This study set out to examine the relationships between HRQL, caregiver role, reciprocity, balance and relationship satisfaction in a sample of caregivers whose partner had experienced a stroke. Furthermore, using equity theory and reciprocity as a basis, we made several predictions regarding the relationships and likely outcomes.
Not surprisingly, following the family member's stroke there was a change in the balance of give and take in the relationship, with almost a third of caregivers' reporting that they were currently doing more for their partner than their partner was doing for them. This contrasts sharply with balance in the relationship prior to their partner's stroke, where the majority perceived the relationship as equitable or were actually overbenefiting from the relationship. From the perspective of equity theory balance is important in maintaining satisfaction in the relationship [25, 44]. We found partial support for this as relationship satisfaction was associated with previous balance prior to the care recipients' stroke but not current balance in the relationship. This suggests that balance may be important generally in relationships but may become less important in terms of relationship satisfaction when one member is in need, for instance following illness such as a stroke. Indeed, perceptions of inequity may be less salient in high quality relationships as both members of the dyad are motivated to maintain a mutually supporting relationship .
However, with respect to the caregiver role, current balance was important, supporting our hypothesis that caregivers who are currently underbenefiting in the relationship have higher levels in the caregiver negative domain than those who are equitable or overbenefiting from the relationship. Similar findings have been reported in caregivers whose partners have cancer or multiple sclerosis .
In our study we found that there was a high degree of perceived reciprocity, with exchanges between members of the dyad rather than in one direction from caregiver to care recipient. Reciprocity was not only important in terms of relationship satisfaction but also in terms of the caregiver identifying positive aspects of their role. This finding supports previous studies where exchanges of an interpersonal nature have been found to still occur and be important for caregiver well-being [14, 18, 27, 29]. One explanation for the associations is that strong relationships, characterized by mutuality and satisfaction may be derived from being able to help one another in times of need. Certainly, being able to maintain care recipients' dignity and self-esteem can be a source of satisfaction . Another possible explanation is that those who are satisfied in their relationship are likely to be more invested in the relationship and this may enhance their perception of competence in the role as caregiver . The findings add support to a smaller number of studies that have examined the caregiver-care recipient relationship following stroke [21, 22]. They highlight the importance of health professionals including assessments of the context of care in terms of the relationship dynamics and how the caregiver is coping with this role. Also, the findings point to potential interventions aimed at encouraging reciprocal exchanges and helping caregivers find meaning in their role. Approaches to restoring the perception of equity, include encouraging reciprocal exchanges between care recipient and caregiver. Care recipients with stroke-related limitations that are limited in their ability to provide material tangible support, could be encouraged to offer reciprocal exchanges of a more emotional nature, such as affection and caring toward their caregiver. Indeed, there is some evidence to support counselling interventions directed at restoring the perception of equity and fostering reciprocity in couples facing cancer .
In our study, we found less support for our prediction that a lack of reciprocity would be inversely related to negative aspects of the caregiver role. Only balance in family caregiving was inversely related. A possible explanation for these contrasting findings, consistent with Gouldner's (1960) premise is that needs rather than reciprocity may prevail under certain conditions . Under circumstances where the care recipient is ill and less able to reciprocate, caregivers may focus on care recipients' needs as they may come to dominate with little expectation of reciprocation. However, when there is reciprocation, these exchanges may positively affirm the caregivers' contributions and bolster self-esteem.
Caregivers' perceptions of caregiving in our study were comparable to other studies with caregivers of stroke survivors [36, 37]. Like Teel, comparing the CRA scores with those of caregivers of a family member with cancer , indicates that caregiving for people with stroke is perceived as more negative, with higher scores on the negative subscales and lower scores on the positive subscale. Our findings also add to the literature in demonstrating that caregiving can be a positive experience for some [4, 5, 9–12] and that both rewards and burdens can co-exist . Research directed toward an understanding of relationship factors that influence positive and negative role perceptions and caregiver outcomes are particularly important for designing interventions to promote the well-being of both members of the dyad. Possible avenues for further investigation include attachment between caregiver and care recipient and how these bonds influence motivations for responding to the needs of another during times of illness .
Comparing caregivers' HRQL to population norms, our sample had lower levels in all domains. These findings parallels others in showing that caregiving can negatively impact on quality of life [1–3]. The multiple regression analysis indicated that older care recipients and caregivers who are themselves older, who are caring for a partner with more impaired functioning and who perceive the caregiver role as having a greater negative impact have lower HRQL physical component summary scores. Similarly, caring for a partner with more impaired functioning and finding caregiving burdensome was associated with the HRQL mental component summary score. Therefore, health professionals caring for individuals following a stroke should be mindful of those caregivers likely to be most affected and implement strategies to support them in their role.
The study has several limitations. First the low response rate meant that the sample size was small, consisting of mainly female caregivers recruited through one stroke rehabilitation clinic setting. Therefore, the generalisability to male caregivers, and those from other settings cannot be determined. Furthermore, the extent to which the sample is biased cannot be determined, as no information was collected on non-responders. A larger more diverse sample would permit more sophisticated multivariate analyses including an analysis of gender and cultural variations. Second, our inclusion criteria meant that caregivers were providing care to stroke survivors whose cognitive ability was not significantly impaired. The experiences of caregivers of individuals with more significant stroke-related cognitive and communication impairment may be very different from the present sample. Third, the cross-sectional correlational design meant that we could not determine the directionality or determine causality between the variables. Future research would benefit from examining the caregiving relationship over time as caregiver-care recipients' transition to the changes brought about by the stroke.