Discussion
This study addressed the issues of caregiver strain, QoL, and symptom distress among dyads of African American cancer survivors and their primary caregivers. Theoretically, it is believed that although there are interactions between the survivors' symptom distress and the amount of caregiver strain, the issue of QoL provides an additional level of interaction that influences both these issues. Adding to the complexity of these interactions is the fact that cultural, economic, environmental factors and attitudes and beliefs play a role in the cancer experience among African Americans. Although total scores of instruments that measure caregiver strain are important, it is equally important to understand the areas that are the most burdensome to the caregiver. Furthermore, it may be more likely that caregiver strain is not an "all or none" phenomenon and may actually exist on a continuum. Therefore, this study looked at caregiver burden from the perspective of having high versus low strain. More than half of these caregivers reported feeling completely overwhelmed. This finding is consistent with those reported by Houldin, who taped face-to-face interviews of survivor-caregiver African American dyads. Participants reported significant personal, relational, and work changes; difficulty maintaining a positive attitude; and difficulty coping and struggled to find a balance in their lives.
The current study also evaluated the relationship between the caregivers' strain and their QoL. Overall, caregivers in this sample had lower QoL scores on several of the subscales (physical functioning, role-physical, general health, social functioning, role-emotional, mental health, and physical and mental component summary score) when compared with the general population without cancer. Caregivers with higher levels of strain reported more bodily pain, poorer social functioning, and poorer role functioning. These facts allow for speculation that the tasks of giving care could easily affect whether the caregiver was able to complete his/her other roles and could also affect his/her ability to participate in his/her usual social activities. The relationship between caregiver strain and bodily pain is even more complex. Pain reported by caregivers could be related to their individual health but could also be related to the amount and level of tasks required to give care.
Perhaps not surprisingly, the survivors had lower QoL scores compared with the caregivers. There were moderately strong relationships between survivors' QoL (role function, bodily pain, general health, social functioning, normalized physical component score) and the level of caregiver strain. These findings suggest that caregivers experience greater strain when caring for survivors with poorer QoL. Findings also showed that caregiver strain was the predictor of caregivers' QoL instead of demographic factors (gender, education, income, marital status) when placed in a regression model. Previous research suggests that African American caregivers may be less likely to utilize support services. This lack of use may be related to financial constraints or lack of knowledge of the availability and eligibility for these types of services.