 (.03)

.19 (.26)

.02 (.14)

.21 (.24)-.03 (-.08)

.03 (-.17)-.05 (-.02)

.18 (.17)-.10 (-.09)

.22 (.04)

Factor 3

.05 (-.09)-.01 (-.13)

.46 (.11)-.12 (-.01)

.25 (-.05)-.09 (.43)

.09 (.08)

.07 (-.14)

.02 (-.35)

.10 (-.26)-.02 (-.05)

.34 (.00)

.15 (.25)

-.01 (.09).14 (.10).13 (.23)

-.04 (.28)-.01 (.37)-.26 (-.06)

.05 (.02)-.04 (.14).07 (.14)

.59 (.58)

.54 (.41)

.41 (.39)

.35 (.29)

.46 (.23)

.40 (.16)

.20 (.01)

-.16 (.13).12 (.14).07 (.05).08 (.07)

-.27 (-.13)

Factor 4

-.09 (-.10).12 (.05)

-.18 (-.08).35 (.13)

-.09 (.16)-.01 (.10).09 (.48).04 (.56).15 (.25),16 (.10).09 (.51)

-.10 (.16).18 (.25)

.04 (-.15)

.12 (-.00)

.00 (.03)-.13 (-.09).02 (-.09).03 (.34).21 (.13)

-.05 (-.01).23 (-.02)

-.04 (.09).20 (.25)

-.03 (.12).16 (.05).23 (.25).19 (.26)

-.10 (.04)

.75 (.81)

.64 (.41)

.61 (.46)

.50 (.50)

.45 (.62)

"Items used to construct comparable factor scores between study sites.(*Factor loadings for San Diego sample shown in parentheses.

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based on our a priori conceptualizations of copingfrom the literature and based on the content ofthose items loading highest on each of the factors.Although these labels typically did not fit all of theitems on each factor, the labels were consistentwith the majority of items loading highest on thefactor. Factor 1 included 11 items that reflected pre-dominantly confrontive and problem-focused cop-ing strategies. The factor included items like bar-gaining or compromising, doubling efforts, andmaking plans. Factor loadings (from the pattern ma-trix) varied from .34 to .77. Factor 1 also includeditems related to accepting responsibi l i ty andself-blame. Factor 1 resembled a combination oftwo factors from the original eight-factor solutionby Folkman and Lazarus (1985): planful problemsolving (2 shared items) and accepting reponsibility(2 shared items). We labeled this new factor behav-ioral confronting to describe the overt and action-based commonalities among most of the items.

Factor 2 included nine items that reflected pre-dominantly avoidant and emotion-focused copingstrategies. It included items such as making light ofthe situation, refusing to think about it, and keepingfeelings from interfering. Factor loadings variedfrom .29 to .72. Factor 2 most closely resembled thedistancing factor identified by Folkman and Lazarus(3 shared items). We labeled this factor cognitivedistancing to describe the covert and disengagingcommonalities among items.

Factor 3 included seven items that reflected pre-dominantly confrontive and emotion-focused cop-ing strategies. It included items such as acceptance,attributing the problem to bad luck or chance, andrecognizing a lack of influence over the problem.These items appeared to express efforts to reap-praise or intellectualize the situation. Factor load-ings varied from .20 to .59. Factor 3 did not resembleany of the factors identified by Folkman and Lazarus.We labeled this factor cognitive confronting to de-scribe the covert, yet confrontive, commonalitiesamong items.

Factor 4 included five items that reflected effortsto seek the assistance of others in meeting the de-mands of the situation. Factor loadings varied from.35 to .75. The factor included items such as talkingto someone who can do something concrete aboutthe problem, asking someone for advice, and seek-ing professional help. Factor 4 most closely resem-bled the "seeking social support" factor identified

by Folkman and Lazarus (5 shared items). We con-ceptualized this desire for instrumental support as anegative assessment of personal resources for deal-ing with the situation. Increased social support waslikely to dilute responsibility for taking personal ac-tion. Therefore, in keeping with the pattern of la-bels for our previous three factors, we labeled thisfactor behavioral distancing to describe the ten-dency for these forms of support to relieve or dilutepersonal responsibility to take action. However, weacknowledge that this is an unusual characteriza-tion for these items given the findings that socialsupport improves personal self-efficacy. Therefore,in subsequent results, we will refer to this factor asbehavioral distancing/social support and we willleave the ultimate choice of labels to the reader.

Internal consistencies (Cronbach's alpha) for thefour factors based on the Shanghai data (assumingequal weighting for items) were .91 for behavioralconfronting (BC), .75 for cognitive distancing (CD),.73 for cognitive confronting (CC), and .75 for be-havioral distancing/social support (BD). The result-ing factor scores (including all items and using theregression method) were intercorrelated becausethe oblique rotation method allowed for nonorthog-onal factors. Zero-order correlations between fac-tors ranged from .07 to .32 (see Table 3).

We were interested in whether the six new itemsadded to the coping questionnaire by our Chinesecolleagues described additional coping factors.Therefore, a second factor analysis of the Shanghaicoping questionnaire was performed using all 40items. English translations of the six added items areas follows:

35. I go to work but don't do much when I amthere.

36. I just let things go; I don't try to fix the prob-lem.

37. I have lost something, but it is all right be-cause I act like I never had it from the begin-ning.

38. It would have turned out like this anyway.39. I try to forget the person who caused the

problem, and instead, concentrate on theother people in my life.

40. Compared to some people I am worse off, butcompared to others I am better off.

Addition of the six factors had very little effect onthe factor analysis results. A scree plot of eigenval-

Table 3.

Coping Factors

Behavioral confronting (BC)Cognitive distancing (CD)Cognitive confronting (CC)Behavioral distancing (BD)

Correlations Between Factor-Analytically Derived Coping Factors for Shanghai ParticipantsUsing Regression Method for Item Weights'

BC CD

1.00 (1.00) .22** (.36**)1.00 (1.00)

CC

.32** (.20**)

.07 (.34**)1.00 (1.00)

.31

.12

.151.00

BD

** (.38**)(.38**)

* (.23**)(1.00)

'San Diego correlations shown in parentheses.*p < .05, 2-tailed; **p < .01, 2-tailed.

Vol. 37, No. 4,1997 495


ues once again leveled after four coping factors,and 32 of the original 34 items loaded the higheston the same factor as in the 34-item solution. Items37 through 40 loaded on the cognitive confrontingfactor. Item 36 loaded on the cognitive distancingfactor. Item 35 failed to load above .30 on any of thefour coping factors because this item was not appli-cable for most of the participants (few were em-ployed outside the home).

Comparative Factor Analysis (San Diego)

In accordance with our central hypothesis, wewere interested in whether the patterns and magni-tudes of factor loadings in the Shanghai copingstudy might be replicated in the San Diego sampleof caregivers and controls. The procedure used tocompare the two samples was to perform an inde-pendent four-factor solution for the San Diego sam-ple using the identical 34 items from the WOC-R.The patterns of factor loadings were then comparedbetween study sites using a coefficient of congru-ence and Cattell's salient similarity index, s (Cattell& Baggaley, 1960; Cattell, 1957) and the magnitudesof factor loadings were compared using Pearsonproduct-moment correlations.

A Principal Axis Factoring (PAF) extraction tech-nique was used to assess the number of identifiablecoping factors in the U.S. sample. As before, bothcaregivers and controls (N = 190) were included inthe PCA computations. A scree plot of eigenvalueswas found to level after four factors, which was con-sistent with the four-factor solution found in theShanghai sample (eigenvalue = 1.24). Although atotal of 10 factors emerged with eigenvalues greaterthan 1.0, the latter ones did not add appreciably(less than 5%) to the proportion of variance ex-plained by the first four alone (41%). The first fourfactor solutions produced eigenvalues of 7.43, 2.40,2.23, and 1.87.

Based on the results of the PAF extraction, anoblique rotation was performed to increase inter-pretability of the four factors using the obliminmethod. Factor loadings (from the pattern matrix)for the San Diego sample are shown in Table 2 (inparentheses, following the Shanghai factor loadingresults). The four-factor solution of the San Diegocoping data produced four recognizably similarfactors to those of the Shanghai sample based onitem content. Internal consistencies (Cronbach'salpha) for the four factors based on the San Diegodata (assuming equal weighting for items) were .73for behavioral confronting, .79 for cognitive distanc-ing, .70 for cognitive confronting, and .82 for be-havioral distancing/social support. The resultingfactor scores (including all items and using the re-gression method) were intercorrelated because theoblique rotation method allowed for nonorthogo-nal factors. Zero-order correlations between factorswere slightly higher for the San Diego sample thanfor the Shanghai sample, ranging from .20 to .38 (seeTable 3).

A coefficient of congruence was computed for

each factor to assess the agreement between thetwo independent factor solutions. The coefficientwas equal to [(proportion of factor items from theShanghai study correctly classified by the San Diegofactor solution) + (proportion of factor items fromthe San Diego study correctly classified by theShanghai factor solution)/2]. This coefficient mightbe considered the "average percentage agreement"of items loading highest on each factor. The com-puted congruence coefficients were 64% for behav-ioral distancing/social support, 58% for cognitiveconfronting, 44% for cognitive distancing, and 22%(only two snared items) for behavioral confronting.For all behavioral coping items (behavioral distanc-ing/social support or behavioral confronting), thecoefficient of congruence was 61%. For cognitivecoping items, the congruence was 56%. Similarly,the coefficient of congruence for distancing copingwas 58%, and 62% for confronting coping.

Although coefficients of congruence describedthe percentage agreement between the items load-ing highest on each factor, we applied a secondcomparative procedure, Cattell's salient similarityindex, that provided a more detailed comparison byincorporating factor loadings as well as factor posi-tion. For computation of Cattell's salient similarityindex, s, two-way frequency tables were con-structed for each of the four factors, with pairs ofloadings for each item on each factor contributing asingle tally to the table according to whether theloadings were positively salient, negatively salient,or neither between the two samples. A cutoff pointof .30 was used to determine salience. From thesefrequency counts, s was computed as .51 for cogni-tive distancing, .40 for behavioral confronting, .67for behavioral distancing/social support, and .43 forcognitive confronting. Estimates of probabilityvalues for s are tabled by Cattell and colleagues(1969) based on the total number of items and thepercentage of cases which are neither positivelynor negatively salient. Based on Cattell's tables, allfour similarity indices were statistically significant(p = .001), providing support for the underlyingcoping factors in both samples. Pearson product-moment correlations were also computed as a thirdmeans of comparing factor solutions between thetwo samples. Correlations between factor loadings inthe Shanghai and San Diego samples (based on all 34items) were moderate but statistically significant. Thecorrelation values were .73 (p = .001) for behavioraldistancing/social support, .50 (p = .003) for cognitivedistancing, .45 (p = .008) for cognitive confronting,and .42 (p = .015) for behavioral confronting.

Cross-Cultural Comparison of CopingIn order to develop coping factors that were valid

across both study sites, the four factors were re-duced to only those items that were marker vari-ables (items that loaded highest on one factor) forthe same factor in both studies. All items includedin the factor scores had factor loadings of .30 orgreater for both study sites. The revised factors con-



sisted of either 4 or 5 items, and these items areshown with a single asterisk in Table 2. Only twoitems (no. 46 and no. 29) loaded highest on thebehavioral confronting factor in both samples. How-ever, two other items (no. 51 and no. 7) had moder-ate loadings (.33 and .41) on the behavioral con-fronting factor, and these items had only a slightlyhigher preference for other factors. Therefore, thesetwo items were added to the behavioral confrontingfactor in order to have at least four items in each fac-tor score. To compute factor scores, these itemswere summed with equal weights (1.0) given to allfactor items, and then a proportional adjustmentwas made to account for the number of items in thescale. Items included in each of these comparablecoping factor scales are listed in boldface in Table 2.In the Shanghai sample, internal consistencies forthe reduced but comparable subscales (Cronbach'salpha) were .63 for behavioral confronting, .73 forcognitive distancing, .63 for cognitive confronting,and .75 for behavioral distancing/social support. Inthe San Diego sample, internal consistencies for thesame factors were .67 for behavioral confronting, .67for cognitive distancing, .59 for cognitive con-fronting, and .74 for behavioral distancing/socialsupport.

A 4 X 2 X 2 Within-Between-Between (CopingFactor X Caregiver Status X Study Site) mixed de-sign analysis of variance (ANOVA) was performedto compare the effects of caregiving on coping be-tween study sites. The results revealed a statisticallysignificant 3-way interaction in a multivariate test[F(3,384) = 6.42, p < .05], providing a basis for furtherexploration of group differences. The 3-wayANOVA results also showed a significant main ef-fect of coping in a multivariate test [F(3,384) = 25.98,p < .05], and a post-hoc comparison of means (aver-aged across caregivers and controls at both studysites) showed that behavioral confronting itemswere endorsed less often than items included in theother three coping factors.

To study simple effects, a Bonferroni adjustmentof the criterion alpha level (.05/4 = .0125) was made,and each of the four coping factors was further ana-lyzed in a 2 X 2 Between-Between (Caregiver Statusx Study Site) ANOVA. Group means for the four2-way group comparisons are plotted in Figure 1.For the coping factors of behavioral confrontingand cognitive distancing, no interaction or main ef-fects emerged (p > .0125), suggesting that theseforms of coping did not vary consistently by studysite or as a result of caregiving stress. For the cogni-tive confronting factor, the interaction was not signif-icant (p > .0125); however, both main effects weresignificant, suggesting that caregiving led to morecoping in both cultures [F(1,386) = 8.59, p < .0125],and that Shanghai participants coped more thanSan Diego participants [F(1,386) = 11.37, p < .0125].There was a statistically significant interaction forthe behavioral distancing/social support factor[/Tl,386) = 7.77, p < .0125], suggesting that caregivingled to increased coping among San Diego partici-pants, but not among Shanghai participants. An in-

spection of the group means (see Figure 1) showedthat San Diego caregivers used behavioral distanc-ing/social support at a rate equal to that of bothcaregivers and controls in Shanghai, San Diego con-trols were the only participant group showing a re-duced use of behavioral distancing/social support.

One possible source of confound in our cross-cultural comparisons of coping factors was the mis-match between the two study sites on age and rela-tionship to the patient. Although in the San Diegosample all caregivers and controls were spouses, inthe Shanghai sample participants included familymembers other than spouses (such as siblings andadult children). Therefore, our group differencessummarized above may have been solely an artifactof the heterogeneity of caregivers in the Shanghaisample. To examine this possibility, we repeated theANOVA computations listed in the previous para-graph, including only the spousal caregivers andcontrols in the Shanghai sample (n = 67). The 3-wayinteraction (Coping Factor X Caregiver Status XStudy Site) remained statistically significant [F(3,231)= 4.46, p < .05]. The main effect for coping also re-mained significant 1/(3,231) = 17.05, p < .05]. Thesimple effects tests (Caregiver Status X Study Site)for each of the coping factors also remained similar.For the cognitive distancing and behavioral con-fronting factors, there were no significant group dif-ferences. For the cognitive confronting factor, bothmain effects remained significant (p < .0125). For thebehavioral distancing/social support factor, the in-teraction no longer reached statistical significance[̂ (1,233) = 2.41, p = .12]. When only spouses were in-cluded in the group comparisons, the cell meansfor the various coping factors changed very little(less than 0.3 scale points), suggesting that age andrelationship to the AD patient were not solely re-sponsible for the observed group differences incoping.

A second possible confound was the differencein questionnaire instructions in the two transla-tions. To address this possible confound, we exam-ined the content of the most stressful experiencesprovided by our Shanghai participants. Seventy-three percent of Shanghai caregivers (68% of con-trols) reported that their most stressful event was aconflict with a family member or a major illness inthe family, which are stressors often associated withcaregiving. Only 7% of Shanghai caregivers (13% ofcontrols) reported that their most stressful eventwas related to work, neighbors, or finances. The re-maining participants reported their most stressfulevent as "other."

Cross-Cultural Comparisons of CopingAssociations With Health

Relationships between coping and other studyvariables were also compared cross-culturally. Table3 lists means and standard deviations for the fourhealth measures used. Table 4 lists Pearson product-moment correlations between the four coping fac-tors and demographic, mental health, and physical

Vol. 37, No. 4,1997 497


o

u.

2"E4-oO2q

3-

Shanghai

San Diego

Caregivers Controls Caregivers Controls

Caregivers Controls

£O)o

I"5

S>3

o

•

-

- • — Shanghai

- • — San Diego

1

Caregivers Controls

Figure 1. Coping comparisons between caregivers and controls in Shanghai and San Diego.

health variables for both the Shanghai and SanDiego caregivers. Statistical significance of within-group correlations is designated with asterisks. Tocompare the correlations cross-culturally, correla-tion coefficients were transformed to Fisher's z1 val-ues to adjust for the inherent skewness in a hypo-thetical distribution of correlation coefficients, and atest was made of the z' differences between inde-pendent samples, assuming a normal curve distribu-tion and a two-tailed test. Correlations that were sig-nificantly different in the two study samples arehighlighted with boxes in Table 4.

The demographic variables of age, gender, in-come, and education were generally unrelated tocoping in both samples. This was, again, reassuring,given the possible confound of age between our

two samples. The correlation between income andthe behavioral distancing/social support factor didreach statistical significance in the San Diego sam-ple of caregivers (r = .22, p < .05), a likely result ofthe increased availability of professional servicesand supports among higher income participants.

Coping was more strongly associated with prob-lem behaviors exhibited by the AD family memberthan with clinical dementia ratings. Only cognitiveconfronting was related (weakly) to dementia rat-ings (r = .19, p < .05). For three of the four copingfactors, weak but statistically significant correlationsexisted in at least one of the study sites with prob-lem behaviors of the AD patient: behavioral distanc-ing/social support (r = .26, p < .01 [Shanghai]), cogni-tive confronting (r = .34, p <.01 [San Diego]), and

498 The GerontologistDownloaded from https://academic.oup.com/gerontologist/article-abstract/37/4/490/611083by gueston 07 February 2018

Table 4. Demographic, Mental Health, and Physical Health Correlations With Coping Factors (Caregivers Only)

Variable Name

AgeGender (1 = m, 2 = f)tIncomeYears educationPatient dementia ratingProblem behaviorsDepression (observer rating)Depression (self rating)Anxiety (self rating)Physical symptoms

Behavioral Confronting

Shanghai(N = 101)

-.16-.01

.12

.01-.04-.03-.17-.20*

.11

.02

San Diego(/V = 106)

.09

.07

.01

.03

.02

.10

.25**

.26**

.24*

.13

Behavioral

Shanghai(N = 101)

-.11.22*.07.16.10.26**.05

-.17.17.08

Distancing

San Diego(N = 106)

-.16.12.22*.10.07.20*.21*.25*.24*.03

Cognitive Confronting

Shanghai(N = 101)

-.06.04

-.04-.04

.19*

.12

.07

.09

.10

.03

San Diego(N = 106)

-.01.18

-.04-.04

.01

.34**

.36**

.44**

.46**

.12

Cognitive Distancing

Shanghai{N = 101)

-.18.01.11.11

-.10.02

-.16-.04

.04-.28**

San Diego(N = 106)

.10

.17-.16-.01-.04

.24*

.21*

.13

.23*

.12 I

*p <, .05, 2-tailed; **p < .01, 2-tailed; tpoint-biserial correlation.

Table 5. Means and Standard Deviations for Mental and Physical Health Variables Among Shanghai and San Diego Caregivers

Shanghai San Diego

Variable Name

Caregivers(N = 110)M(SD)

Controls(N = 110)M(SD)

Reliability(alpha)

Caregivers(N = 141)M(SD)

Controls(N = 49)M(SD)

Reliability(alpha)

Depression (observer rating)Depression (self rating)Anxiety (self rating)Physical symptoms

2.6.26.23

5.9

(3.0)(.52)(.27)

(4.3)**

1.8.22.21

4.0

(3.1)(.43)(.29)

(4.2)

0.740.840.55N/A

5.3.67.63

10.5

(4.5)**(.68)**(.59)**

(8.5)

2.5.28.27

8.5

(3.3)(.56)(.40)

(7.9)

0.740.830.73N/A

**Caregivers different from controls, p < .01, 2-tailed.

cognitive distancing (r = .24, p <.O5 [San Diego]). Therelationships between coping factors and patientbehaviors did not differ significantly (p > .05) be-tween study sites.

Four variables were used to assess mental andphysical health in the two samples: an observer-rated depression score (Hamilton), a self-reporteddepression score (BSI), a self-reported anxiety score(BSD, and a self-reported list of physical symptoms(IMED). Before examining relationships with cop-ing, each of these measures was subjected to a 2 x2 (Caregiver/Control Status x Study Site) ANOVA toassess caregiver and cultural effects on the report-ing of mental and physical health (for a more de-tailed review of these findings, see Patterson et al.[1995]). Means and standard deviations for thesemeasures are shown in Table 5. Group means areplotted in Figure 2. On all three measures of mentalhealth, San Diego caregivers showed elevated dis-tress levels, while Shanghai caregivers did not. Inthe ANOVA, each of these effects produced a sig-nificant interaction term: observer-rated depression[F(1/397) = 6.03, p < .05], self-reported depression[F(1,406) = 8.79, p < .05], and self-reported anxiety[F(1,405) = 14.17, p < .05]. On the measure of physi-cal symptoms, caregivers showed elevated reportsof symptoms in both study sites [5(1,406) = 8.10, p <.05], and San Diego participants reported moresymptoms than Shanghai participants [F(1,406) =48.12, p <.O5]. The site differences in reporting re-mained statistically significant when only spousal

caregivers were included in the analysis (thus elimi-nating the potential confound of age and relation-ship) [F(1,253) = 11.50, p < .05].

The associations between the four coping factorsand.the four mental and physical health measuresfor caregivers in both study sites are shown in Table4. In general, increased coping was associated withgreater psychological distress in the San Diegocaregivers than in the Shanghai caregivers. AmongSan Diego caregivers, all four coping factors wererelated to depression and anxiety. Several differ-ences emerged in the Shanghai sample. First, cogni-tive confronting was unrelated to distress amongShanghai caregivers, while this coping factor hadthe strongest association with distress in the SanDiego sample. Second, behavioral confronting, be-havioral distancing/social support, and cognitivedistancing were positively correlated with distressin the San Diego sample, but these coping strate-gies were not correlated with distress in the Shang-hai sample. Third, physical symptoms were unre-lated to coping in the San Diego sample, butcognitive distancing was negatively correlated withphysical symptoms in the Shanghai sample.

Discussion

This study is the first to compare coping amongindividuals who are facing similar forms of life adver-sity in culturally diverse and language-discordant cul-tures. In this study, cross-cultural similarities sug-

Vol. 37, No. 4, 1997 499




Figure 2. Mental and physical health among San Diego and Shanghai family caregivers.

gested four fundamental coping strategies that maytranscend cultural diversity: behavioral distancing/so-cial support, behavioral confronting, cognitive dis-tancing, and cognitive confronting. The results alsoindicate that coping may affect (or respond to) men-tal and physical health differentially in diverse cul-tures. Most striking is the different relationshipsbetween coping and perceived distress in these twocultures. Greater levels of coping were associatedwith greater distress in the U.S. sample, while greaterlevels of coping were not associated with distress inthe Shanghai sample. These findings suggest thatwhile coping strategies can be similarly differenti-ated in distant cultures, the application of thesestrategies to life adversity and the relationship of cop-ing to psychological distress may differ substantially.

The Shanghai modified version of the WOC-Rmeasure is the first to introduce a coping measurein Mandarin Chinese that has a comparable Englishcounterpart. This first administration of the Shang-hai WOC-R has provided evidence of suitable relia-bility (from .76 to .91 for factor scores). The factora-bility of the scale into factors supports the generalvalidity of coping as a psychological construct inthis Eastern culture. The validity of the measure isfurther supported by its close association with theoriginal WOC-R version, which was validatedagainst measures of psychological distress, situ-ational factors, and temporal change (Folkman &Lazarus, 1980,1985).

The four-factor solution of the Shanghai WOC-Rmost closely resembles the second tier of the hier-

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archical factor structure proposed by Tobin et al.(1989). The four factors of behavioral confronting,behavioral distancing/social support, cognitive con-fronting, and cognitive distancing suggest a two-dimensional model of coping. One dimension con-sists of internalization (cognitive versus behavioralmanifestations) and the other dimension is resis-tance, the extent to which problems are addressedor ignored (confronting versus distancing). Tobin etal. (1989) referred to this second dimension as en-gagement versus disengagement. The validity ofthese four coping factors was also supported byconfirming the same factor structure in the SanDiego sample. Although the coping factor struc-tures proposed by others have typically includedmore than four coping factors, the two concepts ofinternalization and resistance appear to be commonto most factor schemes. Our own results, as well asprevious findings, suggest some degree of univer-sality to these two basic coping dimensions.

Three methods for analyzing similarities betweenthe two site-specific factor solutions were used: acongruency coefficient (assessing patterns of maxi-mum loading preference), Cattell's salient similarityindex (assessing patterns of factor loadings), andPearson product-moment correlation (assessingboth patterns and magnitudes of factor loadings).The first two methods generated convincing evi-dence that patterns of factor loadings were consis-tently similar, with most values reflecting 40 to 70%agreement. The third method, a more stringent cri-terion for judging similarities, produced statisticallysignificant correlations between factor loadings, butthe correlations were not large, ranging from .42 to.50 for three of the four factors. While items couldbe generally sorted into the same coping factors inboth samples, the strength with which individualitems described the particular coping construct var-ied substantially between the two groups. There-fore, while the four coping factors may be constantacross cultures, the language used to best explainthese cognitive and behavioral experiences mayvary substantially.

Comparison of the Shanghai and San Diego sam-ples on the behavioral confronting factor showedno statistically significant effects by caregiving sta-tus or by study site. We hypothesized that more as-sertive, action-based forms of coping (like those de-scribed by the behavioral confronting factor) mightbe more prevalent in Western than in Eastern cul-tures. This hypothesis was not supported. The cog-nitive distancing factor, which described efforts todeny the problem or avoid thinking about it, alsoproduced no statistically significant effects by care-giving status or by study site. These two copingstrategies, behavioral confronting and cognitive dis-tancing, may reflect more stable, trait-like aspects ofcoping that are less situational and culture-bound.Another possibility is that in both cultures thesecoping strategies may be poorly suited for dealingwith the role of caregiving, given the unchangeableand unavoidable nature of Alzheimer's disease.Confrontive coping strategies may seem worthless

if the caregiver is convinced of his or her inability tochange the disease course of the spouse's illness.However, distancing coping strategies may also bedifficult, given the close proximity and relationshipto the family member with AD.

Comparison of the Shanghai and San Diego sam-ples on the cognitive confronting factor showedstatistically significant main effects for both caregiv-ing status and study site, although the interactionwas only marginally significant (p = .03 vs an alphacriterion of .0125). We hypothesized that copingstrategies involving cognitive reappraisal and intel-lectualization (like those described by the cognitiveconfronting factor) might be more prevalent in East-ern than in Western cultures. This hypothesis wassupported. The marginally significant interaction forthis factor also suggested that the San Diego partici-pants increased this type of coping (to levels com-mon with our Shanghai participants) only in thepresence of caregiving. Therefore, in Western cul-tures, cognitive confronting may occur only in thepresence of substantial and unchangeable life stres-sors, while these coping strategies are more uni-formly prevalent in Eastern cultures.

Comparison of the Shanghai and San Diego sam-ples on the behavioral distancing/social support fac-tor showed not only statistically significant main ef-fects for both caregiving status and study site, butalso a significant interaction. We hypothesized thatcoping strategies involving the acquisition of socialsupport and the recognition of interpersonal de-pendence (like those described by the behavioraldistancing/social support factor) would be moreprevalent in Eastern than in Western cultures. Thishypothesis was supported. The interaction also sug-gested that the San Diego participants increasedthis type of coping (to levels common with ourShanghai participants) only in the presence of care-giving. Therefore, as with cognitive confronting, be-havioral distancing (by seeking the help of others)may occur in Western cultures only in the presenceof life stress, while these coping strategies are moreuniformly prevalent in Eastern cultures. This findingis consistent with the Western stereotypical ideal ofrelative independence and self-reliance in the ab-sence of major adversity.

We addressed two possible sources of confoundin our cross-cultural comparisons of coping factors:the first was related to group differences in age andrelationship to the patient, and the second was re-lated to the differential instructions provided in thetwo translations of the coping questionnaire. Theformer was addressed by repeating group compar-isons using only spousal participants from theShanghai sample, an approach that resulted in nochanges to our original findings. The latter was ad-dressed by examining the content of the specificlife stressors volunteered by the Shanghai partici-pants before completing the coping questionnaire.Approximately three-quarters of the Shanghai par-ticipants (73% of caregivers, 68% of controls) con-sidered their most stressful event to be related toa family member or a major illness in the family.

Vol. 37, No. 4,1997 501


Therefore, participants from both study sites ap-peared to be considering primarily family conflictwhile responding to items on the coping question-naire. Another argument against this confound isthat in both study sites participants completed thecoping questionnaire only after an intensive 1- to2-hour interview related to problems associatedwith their caregiving role. Therefore, it seems likelythat difficulties related to caregiving (or familial re-sponsibilities, in the case of controls) would pre-dominate in participants' recollections of life adver-sity and coping. Furthermore, previous work byFolkman and Lazarus (1980) would suggest thatfamily conflict stressors would elicit less problem-focused coping than other sources of stress (for ex-ample, work stress). Therefore, if a confound ex-isted, one would expect the San Diego participants(who reported entirely from experience with spousalconflict) would report less problem-focused copingthan Shanghai participants, but this was not thecase. Based on these arguments, we feel that thecultural differences in the present study cannot beattributed solely to methodologic confounds.

Another possible explanation of the higher ratesof coping (behavioral distancing/social support andcognitive confronting) among Shanghai controls is asampling one. Controls in the San Diego study werelargely unsolicited community volunteers who hadcontacted the University to participate in ongoingscientific research. Therefore, a self-selection biasmay have resulted in a San Diego comparison groupthat was more homogeneous and better adjustedthan their caregiver counterparts. Comparison ofdemographic variables between San Diego care-givers and controls did indicate that controls wereslightly, but not significantly, more educated and ofhigher family incomes. This was not the case in theShanghai sample. Because controls in the Shanghaistudy were solicited based on door-to-door in-quiries, they are a fairly representative communitysample. However, cross-cultural comparisons of thecontrol subjects on measures of psychological dis-tress did not detect more distress among Shanghaicontrols than among San Diego controls. This find-ing suggests that San Diego controls did not repre-sent an unusually well sample.

Comparison of the Shanghai and San Diego sam-ples on three measures of psychological distress(observer-rated depression, self-reported depres-sion, and self-reported anxiety) reflected increasesin distress among San Diego caregivers, but notamong Shanghai caregivers. Controls in both stud-ies showed low levels of psychological distress. Thisfinding suggests that the caregiving role may lead togreater distress in Western than in Eastern cultures,perhaps because family caregiving is perceived asmore normative in Eastern cultures. Cultural idealsthat emphasize personal interdependence amongfamily members, encourage the veneration of olderfamily members, and suggest passive acceptance oftraditional familial roles may depict the caregivingrole as more of an "honor" and less of an "obliga-tion." This conclusion, however, is fairly stereotypi-

cal, and is in conflict with our findings that ShanghaiAD caregivers reported equal amounts of burdenand dissatisfaction with their caregiving role as didU.S. caregivers.

Several studies have suggested that individualsfrom Eastern cultures underreport their mentalhealth problems when assessed using a conven-tional Western framework of psychological termsand expressions (Lin, 1985; Lin, Kleinman, & Lin,1981). Nevertheless, translations of Western mea-sures of psychiatric symptomatology appear to haveat least moderate validity in Eastern cultures (Lee,1981; Lin, 1985), especially when objective ratingsare used with fairly concrete terminology (theHamilton Depression Scale, for example). In ourstudy, we saw no noticeable differences in resultsbetween our observer-rated and self-reported mea-sures of depression. The present study, however,did show increases among Shanghai caregivers inphysical health symptoms reported. This is a partic-ularly interesting finding, given that decrements inphysical health demonstrated in English-speakingcaregiving studies have often been attributed to anegative reporting bias related to depressed mood.Perhaps what can be concluded is that cultural dif-ferences in the expression of psychological distressmay be large enough to obscure small, subclinicalchanges in mood, particularly when these changesare extrinsically motivated by life stress.

Our study of the relationships between the vari-ous coping factors and other study variables pro-vided many significant correlations and severalnotable site differences in these relationships. Be-cause of the large number of comparisons madeand the need for replication, we will address onlythe more general findings of these results. The gen-eral findings can be summarized as follows: (a)Some forms of coping appeared to be related toproblem behaviors of the AD patient receiving careacross both study sites, (b) coping was positivelycorrelated with psychological distress in the SanDiego sample, but unrelated to distress in the Shang-hai sample, and (c) the strongest relationship in theShanghai sample was a negative correlation betweencognitive distancing and physical symptoms.

Problem behaviors of the patient were related tothe use of more coping of all types in the San Diegosample and, to a lesser degree, in the Shanghai sam-ple. This suggests that the frequency of coping re-sponses in both cultures is, in part, a reaction toproblems and conflicts that have arisen as a resultof the caregiving role. In the San Diego sample, thefour coping factors were similarly correlated toproblem behaviors of the patient. In the Shanghaisample, although caregivers and controls showedno significant group differences in behavioral dis-tancing/social support or cognitive confronting,these two coping factors showed significant correla-tions with problem behaviors of the patient, suggest-ing at least some influence of caregiving on coping.

The most unexpected result was the differing rela-tionships between coping factors and psychologicaldistress between the two study sites. This contrast



was most pronounced for the behavioral confront-ing and behavioral distancing/social support factors.In Shanghai, participants who were more depressedor anxious felt less compelled to overtly respond insome way to life adversity (to "cope"). This findinghas not been reported elsewhere, and interpretationis difficult to conceptualize. Perhaps this reflects atendency for distressed individuals in Eastern cul-tures to hide their unhappiness to a much greaterextent than those in Western cultures. In China, self-control of emotions is expected (Wu & Tseng, 1985),and feelings are typically expressed only to closefamily members (Hsu, 1985). This would also explainour finding that Shanghai caregivers did not reportincreased distress compared with controls. U.S.studies, in contrast, have reported that distressed in-dividuals increase all of their coping strategies in afrantic effort to "try anything" that might help. Whilethe Western concept of coping accurately describescognitive and behavioral experiences in Eastern cul-tures, the mobilization of these strategies in re-sponse to life adversity or psychological distress ap-pears to be markedly different in Eastern andWestern cultures.

This study highlights the need for examining psy-chosocial variables, and especially the construct ofcoping, across diverse cultures. While similar factorstructures were apparent in both cultures, the rela-tionships between coping factors and outcome vari-ables varied markedly between study sites. Whileincreased coping was related to depressive symp-toms in the San Diego sample, the Shanghai sampleshowed no relationships for three of the four cop-ing factors. These differences between coping andpsychological distress symptoms may be partiallysupported by sociocultural differences; however,further study of coping in non-English-speakingpopulations is needed. Mobilization of coping in re-sponse to life adversity may be driven mainly byculture-specific "scripts" that dictate appropriateresponses.

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Received June 27,1995Accepted December 20,1996

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