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Interpersonal Conflict and Health
Perceptions in Long-Distance Caregiving
Relationships
a
b
b
Jennifer L. Bevan , Sean K. Vreeburg , Sherri Verdugo & Lisa
Sparks
c d
a
Department of Communication Studies, Chapman University,
Orange, California, USA
b
Schmid College of Science, Chapman University, Orange,
California, USA
c
Schmid College of Science, Chapman University, Orange, California
d
Chao Family Comprehensive Cancer Center, University of
California, Irvine, Irvine, California, USA
Version of record first published: 29 May 2012
To cite this article: Jennifer L. Bevan, Sean K. Vreeburg, Sherri Verdugo & Lisa Sparks (2012):
Interpersonal Conflict and Health Perceptions in Long-Distance Caregiving Relationships, Journal of
Health Communication: International Perspectives, 17:7, 747-761
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Journal of Health Communication, 17:747–761, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 1081-0730 print/1087-0415 online
DOI: 10.1080/10810730.2011.650829
Interpersonal Conflict and Health Perceptions in
Long-Distance Caregiving Relationships
JENNIFER L. BEVAN
Department of Communication Studies, Chapman University, Orange,
California, USA
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SEAN K. VREEBURG AND SHERRI VERDUGO
Schmid College of Science, Chapman University, Orange, California, USA
LISA SPARKS
Schmid College of Science, Chapman University, Orange, California, and
Chao Family Comprehensive Cancer Center, University of California,
Irvine, Irvine, California, USA
With job markets expanding globally and life expectancy continually increasing,
more demands are being placed on distant relatives to provide care for their
aging family members, creating a health care situation known as long-distance
caregiving. An online survey explored the relations between negative health
perceptions by long-distance caregivers and conflict frequency and conflict
strategy usage. The authors observed positive significant relations between
distant caregiver negative health perceptions and conflict frequency and usage
of the distributive and avoidance conflict strategies. However, they observed no
significant associations between distant caregiver negative health perceptions and
usage of the two integrative strategies. Implications for long-distance caregiving
communication are discussed.
Current rapid technological and medical improvements are remarkably boosting
life expectancy and continually creating novel and distinct research issues regarding
eldercare. As the elderly population continues to grow, elongated comprehensive
care often becomes the responsibility of the aging adult’s family (Miller, Shoemaker,
Willyard, & Addison, 2008). Indeed, 29% of U.S. adults, or roughly 65.7 million
Americans, engage in informal care (National Alliance for Caregiving/American
Association for Retired Persons, 2009). Of these, 5–7 million provide care from a
distance, a figure that is expected to double within 15 years (Benefield & Beck, 2007).
The study was funded by a 2008–2009 Chapman University Chancellor’s Research Fund
Grant awarded to Lisa Sparks. The authors acknowledge the valuable contributions of Nicole
Andrews, Maggie Hui, Ashley Jupin, and Kathryn Rogers to this project. An earlier version
of this article was presented at the 2011 annual meeting of the Western States Communication
Association, where it was named a Top Four Paper in the Health Communication Interest
Group.
Address correspondence to Jennifer L. Bevan, One University Drive, Chapman University,
Orange, CA 92866, USA. E-mail: bevan@chapman.edu
747
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748
J. L. Bevan et al.
As family residential distance increases (e.g., Zechner, 2008), stress is often placed
on individuals who provide distant care to an aging adult. Caregiving is a potential
public health issue that will challenge society with caregivers who themselves suffer
from various medical conditions (Talley & Crews, 2007). Further, long-distance
caregiving (LDC) is a significant enough health issue that The American College of
Physicians recently recommended that doctors “recognize that geographically distant
caregivers may face unique challenges” in their ethical guidelines for caregivers
(Mitnick, Leffler, & Hood, 2010, p. 257). As such, LDC communication is identified
as a health care topic that should be more thoroughly investigated to better understand
the repercussions it has on care providers, care recipients, and the overall health care
system (Bevan & Sparks, 2011).
Of particular interest here is examining how specific LDC communication barriers
between care recipients and caregivers are related to negative health perceptions.
A significant communication barrier that is ubiquitous across close relationships
is interpersonal conflict (Canary, Cupach, & Messman, 1995). Interpersonal
conflict occurs in caregiving (e.g., Pecchioni & Nussbaum, 2001) and long-distance
relationships (e.g., Stafford, 2010). Professional geriatric care managers, who can
assist long-distance caregivers, note that family conflict is their greatest occupational
challenge (Kelsey & Laditka, 2009). Accordingly, our study extends and combines the
research consensus that interpersonal conflict (e.g., Graham, Christian, & KiecoltGlaser, 2006) and caregiving (e.g., Miller et al., 2008) are related to compromised
health by examining the associations between negative distant caregiver health
perceptions and LDC conflict frequency and strategy usage.
Long-Distance Caregiving
Caregiving involves providing help for another, the time spent assisting, and the
amount of tasks performed for the betterment of an individual in need (Ellis, Miller,
& Given, 1989). There is no defined time limit for caregiving, which is typically
unpaid (Ellis et al., 1989). Caregiving further involves daily activities that directly
and indirectly benefit the care recipient. Direct activities of daily living (e.g., Katz,
Ford, Moskowiz, Jackson, & Jaffe, 1963), include providing medication, and help
with bathing, dressing, and feeding. Indirect instrumental activities of daily living
(e.g., Lawton & Brody, 1969) involve cleaning, laundry, food preparation, errands,
financial management, and arranging or supervising outside services. Distant
caregivers typically participate in more instrumental activities of daily living than do
proximal caregivers (Koerin & Harrigan, 2002).
Although distance presents an additional caregiving burden (e.g., Kelsey
& Laditka, 2009; Mitnick et al., 2010), how much distance constitutes an LDC
relationship is variable and subjective (Finch & Mason, 1993). Further, Stafford
(2005) defined a long-distance relationship as one in which communication is
restricted by geographic barriers. Therefore, LDC involves the elements of Ellis and
colleagues’ (1989) definition enacted by individuals who perceive themselves as being
geographically distant (Bevan & Sparks, 2011).
Individuals providing LDC typically encounter different issues that may cause
increased stress compared with those at a more proximal, convenient distance. For
example, time off work, proximal family responsibilities, and distance traveled to
provide care can result in emotional stress, fatigue, and financial difficulty (Ilardo &
Rothman, 1999), each of which can initiate LDC conflict. In addition, many distant
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Conflict and Health Perceptions in Long-Distance Caregiving
749
caregivers feel as if they are not doing enough and that they were not initially given
“license to leave” by their families (Baldock, 2000, p. 209), which may produce guilt,
regret, and frustration that could give rise to conflict. Baldock (2000) also suggested
that conflict could occur if distant caregivers’ request that their care recipients move
closer is resisted. As such, the LDC situation could be prone to conflict.
Perhaps more notable is that caregiving itself (regardless of whether conflict
is present) is correlated with negative caregiver health. For example, 17% of U.S.
caregivers report fair or poor health, compared with 13% of the general adult
population (National Alliance for Caregiving/American Association for Retired
Persons, 2009). Further, caregivers experience more depression and stress as well
as poorer subjective and objective physical health than do noncaregivers (Pinquart
& Sorensen, 2003b). Pinquart and Sorensen (2003a, 2007) also determined that
poorer caregiver health was correlated with greater levels of care recipient behavioral
problems, caregiver psychological distress, more caregiving hours a week, and longer
caregiving duration. A next important research step, then, is to ascertain what specific
communicative caregiving aspects are linked to these health assessments to ultimately
improve caregiver health. We now turn to two LDC conflict elements that may be
linked to negative distance caregiver health perceptions: frequency and strategy usage.
Interpersonal Conflict Elements
Interpersonal conflict involves relational partners’ pursuit of incompatible goals
(Canary & Spitzberg, 2006). Distance adds to conflict’s inherent incompatibility.
Stafford (2010) recently noted that those in long-distance romantic relationships may
compensate for fewer opportunities for physical intimacy by engaging in less conflict.
Although rising life expectancy means that intergenerational communication
in adulthood (which frequently characterizes LDC) will be increasingly important,
researchers have not sufficiently examined conflict in this domain (Bengtson, 2001).
Further, intergenerational barriers such as stereotyping, memory, and language
issues often present multiple communication problems for older adults, which
can create conflict and hinder effective health care (Sparks & Nussbaum, 2008).
In addition, Sahlstein (2006) noted that there is minimal information regarding
long-distance conflict management, even though conflict is linked to relational
satisfaction and stability. Each of Sahlstein’s (2006) negative qualities in longdistance family relationships could spark LDC conflict, including the following: (a)
relational maintenance difficulties (e.g., expense or inconvenience); (b) tension and
stress; (c) minimal interaction quantity/frequency; (d) difficulty maintaining current
information; (e) difficulty reassuring, comforting, and supporting one other; and (6)
difficulty managing individual and family challenges.
Conflict Frequency
Although interpersonal conflict research tends to focus on communicative styles or
strategies, conflict frequency is also integral to relational quality. Specifically, conflict
frequency contributes to marital disruption above and beyond the effects of conflict
style or resolution (McGonagle, Kessler, & Gotlib, 1993). Further, as older wives’
marital quality (which included a measure of conflict frequency) decreased over a
2-year period, their depressive symptoms increased (Kim & Moen, 2002). These
findings suggest that LDC conflict frequency may be similarly linked to distant
caregiver negative health perceptions.
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J. L. Bevan et al.
In the caregiving context, conflict is a frequent event (Usita, Davis, & Hall, 2006).
Specifically, sibling conflict about care provision for an elderly parent, which was
frequent, ongoing, and sometimes involved the parent (Merrill, 1996), could hamper
collaboration (Fowler & Fisher, 2009). In addition, the presence of caregiver–care
recipient conflict was strongly related to caregiver strain and negative affect (Sheehan
& Nuttall, 1988).
Frequency of distant caregiver–care recipient conflict could be linked with
distant caregivers’ negative health perceptions, which involve a general sense of
physical well-being (Pinquart, 2001). For example, Koerner, Shirai, and Kenyon
(2010) determined that the more frequent family conflict about care provision, the
greater caregivers’ experience of physical health symptoms. Further, lower family
relationship quality (which included conflict) was linked to increased caregiver health
difficulties (Francis, Worthington, Kypriotakis, & Rose, 2010). Family conflict
regarding care was also positively related to caregiver mental impairment and strain
(Sharlach, Li, & Dalvi, 2006). Last, that caregivers had greater depression and
anxiety than noncaregivers was explained by greater conflict frequency (Butterworth,
Pymont, Rodgers, Windsor, & Anstey, 2010). We thus offer the first hypothesis for
the LDC context:
The more frequently distant caregivers engage in conflict with their care
recipients, the greater the distant caregivers’ negative health perceptions.
Conflict Strategies
Putnam and Wilson’s (1982) distributive, avoidance, and integrative conflict
strategies have each been observed in caregiving conflicts (Pecchioni & Nussbaum,
2001). Distributive communication involves being intimidating and adamant about
getting one’s own way. Avoidance involves evading the conflict or downplaying
differences between the two parties. The integrative strategy focuses on collaborating
or compromising in order to arrive at a satisfying resolution and was later dissected
into distinct compromise and collaborative conflict strategies (Wilson & Waltman,
1988).
Preliminary research suggests that avoidance may be a recurrent, frequent
method for managing conflict about caregiving (e.g., Kam, 2008). Caregivers may
not want to challenge care recipients and so avoid conflict to preserve established
familial roles (Plowfield, Raymond, & Blevins, 2000). As for negative health
perceptions, avoidance has been associated with caregiver distress (Knussen et al.,
2008), increased anxiety (Claar et al., 2005; Dew, Myaskovsky, DiMartini, Switzer,
Schulberg, & Kormos, 2004), and greater depression (Stephens, Norris, Kinney,
Ritchie, & Grotz, 1988). Further, Kiecolt-Glaser and colleagues (1996) found
that wives’ stress-response hormones increased when their husbands withdrew
from conflict and Stafford (2010) recently determined that long-distance romantic
relationships used conflict avoidance more than geographically close partners.
Family caregivers also responded to other family members’ conflict avoidance with
anger and depression (Davis, 1997).
Hostile, negative spousal conflict behaviors (which are similar to the distributive
strategy) are consistently related to increased immune function dysregulation, changes
in stress hormones, and cardiovascular activity (e.g., Robles & Kiecolt-Glaser, 2003;
Whitson & El-Sheikh, 2003). Further, Graham, Robles, and colleagues (2006) found
Conflict and Health Perceptions in Long-Distance Caregiving
751
that caregiver hostility was related to increased C-reactive protein levels (as an indicator
of systemic inflammation), pain, and depression. Distant caregivers in conflict may be
particularly prone to negative health perceptions. At least five positive acts are needed
to counteract a single negative behavior (Gottman, 1994), and distance and fewer
opportunities and channels for interaction may make achieving this ratio difficult
for distant caregivers. Taken together, these research findings suggest that distant
caregivers’ use of distributive communication and avoidance in conflict with their
care recipients will be positively associated with their negative health perceptions.
Hypothesis 2 thus states the following:
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The more distance caregivers use the (a) distributive and (b) avoidance
conflict strategy with their care recipients, the greater the distant caregivers’
negative health perceptions.
Constructive (i.e., integrative) conflict strategies are used more by aging mothers
and their adult daughters than destructive and avoidant strategies (Fingerman,
1995). Further, solution-oriented conflict strategies were most frequently observed
between mothers and daughters when discussing future care provision (Pecchioni &
Nussbaum, 2001) and by caregivers in conflict (Usita et al., 2006). It is unsurprising
that caregivers’ ability to use solution-oriented conflict strategies could enhance
care quality (Shaffer, Dooley, & Williamson, 2007). Caregivers who adopt solutionoriented communication styles may also experience more positive caregiving outcomes
and be less likely to abuse the care recipient (Plowfield et al., 2000).
Findings regarding the integrative strategy’s relationship to health are mixed.
Although Kiecolt-Glaser and colleagues (1996) observed a positive relation between
positive conflict behaviors and lower stress-response hormone levels for wives but not
husbands, another study (Kiecolt-Glaser et al., 1993) found no significant relationship
between usage of problem-solving and positive conflict strategies and spouses’ blood
pressure and immunological changes. Further, physiological correlates of positive
marital interactions are in need of more empirical attention (Robles & Kiecolt-Glaser,
2003). As such, we explored whether integrative LDC conflict strategy usage is linked
to distant caregiver negative health perceptions by asking the following research
question:
Are (a) collaborative and (b) compromise conflict strategies used by
distance caregivers with their care recipients related to distant caregiver
health perceptions?
Method
Participants and General Procedures
This study was conducted at a small, private university in the Western United States
using an online survey on SurveyMonkey.com, a secure web-based survey portal. The
criteria for inclusion as a distant caregiver included the following: (a) caring for a
person who is 55 years or older, (b) being at least 18 years old, and (c) perceiving a
geographical barrier when traveling to provide care (consistent with Sahlstein [2004,
2006] and Finch & Mason [1993]). Three participants reporting minimal distance and
easy accessibility to their care recipients and two respondents whose care recipients
were younger than 55 were removed (final n = 137).
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J. L. Bevan et al.
Respondents were mostly female (n = 95, male n = 10) and White/Caucasian
(n = 94, African American n = 4, Hispanic n = 3, Asian n = 1, Native American n = 1)
and averaged 49.4 years (SD = 10.58, range = 26–70).1 Their care recipients were
also primarily female (n = 65, male n = 35) and averaged 79.2 years (SD = 10.56,
range = 55–98). Participant household income ranged from $11,000–$20,000 (n = 5),
$21,000–$30,000 (n = 4), $31,000–$50,000 (n = 14), $51,000–$75,000 (n = 13), $76,000–
$100,000 (n = 20), $101,000–$150,000 (n = 23), and more than $150,000 (n = 16). Most
participants’ highest degree was a bachelor’s (n = 40) or master’s (n = 34, high school/
GED n = 6, associate’s n = 8, PhD/EdD n = 15, MD n = 3). Participants were mostly
American (n = 100), but also were English (n = 1), Canadian (n = 1), Romanian (n = 1),
and Belgian (n = 1).
The average distance between caregiver and care recipient was 811 miles
(SD = 1,234.80, range = 8–10,000). Participants provided distant care for 54 months
average (SD = 46.39, range = 3–240 months), and most served as distant caregivers
when they completed the survey (n = 104, no longer providing distance care n = 29,
don’t know n = 2). Distant caregiving involvement included being the only (n = 9)
or main caregiver (n = 32), equally sharing care with another (n = 35), or assisting
a main caregiver (n = 59). Distant caregivers engaged in activities of daily living
such as giving medicines/injections (23%), getting the care recipient in and out of
chairs/beds (22%) and to and from the toilet (15%), dressing (19%), feeding (12%)
and bathing (20%) the care recipient, and with diapers or continence (14%), and
in instrumental activities of daily living such as transportation (49%), managing
finances (63%), housework (43%), grocery shopping (47%), meal preparation
(35%), and service arrangement and supervision (70%; Katz et al., 1963; Lawton
& Brody, 1969).
Participants cared for a biological parent (n = 100), grandparent (n = 7), parentin-law (n = 7), aunt (n = 5), other relative (n = 4), nonrelative/friend (n = 4), or multiple
care recipients (n = 7) and typically provided 1–3 hours of care per week (n = 52, less
than 1 hour n = 28, between 4 and 8 hours n = 34, 9 or more hours n = 22). Participants
contacted their care recipients multiple times daily (n = 21), once daily (n = 23), a few
times weekly (n = 48), once weekly (n = 24), a few times monthly (n = 9), monthly (n = 4),
once every few months (n = 3), or once yearly or less (n = 3) and visited their care
recipients either once daily (n = 5), a few times weekly (n = 13), weekly (n = 10), a few
times monthly (n = 13), monthly (n = 29), once every few months (n = 49), or once yearly
or less (n = 17).
Participants were recruited through online via short e-mails or announcements
and the survey link. Study information was also placed on Facebook, LinkedIn, and
Twitter. Relevant public Internet message boards (e.g., American Association for
Retired Persons Online Community Caregiving Group, Caring from a Distance Group
Discussion and Message Board), listservs (e.g., National Alliance for Caregiving,
National Center on Caregiving), and websites (e.g., www.SilverPlanet.com) were
also used to recruit. Permission to post was obtained for all sites requiring moderator
approval. The data were anonymous. Participants could provide an optional e-mail
address to receive a $10 gift card as compensation.
Totals do not add up to 100% because some respondents did not complete the demographic items, which were located at the end of the survey.
1
Conflict and Health Perceptions in Long-Distance Caregiving
753
Measures
Conflict Frequency
One item, reported on a 7-point scale ranging from 1 (none at all) to 7 (a great deal),
assessed distant caregiver–care recipient conflict frequency (“What is the extent to
which you have conflict with the care recipient over caregiving?”; M = 2.96, SD = 1.64).
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Conflict Strategies
Putnam and Wilson’s (1982) Communicative Strategies in Organizational Conflicts
Scale measured distant caregiver strategies in disagreements with their care recipients
about their care and health on a 7-point scale ranging from 1 (none at all) to 7 (a great
deal). Five items each evaluated collaboration (e.g., “I suggest we work together to
create solutions to disagreements”; M = 4.71, SD = 1.04, α = .80) and compromise (e.g.,
“I will go 50–50 to reach a settlement with the care recipient”; M = 4.20, SD = 1.05,
α = .82). We assessed avoidance with 12 items (e.g., “I shy away from topics that
are sources of disputes”; M = 3.44, SD = 1.09, α = .89). We measured distributive
communication using seven items (e.g., “I assert my opinion forcefully”; M = 3.17,
SD = 1.12, α = .84).
Negative Health Perceptions
Cohen and Hoberman’s (1983) 36-item semantic differential Physical Symptoms
Checklist measured distant caregiver negative health perceptions on a 5-point scale
ranging from 0 (not at all bothered) to 4 (extremely bothered) regarding, for example,
muscle tension or soreness, headache, sleep problems, cold or cough (M = 1.97,
SD = .97, a = .98).
Results
Preliminary Analyses
As communication between long-distance relational partners may be influenced
by distance in miles and visit and contact frequency of visits (Merolla, 2010), these
variables were correlated with the conflict and health variables. No correlations were
significant at p < .05. Because age, hours providing care, income, and education are
related to caregiver health (Pinquart & Sorensen, 2007), these variables were correlated
to negative health perception.2 As the relation between distant caregiver age and
negative health perceptions was significant (r = –.26, p < .05), age was controlled for
in the main analyses.
Primary Analyses
We examined the research question and hypotheses using hierarchical regression
analyses, with distant caregiver age entered in the first block, the conflict variable in
the second block, and negative health perceptions as the dependent variable.
2
Although female caregivers tend to experience more negative health than do male caregivers, the small number of male distant caregivers who participated in this study (n = 10) meant
that we could not confidently test gender as an additional covariate.
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J. L. Bevan et al.
The regression model for Hypothesis 1 was significant, F = 7.44, p < .01, adjusted
R2 = .12. Conflict frequency was a significant, positive predictor of distant caregiver
negative health perceptions, β = .25, t = 2.64, p < .01, and age was a significant, negative
covariate, β = –.24, t = –2.47, p < .05. Thus, Hypothesis 1 was supported.
The regression model of Hypothesis 2a was significant (F = 7.18, p < .01, adjusted
R2 = .13) and distributive communication was a significant, positive predictor of
distant caregiver negative health perceptions (β = .25, t = 2.61, p < .01). The regression
model of Hypothesis 2b was also significant (F = 10.11, p < .001, adjusted R2 = .16),
and avoidance was a significant, positive predictor of negative health perceptions
(β = .33, t = 3.50, p < .001). Age was a significant, negative predictor for both models:
distributive (β = –.21, t = –2.16, p < .05) and avoidance (β = –.25, t = –2.63, p < .05).
Thus, Hypothesis 2 was supported.
For the research question, although the collaboration (F = 3.72, p < .05, adjusted
R2 = .05) and compromise (F = 3.83, p < .05, adjusted R2 = .06) regression models were
significant, neither collaboration (β = –.06, t = –.62, p = .54) nor compromise (β = .08,
t = .76, p = .45) significantly predicted negative health perceptions. Age was a significant
predictor in the collaboration (β = –.25, t = –2.50, p < .05) and compromise (β = –.26,
t = –2.67, p < .01) models. Neither collaboration nor compromise is related to distant
caregiver negative health perceptions.
Correlations between study variables are shown in Table 1.
Discussion
Understanding how health is related to conflict in informal illness management
can contribute to a productive and positive environment for care recipients and
caregivers. Thus, we investigated conflict frequency and strategy usage in relation to
negative health perceptions in LDC. As predicted, conflict frequency (Hypothesis 1)
and usage of distributive and avoidant (Hypothesis 2) conflict strategies positively
predicted distant caregivers’ negative health perceptions. However, collaboration and
compromise (research question) were not associated with negative health perceptions
in LDC. These findings and their implications are discussed below.
Conflict Frequency
Consistent with Hypothesis 1, frequency of care provision conflict between distant
caregiver and care recipient positively predicted negative distant caregiver health,
which aligns with recent findings that link family conflict and caregiver health (e.g.,
Table 1. Correlations between study variables
Variable
1
2
1. Conflict frequency
2. Collaboration
3. Compromise
4. Distributive
5. Avoidance
6. Negative health perceptions
—
.00
—
**Significant at p < .01; ***significant at p < .001.
3
–.10
.55***
—
4
.34***
.04
.06
—
5
6
.36***
.02
.32***
.05
—
.29**
–.10
.08
.30***
.34***
—
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Conflict and Health Perceptions in Long-Distance Caregiving
755
Francis et al., 2010). Our study further expands these findings to include conflict
with the care recipients themselves, who are clearly crucial actors in the caregiving
situation. In addition, the moderate amount of LDC conflict (2.96 on a 7-point scale)
that we observed is generally consistent with caregiving conflict frequency research
(e.g., Usita et al., 2006) and suggests that distance may not be inhibiting how much
conflict occurs in LDC.
Further, conflict frequency was significantly, positively related to distributive
communication and avoidance, but unrelated to compromise or collaboration.
Adding distance to this negative conflict pattern could exacerbate the likely
deleterious effects, as there may be fewer opportunities to engage in the positive
interactions that will counteract negative behaviors (e.g., Gottman, 1994). Overall,
our preliminary findings tentatively extend conflict frequency’s association with
relational quality (McGonagle et al., 1993) to individual health perceptions in LDC.
One logical future question arising from the findings of Hypothesis 1 and from
Butterworth and colleagues’ (2010) research is the extent to which conflict explains
why distant caregivers have greater negative health perceptions than noncaregivers
and proximal caregivers.
Conflict Strategy Usage
Distributive Communication
Reviews of conflict and health studies (e.g., Graham, Christian, et al., 2006) conclude
that negative communication elicits pronounced physiological arousal. Further,
Robles and Kiecolt-Glaser (2003) implicated marital strain (including negative
conflict interactions) as a psychosocial risk factor that can negatively affect one’s
health as much as smoking or physical inactivity. Support for Hypothesis 2a, which
found that distant caregiver distributive conflict strategy usage was positively related
to negative health perceptions, thus adds to the considerable research examining these
two variables. More important, because caregivers were found to have marginally
more hostility than noncaregivers (Graham, Robles, et al., 2006), this preliminary set
of findings is particularly relevant to caregiving scholars. Health care professionals
should advise caregivers to minimize distributive conflict with their care recipients.
This recommendation may be especially important in LDC, where fewer chances for
interaction may mean that using distributive conflict strategies will potentially be
more pronounced and deleterious to caregivers’ health.
Avoidance
Hypothesis 3 revealed a significant, positive relationship between conflict avoidance
and increased distant caregiver negative health perceptions. This finding is consistent
with Davis (1997), who determined that conflict avoidance was related to caregiver
anger and depression, and with the body of research linking caregivers’ use of the
avoidance coping strategy with individual well-being (e.g., Knussen et al., 2008).
Stafford (2010) noted that conflict avoidance may be less illicit for long-distance
romantic relationships than for those in proximal relationships, and instead could
be relationally comforting and optimistic. As such, distant caregivers may avoid
conflict to protect their relationships (e.g., Roloff & Wright, 2009), but doing so may
exacerbate their negative individual health perceptions. Using this reasoning, LDC
conflict avoidance could possess benefits and drawbacks.
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J. L. Bevan et al.
Distant caregiving may provide an optimal backdrop for a link between conflict
avoidance and negative health perceptions. Although avoidance may seem to be an
appealing short-term option in circumstances where distant caregivers do visit or
contact their care recipient as often as they could if they were geographically close,
it can become damaging over time (e.g., Stephens et al., 1988). As with research that
recommends assisting caregivers in more adaptive coping (e.g., Claar et al., 2005;
Knussen et al., 2008), we suggest that distant caregivers be advised of the potential
peril to individual well-being that can accompany conflict avoidance.
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Integrative Communication
The integrative conflict strategies, collaboration and compromise, were unrelated
to distant caregiver negative health perceptions (research question). Perhaps distant
caregivers select integrative conflict strategies as a way to preserve their relationships
with care recipients. Integrative communication is typically best for a satisfying
relationship (e.g., Pecchioni & Nussbaum, 2001) and caregivers in conflict with their
aging parents chose constructive communication to prevent relational harm (Usita
et al., 2006). Stafford (2010) noted that long-distance romantic relationships may
compensate for distance by being more positive in their interactions, which then
creates positive relational affect and fulfills critical relational needs. The distance itself
may thus be an additional relationship-centered (rather than individual-centered)
consideration when distant caregivers select collaboration or compromise in conflict.
Despite their lack of significant association with negative health perceptions,
the moderate-to-high usage of these two conflict strategies that we observed is
still promising, as solution-oriented strategies can improve caregiving quality and
outcomes (Plowfield et al., 2000; Shaffer et al., 2007). However, the minimal attention
(e.g., Robles & Kiecolt-Glaser, 2003) and inconsistent research findings (e.g., KiecoltGlaser, 1996) regarding positive communication and health mean that further
scholarly investigation is warranted.
Overall, an interesting aspect of our findings that may be unique to LDC emerged.
Our sample of distant caregivers diverges from the typical caregiver (according to the
National Alliance for Caregiving/American Association for Retired Persons, 2009),
in that they spend less time providing care, visit the care recipient less, and are less
likely to assist with activities of daily living or be the primary caregiver. Further,
the National Alliance for Caregiving/American Association for Retired Persons’s
participants reported poorer health if their caregiving was high burden, they lived
with their care recipients, and they provided more than 20 hours of care per week.
In contrast, although our participants typically shouldered relatively less caregiving
burden and responsibility, they also reported moderate conflict frequency, usage of
distributive and avoidant conflict strategies, and negative health perceptions (i.e., 1.97
on a 5-point scale). As such, even caregiving that involves comparatively less time,
burden, and responsibility appears to be characterized by destructive communication
and compromised health. The extent to which this is evident in LDC should be
considered in future research.
Practical Applications
Our preliminary findings suggest a number of practical suggestions for improving
LDC conflict. We propose that formal health services not only recognize that conflict
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Conflict and Health Perceptions in Long-Distance Caregiving
757
exists in family caregiving (per Sheehan & Nuttall’s [1988] recommendation), but
also understand that this conflict is communicatively handled in different ways
that may or may not be related to caregivers’ perceptions of their health. Further,
the growth of distant caregiving makes the formal acknowledgment of and
assistance with conflict management even more pressing, as the limited interaction
opportunities in LDC may be spent in conflict about caregiving rather than on
care provision. As successful past caregiver interventions have been conducted via
telephone (e.g., Grant, Elliott, Weaver, Bartolucci, & Giger, 2002), distance should
not be a significant obstacle in the design and implementation of conflict-based
caregiver interventions.
Rivera, Elliott, Berry, Grant, and Oswald (2008) concluded that the absence of
negative problem solving was more important than the presence of positive problem
solving in predicting depression risk for caregivers. This same logic can certainly
extend to the four conflict strategies examined here and their associations with distant
caregiver negative health perceptions. Our second practical suggestion, then, is that
rather than encouraging the use of positive conflict strategies in LDC, health care
professionals may instead consider focusing on curbing usage of distributive and
avoidant conflict strategies to better safeguard the LDC relationship.
Last, communication competence has been offered as a potential solution for
allaying caregiving conflict (Kam, 2008; Lobchuk, 2006) and this suggestion can
extend to LDC as well. Competence is a major component of interpersonal conflict
research (e.g., Canary, Cupach, & Serpe, 2001; Canary & Spitzberg, 2006), and the
balancing of effectiveness and appropriateness is a concept that distant caregivers can
likely understand and easily implement in their interactions with their care recipients.
In addition, future research could consider the extent to which communication
competence in interactions between distant caregivers and care recipients could buffer
against distant caregiver negative health perceptions.
Limitations and Conclusions
Although our study produces some interesting insights, it also possesses limitations.
First, our few male distant caregiver participants prevented gender comparisons,
which are particularly important because female caregivers report greater depression
and poorer subjective and physical health than do male caregivers (Pinquart &
Sorensen, 2003). In addition, it is possible that our participants may represent a
segment of the population that is comfortable with disclosing information regarding
the occurrence of conflict and use of conflict strategies. Differences that exist between
those who comfortably disclose personal information and those who do not were not
accounted for in this study. Last, this study examined retrospective recall data, which
was necessary to the extent that distance would likely preclude bringing caregivers
and their care recipients together to participate. A longitudinal, dyadic examination
of actual conflicts that occur between care recipients and their distant caregivers (as
well as other caregivers, if they are present) would be a useful area of future research.
In conclusion, this study provides introductory steps toward understanding
the relationships between conflict frequency and strategy usage and corresponding
negative health perceptions in the long-distance caregiving context. Our findings
suggest that conflict between distant caregiver and care recipient is not only present
but is associated with distant caregivers’ negative perceptions of their health. As such,
the care recipient and the distant caregiver could experience compromised health
758
J. L. Bevan et al.
when engaging in conflict with one another about caregiving. Bevan and Sparks
(2011) underscore the value of focusing on LDC communication and our conflict
findings offer initial understanding of this important, and growing, long-distance
health relational context.
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