The Gerontologist (in press) Validating the Revised Scale for Caregiving Self-Efficacy: A Cross-National Review Ann M. Steffen, Ph.D., University of Missouri-St. Louis, USA Dolores Gallagher-Thompson, Ph.D., Stanford University School of Medicine, USA. Katherine Arenella, MA, University of Missouri-St. Louis, USA Alma Au, Ph.D., The Hong Kong Polytechnic University, People’s Republic of China Sheung-Tak Cheng, Ph.D., The Education University of Hong Kong, People’s Republic of China María Crespo, Ph.D., Universidad Complutense de Madrid, Madrid, España Victoria Cristancho-Lacroix, Ph.D., Assistance Publique des Hôpitaux de Paris, Pôle de Gériatrie, Paris, France - Research Unit EA 4468, University Paris Descartes, Paris, France Javier López, Ph.D., Universidad San Pablo-CEU,Madrid, España Andrés Losada Baltar, Ph.D., Universidad Rey Juan Carlos, Madrid, España María Márquez-González, Ph.D., Universidad Autónoma de Madrid, Campus de Cantoblanco, España Celia Nogales-González, Ph.D., Universidad Rey Juan Carlos, Madrid, España Rosa Romero-Moreno, Ph.D., Universidad Rey Juan Carlos, Madrid, España Contact: Ann M. Steffen, Ph.D., Department of Psychological Sciences University of Missouri-St. Louis, USA ann_steffen@umsl.edu 1.314.516.5382 Abstract Background and Objectives: This paper reviews an instrument used in cross-national research with dementia family caregivers - the Revised Scale for Caregiving Self-Efficacy (RSCSE; Steffen, McKibbin, Zeiss, Gallagher-Thompson & Bandura, 2002). Although the RSCSE has been translated into multiple languages, few studies have examined scale performance across samples. We examine congruence of psychometric, reliability and validity data to inform research and practice. Methods: We conducted citation searches using Scopus, Google Scholar, Web of Science and PsycINFO. Identified dementia caregiving studies cited the original RSCSE paper and described results of English and/or non-English translations of the scale. Results: Peer-reviewed published studies (N = 58) of dementia family caregivers included data for Arabic, Chinese, English, French, Italian and Spanish translations of the RSCSE; the majority (72%) reported use of non-English translations. Studies utilizing Confirmatory Factor Analytic (CFA) approaches reported findings consistent with the original development study. Internal consistency, convergent/discriminant validity and criterion validity indices were congruent across diverse cross-national caregiving samples assessed with different translations. Data supported the RSCSE’s sensitivity to change following specific psychosocial caregiving interventions. Discussion: The reliability and validity of different translations of the Revised Scale for Caregiving Self-Efficacy support continued use with cross-national samples of dementia family caregivers. Limitations of the scale point to the need for further self-efficacy measurement development within caregiving domains. Consistent with Bandura’s (2002) discussion of social cognitive theory in cultural contexts, personal agency for caregiving challenges remains generalizable to cross-national populations. This review discusses the implications for cross-cultural research and practice. Key Words: Dementia, Psychometrics, Measurement, Intervention Outcome The construct of self-efficacy has been useful in advancing psychosocial research and practice with dementia family caregivers. Grounded in Bandura’s (1997, 2002, 2012) social cognitive theory, self-efficacy beliefs reflect confidence in the ability to execute specific behaviors in response to situational demands. Unlike general constructs such as mastery or self-esteem, self-efficacy varies across multifaceted task demands. Self-efficacy beliefs have been demonstrated to influence the initiation of coping, expenditure of effort, and the degree that behaviors are sustained in challenging situations (Bandura, 1997). Relevant to family caregiving, self-efficacy beliefs show strong predictive validity across health conditions and domains of health behaviors (Anderson, Winett & Wojcik, 2007; Plotnikoff, Lippke, Courneya, Birkett & Sigal, 2008). Careful attention to measurement is needed when applying the self-efficacy construct to caregiving responses and change processes. Bandura (2006) recommends that self-efficacy scales focus on specific functional domains and include behaviorally detailed items that progressively increase in difficulty. Items should reflect multifaceted task demands and gradations of challenges or impediments, allowing for assessment of patterns of strengths and limitations in perceived capability. Two scales were originally developed to assess family caregiving self-efficacy in the domains of problem-solving and self-care (Zeiss, Gallagher-Thompson, Lovett, Rose & McKibbin, 1999). These scales demonstrated good internal consistencies, test-retest reliabilities, and were related to measures of depression and burden. Data from independent samples of dementia caregivers were then used to revise and extend these scales, leading to development of the Revised Scale for Caregiving Self-Efficacy (RSCSE; Steffen, McKibbin, Zeiss, Gallagher-Thompson & Bandura, 2002). The RSCSE assesses caregivers’ confidence in responding to three high challenge domains of dementia caregiving: Obtaining Respite (SE:OR; e.g. ‘…ask a friend or family member to stay with NAME for a day when you need time for yourself?’); Managing Disruptive Behaviors (SE:MB; e.g. ‘When NAME forgets your daily routine and asks when lunch is right after you’ve eaten…answer without raising your voice?’); and Controlling Upsetting Thoughts (SE:CT; e.g. ‘…control worrying about future problems that might come up with NAME?’). These three domains reflect distinct and common behavioral and cognitive challenges for dementia family caregivers. Following Bandura’s (2006) guidelines, domain-specific items are presented in order from lower to greater challenge (based on mean scores in the development sample) and represent gradations of challenges or impediments to successful performance. Items reflecting self-esteem, locus of control, or outcome expectations are avoided. Confirmatory factor analyses supported the purported 3-factor structure, with data consistent with subscale reliability and convergent/ discriminant validity (Steffen et al., 2002). The final version of the RSCSE consists of 15 items (5 items per subscale). Due to the domain specificity of the self-efficacy construct and the differing relationships between subscale scores and other coping and health outcome variables, no total score was examined or recommended by the scale developers. The RSCSE has been evaluated in several reviews of caregiving-specific instruments. In a selective review of self-efficacy measures (Betz, 2013), scale development for the RSCSE was described as exemplifying high research standards. A separate evaluation of caregiving measures rated the RSCSE as within the top third of scales meeting 10 criteria (Harvey et al., 2008). The scale has also been discussed in dementia-specific reviews of conceptual models of stress and health (Crellin, Orrell et al., 2014), health care triads (that is, primary care physicians, family caregivers, and persons with dementia; Fortinsky, 2001), and within the international caregiving intervention research literature (McKechnie et al., 2014). A recent review of positive psychology scales for family dementia caregivers evaluated measurement studies on seven criteria and evaluated the original RSCSE paper as moderate in quality (Stansfeld et al., 2017). Specifically, quality of data and methodology within the Steffen et al (2002) study was described as well-designed and reported for content validity, internal consistency, construct validity and agreement (test-retest reliability). The original study was evaluated as lacking information in several key measurement domains (e.g., criterion validity, responsiveness, floor and ceiling effects, and interpretability; Stansfeld et al., 2017), pointing to the value of investigators reporting additional information about the scale. Self-efficacy beliefs have been demonstrated to predict caregiving physical and mental health outcomes (Crellin, Orrell et al., 2014) and are sensitive to the impact of relevant psychosocial interventions (McKechnie et al., 2014). Dementia caregiving research and clinical practice with diverse (Yeo & Gallagher-Thompson, 2006) and cross-national populations (Losada et al., 2006) has significantly expanded. As a part of these developments, the RSCSE has been used in published by investigators across North America, Europe, the Middle East and Asia representing a range of disciplines (e.g., human development, medicine, nursing, occupational therapy, psychiatry, psychology, public health, social work, and sociology). The RSCSE has been translated into multiple languages, however, few studies have examined scale performance across samples Although other measures of caregiving self-efficacy are available in the literature, the RSCSE has been cited with sufficient frequency to merit a review examining the reliability, validity and utility of the published translations. In this paper, we aim to: (1) Identify published studies utilizing the RSCSE (2) Describe data on RSCSE reliability and validity, including factor structure, reported for the English version and published translations of the scale, (3) Reflect on further research developments using the RSCSE, and (4) Provide recommendations about the utility of the RSCSE in research and practice settings. Method Inclusion criteria consisted of (a) empirical studies reporting use of the RSCSE in data collection with (b) dementia family caregivers (i.e., Alzheimer disease, other neurocognitive disorders, cognitively impaired) of (c) older adults living in a (d) range of community and residential care settings, with the (e) studies published in English language professional journal, and excluding (f) case studies and research with very small sample sizes (N < 10). Citations listed for the Steffen et al (2002) measurement paper in Scopus (n = 159), Web of Science (n = 70) and Google Scholar (n = 312) were identified and exported into bibliographic management software (i.e., EndNote). Two different search processes were used within PsychINFO (n=109); first, the name of the scale was inserted as a phrase in double quotes with and without a hyphen (“Revised Scale for Caregiving Self-Efficacy,” “Revised Scale for Caregiving Self Efficacy,”) searching within all text. The second PsycINFO search used the Cited References feature, specifying author, year and the phrase search “Revised Scale for Caregiving Self-Efficacy” in double quotes. Citations from all of the combined above procedures (N = 650) were exported into EndNote, with duplicates identified and removed by EndNote. Figure 1 depicts the outcomes for the various steps in the extraction process, which were completed by the first author. Facets of study quality are noted in the review, including attention to sample size and research design (e.g., discussion of intervention studies separated by those utilizing randomized clinical trial (RCT) versus quasi-experimental (pre-post) design. Results A total of 58 published papers were identified as eligible for inclusion and are presented in Tables 1 and 2 in alphabetical order by first author. Table 1 displays the published works for the scale administered via in-person interview (n = 46), and Table 2 displays studies using self-report data collection strategies (n = 12). Information about the scale’s performance has been organized with attention to translation procedures, psychometric properties, factor structure, validity and utility within a cross-cultural perspective. Our review of these selected works has been organized by the function served by the RSCSE within the published research: (1) evaluating the scale’s psychometrics and factor structure (2) conceptual model testing (predictors of RSCSE scores, or RSCSE scores as predictors of physical and mental health indices), and (3) as outcomes within interventions (i.e., providing support for the scale’s construct validity and sensitivity to change). Within these specific functions, works are identified in subscript by the number corresponding with their position in the review tables, and provided in brackets following the relevant citation. We pay particular attention to translation procedures and support for validity of non-English translations of the scale. Translation Strategies The World Health Organization (WHO, 2017) recommends a process of translating instruments for research purposes in order to achieve different language versions that are conceptually equivalent – rather than linguistically or literally equivalent.  WHO guidelines include the following steps: 1) forward translation by a native speaker of the target language; 2) bilingual expert panel back translation; 3) pre-testing; and 4) final version. In a methods review of the instrument translation process by Maneesriwongul and Dixon (2004), strengths and weaknesses of these various steps have been explored. From that review, the instruments below meet the criteria for proper translation procedures to produce conceptually equivalent versions of the RSCSE. Of the 58 studies identified in this review as using the RSCSE, almost three-fourths (n = 42;72%) have used non-English translations. Arabic (n=1) There is one published study reporting use of an Arabic translation of the RSCSE (Séoud & Ducharme, 2015)[38] , conducted in Lebanon. The authors report following the translation processes recommended by Haccoun (1987), including parallel back-translation. Chinese (n=15) For participants preferring Chinese language materials in studies conducted in the USA, Gallagher-Thompson and colleagues (Gallagher-Thompson et al., 2007 [19]; Holland, Thompson, Tzuang & Gallagher-Thompson, 2010 [25]) followed the WHO guidelines (WHO, 2017). WHO steps 1 and 2 were followed by pilot testing in the target groups to ensure that the meaning of the questions and the response options were accurately preserved. Au and colleagues (2009, 2010a, 2010b) [1-3] piloted the above Chinese translation with dementia caregivers in Hong Kong, and reported that no changes were deemed necessary. Cheng and colleagues (2013, 2014, 2016, 2017) [5-8] performed their Chinese translation, back-translation and piloting of the English-language scale independently of Gallagher-Thompson’s and Au’s research groups. These authors also reported not encountering any problems with the translation and that the items have been relevant for Hong Kong Chinese caregivers. Studies using Chinese translations of the scale have been conducted in China (Au et al., 2009[1]; Au et al., 2010a[2]; Au et al 2010b[3]; Au et al 2014[4]; Cheng et al., 2013[5], Cheng et al., 2014[6]; Cheng et al., 2016[7]; Cheng et al., 2017[8]; Hou et al., 2014[51]; Liu & Huang, 2016[26]; Kwok et al., 2013[52]; Kwok et al., 2014[53]; Wang, Yip & Chang, 2016[58]) and the USA (Gallagher-Thompson et al., 2007[19]; Holland et al., 2010[25]) French (n = 9) Cristancho-Lacroix and colleagues (2015 [12]) reported using the French Canadian translation of the RSCSE (Marziali and Garcia, 2011)[56] with Parisian caregivers using face-to-face interviews. In order to adapt verbal expressions from French Canadian to Metropolitan French, several words were replaced. The authors reported that a few of the SE:CT items were considered “not applicable” by some participants, possibly due to cultural and religious issues. For instance, some French participants originating from Asiatic and Maghreb countries rejected SE:CT items that referred to thinking about caregiving situations as unpleasant or unfair. A few SE:MB items were considered too similar by some participants and interviewers had to explain to clarify them. Ducharme, Lévesque, Lechance, Kergoat and Coulombe (2011) [14] reported using a parallel-back translation procedure described by Haccoun (1987) for their French Canadian translation of the RSCSE, which was then used for subsequent projects. Studies using French translations of the scale were conducted in Canada (Ducharme et al., 2011a[14]; Ducharme et al., 2011b[15]; Ducharme et al., 2012[16]; Ducharme et al., 2015a[17]; Ducharme et al., 2015b[18]; Marziali & Garcia, 2011[56]) and France (Cristancho-Lacroix et al., 2015[12]; Wawrziczny et al., 2017a[44]; Wawrziczny et al., 2017b[45]) Italian (n=1) There is one published study reporting use of an Italian translation of the RSCSE (Grano et al., 2017)[24]; translation details were provided in a paper published in an Italian-language journal. Spanish (n = 16) The first known Spanish translation was developed by Gallagher-Thompson and colleagues for participants in the USA using WHO (2017) guidelines (Depp et al., 2005 [13]; Montoro-Rodriguez & Gallagher-Thompson, 2009 [30]; Rabinowitz et al. 2007 [33]; Rabinowitz, Mausbach & Gallagher-Thompson, 2009 [34]; Rabinowitz, Saenz, Thompson & Gallagher-Thompson, 2011 [35]; Waelde, Thompson & Gallagher-Thompson, 2004 [43]). Márquez-González, Losada-Baltar, López and Peñacoba-Puente (2009) [28] described a Spanish version of the RSCSE for studies in Spain, following recommendations for adapting tests (Hambleton & Patsula, 1998) similar to WHO guidelines.  The researchers did not report difficulties applying the scale to Spanish populations, as the concept of SE exists in the Spanish culture with the same meaning it has in Anglo-Saxon language and culture. Thus, construct equivalence was assumed; four translators highly proficient in both English and Spanish languages and familiar with both cultures translated and back-translated the instrument. In a separate process, Crespo and Fernandez-Lansac (2014) [11] developed another Spanish translation of the scale. Two researchers from their group translated the RSCSE without substantive changes from the published English language version, including the instructions, items content and order or response choices. This version was later revised and edited by two other members of the research group. The final draft was finally reviewed and piloted by Spanish-speaking people with no knowledge of the English version to ascertain that the meaning in Spanish was close enough to the original version in its entirety. Studies using Spanish translations of the scale have been conducted in Spain (Crespo & Fernandez-Lansac, 2014[11]; Lopez et al., 2012[27]; Márquez-González et al., 2009[28] ; Nogales-González et al., 2015[31] ; Peñacoba, Losada, López and Márquez-González, 2008[32]; Romero-Moreno et al., 2011[36]; Romero-Moreno et al., 2012[37]) and the USA (Depp et al., 2005[13]; Gallagher-Thompson et al., 2007[19]; Gonyea, López & Velásquez, 2016[23]; Holland et al., 2010[25]; Montoro-Rodriguez & Gallagher-Thompson, 2009[30]; Rabinowitz et al., 2007[33], Rabinowitz et al., 2009[34]; Rabinowitz et al., 2011[35]; Waelde et al., 2017[42]). RSCSE Psychometrics and Factor Structure As shown in Table 1, internal reliabilities for interview administrations of the RSCSE have been strong: SE:OR α = .84 - .95; SE:MB α = .79 - .95; SE:CT α = .75 - .92. The original scale developers presented the RSCSE as multidimensional and recommended against averaging scores across all three domains; some investigators have nonetheless treated the scale as unidimensional (full-scale α= .70 - .92). Although not as frequently reported, reliability indices for RSCSE collected via self-report have been similar; these are reported in Table 2 (SE:OR α = .90; SE:MB α = .93 - .95; SE:CT α = .91 - .92; Full-scale: α = .90). Two confirmatory factor analytic studies support the 3-factor structure identified in the original development paper. Using a sample of caregivers from Hong Kong and a Chinese translation of the scale, Cheng et al. (2013)[5] performed a confirmatory factor analysis (CFA), analyzing the covariance matrix of the items using maximum likelihood estimation for CFA. The 3-factor model fit the data very well, resulting in a nonsignificant chi square after letting the residuals of two items load freely. The fit of the original 3 factor model for one of the Spanish translations was assessed by Peñacoba et al. (2008) [32] through Confirmatory Factor Analysis (CFA). A good fit of the data to the original three factor structure of the scale was obtained by allowing a covariance between the errors from items 4 and 5 (both items from the SE:OR subscale). For the remainder of this review, relevant works are listed and then described within Tables 1 and 2. More complete descriptions of the studies and key findings are provided in the Supplemental Appendix A. Predictors of self-efficacy Several studies conducted in the USA and Canada have examined demographic (i.e., ethnicity, kinship, gender) and caregiving-context predictors of self-efficacy among English, French and Spanish-speaking caregivers (Depp et al. 2005 [13]; Ducharme et al., 2011a [14]; Ducharme et al. 2015a [17]; Montoro-Rodriguez & Gallagher-Thompson 2009 [30]; Wawrziczny et al., 2017b [45]). Ethnicity (i.e., being Hispanic/Latino), kinship (e.g., being a daughter/daughter-in-law), gender (e.g., male) and onset (e.g., late onset) have been found to be directly related to caregivers’ level of self-efficacy. Caregiving self-efficacy as a predictor of physical health Several studies have utilized the RSCSE to predict variables related to physical health, including research conducted in Hong Kong (Au et al., 2010a [2]) and in the US (George & Steffen, 2014 [21]; Holland et al. (2010) [25]; MacDougall & Steffen, 2016 [55]; Rabinowitz et al., 2007 [33]; Rabinowitz et al., 2011) [35]. Across these, data suggest complex bi-directional relationships between self-efficacy, depression and health risk. Specifically, SE:CT has been found to be positively associated with better health behaviors, health-related quality of life, emotional eating, along with less utilization of psychotropic medications. Caregiving self-efficacy as a predictor of mental health The RSCSE has been used as a predictor of mental health outcomes in caregivers. Although the majority of the studies focused on depressed mood/depressive symptoms, some examined perceived burden, anger and positive indices such as resilience. Direct effects between self-efficacy and mental health outcomes have been found in research conducted in Canada, Italy, Lebanon, Spain, Taiwan and the USA (Crespo & Fernández-Lansac, 2014 [11]; Gilliam & Steffen, 2006 [22]; Liu & Huang, 2016 [26]; López et al., 2012 [27]; Marziali et al., 2010 [29]; Romero-Moreno et al., 2012 [37] and Séoud & Ducharme, 2015 [38].) Mediational relationships have been found in China (Au et al.,2009 [1] ; Wang et al., 2016[58]), Taiwan (Liu & Huang, 2016[26 ]) and in Italy (Grano et al. 2017[24]). Wawrziczny et al. (2017a) [44] did not find that the subscales contributed to the final model of spousal distress (i.e., depression, health problems, disrupted schedule, and psychological distress) in French spousal caregivers. Moderating effects of specific RSCSE subscales have received support in the literature, in Hong Kong by Cheng and colleagues (2013[5]), in Spain (Márquez-González et al., 2009 [28]; Nogales-González et al., 2015 [31]; Romero-Moreno et al., 2011 [36]) and in the USA (Rabinowitz et al., 2009 [34]). In general terms, results from different studies show that SE:MB and SE:CT moderate the impact of stressors on distress (i.e., burden, depressive and anxiety symptoms), buffering the effects of stressors. Intervention Research In our review of interventions reporting use of the RSCSE, nine randomized clinical trials (RCTs) and five quasi-experimental studies designated the RSCSE as a primary outcome measure, with an additional 5 RCTs reporting results for the RSCSE as a secondary measure of outcome or as a mediator or moderator of outcome. No publications used a cut-off score to determine eligibility for inclusion, and there was support for RSCSE being sensitive to change with statistically significant findings in most reports (Au et al., 2010b [3]; Cheng et al., 2016 [7], Cheng et al., 2017 [8]; Coon, Thompson, Steffen, Sorocco & Gallagher-Thompson, 2003 [9]; Ducharme et al., 2011b [15]; Ducharme et al., 2012 [16]; Ducharme et al., 2015b [18]; Gallagher-Thompson et al., 2007 [19]; Gant, Steffen & Lauderdale, 2007 [20]; Glueckauf et al. 2004 [49]; Glueckauf et al., 2007 [50]; Gonyea et al., 2016 [23]; Hou et al., 2014 [51]; Kwok et al., 2013 [52]; Kwok et al., 2014 [53]; Lorig et al., 2012 [54]; Marziali & Garcia, 2011 [56]; Steffen, 2000 [39], Steffen & Gant, 2015 [41]). Five studies reported non-significant findings for the RSCSE (Au et al., 2014 [4];Cristancho-Lacroix et al., 2015 [12]; Easom, Alston & Coleman, 2013 [47]; Waelde, Meyer, Thompson, Thompson & Gallagher-Thompson, 2017 [42]; Williams et al., 2010 [46]). Pre-treatment subscale means varied across the publications (ranges SE:OR 47.0-70.7; SE:MB 55.5-72.9; SE:CT 54.2-70.0; Total score 53.0 - 71.8), as did post-treatment means (ranges SE:OR 54.7 – 74.4; SE:MB 59.8 – 81.1; SE:CT 59.7 – 81.0; Total score 62.0 – 78.3). Several quasi-experimental studies, utilizing single group pre-post designs, have included the RSCSE as a measure of intervention impact. Of these five studies, four reported intervention effects on RSCSE scores (Glueckauf et al., 2004 [49]; Kwok et al., 2014 [53]; Lorig et al., 2012 [54]; Waelde et al., 2004 [43]) while one examined effects on a RSCSE total score and did not (Easom et al., 2013) [47]. Due to the lack of control or comparison groups, the results of those studies should be interpreted with caution. We present them as pilot studies worth some consideration due to the novel components of either the sample or approach to intervention delivery. In summary, our review of the 21 published intervention studies utilizing the RSCSE as a primary or secondary outcome variable concludes that 17 (81%) reported that significant changes were observed in the RSCSE subscales or total score, suggesting that the scale can be used as a measure of outcome or as a mediator or moderator of treatment effects. Discussion The construct of SE appears to be relevant and readily measurable in diverse cultures. Considering our first aim of identifying published studies using the RSCSE, a number of empirical studies (58) have been found that have used the scale, with translations in Arabic, Chinese, English, French, Italian and Spanish. In response to our second aim, all of the reviewed studies support the internal reliability of the subscales (Cronbach’s alpha ranging from .79 to .95). Although the majority of studies followed Steffen et al.’s (2002) recommendations for collecting data via interview, a sufficient number of studies have reported strong reliabilities and outcomes to justify self-report administration as well. In terms of the factor structure of the RSCSE, cross-national researchers were able to include the same items in the three subscales, which translated fairly well across multiple languages and cultures. In addition, the 3-factor structure addressing respite, disruptive behaviors and upsetting thoughts has been confirmed for Chinese (Cheng et al., 2013) [4] and Spanish (Peñacoba et al., 2008) [30] caregivers. From the reviewed studies conducted in individualistic (e.g., the USA) and more collectivistic (e.g., China) cultures, these findings provide preliminary support for the cross-national utility of the scale. Despite the above, the Depp et al. (2005) [13] study conducted in the USA suggests possible differences by ethnicity in SE mean scores. Specifically, when compared to Caucasian participants, Hispanic/Latina caregivers reported higher self-efficacy on two of the three subscales (SE: MB, SE:CT). Future studies should examine measurement invariance before using the RSCSE for comparisons across cultural or ethnic groups. The impact of culture in the caregiving process has been recognized by models such as the socio-cultural stress and coping model (Aranda & Knight, 1997; Losada et al., 2010). Constructs such as coping and familism (i.e., placing priority of family needs over individual ones) vary in presentation or play a different role in the stress and coping process depending on the cultural or ethnic background of caregivers. Differences in predictors or effects of SE in different cultural groups are plausible. Several components of SE may play a greater role or may be more relevant as treatment targets in one culture compared with others (e.g., asking a friend/relative to stay with the care-recipient for a day when the caregiver needs a break may be more difficult for those from a collectivist cultural background than for someone from an individualistic cultural background.) Being aware of these differences could result in greater cultural sensitivity when designing and delivering interventions. In addition to analyzing the functioning of the RSCSE scale in different cultures, another needed area of further research has to do with examining differences in RSCSE scores by gender. Only the study by Ducharme et al. (2011a) [14] analyzed gender differences in the RSCSE, finding lower SE ratings for women than for men. This was echoed by Gant et al.’s (2007) study [20], whose sample of male-only caregivers reported relatively high SE scores at baseline. Self-efficacy is domain specific, such that SE in one domain does not suggest SE in other domains. Therefore, gender differences in SE are likely different depending on the specific domain assessed. Investigators who include male caregivers are encouraged to report data separated by gender. Moreover, there is a need to address the cultural basis of such gender differences as they are likely influenced by gender stereotyping and modeling opportunities for caregiving behaviors. Steffen et al. (2002) recommended against averaging all items together as a total score. A number of studies confirm this point; the three subscales show differential associations with physical and mental health indices and respond differentially to select interventions. Although some have successfully used a total RSCSE score to demonstrate treatment effects (Ducharme et al., 2011b [15], 2015b [18]; Gonyea et al., 2016 [23]; Lorig et al., 2012 [54]; Marziali & Garcia, 2011 [56]), one study using a total score resulted in null findings (Easom et al., 2013 [47]). To limit the number of variables, we suggest targeting a specific RSCSE subscale a priori for analysis. There are some valid concerns regarding score distribution and ceiling effects, as relatively high pre-treatment means for the SE:MB and the SE:CT subscales have been reported by some of the studies in this review. To improve sensitivity to change, we encourage investigators to add higher challenge items and continue measurement development work. An important limitation of this measure is related to its development within the context of mid-stage Alzheimer disease. The 3 subscales reflect specific domains that were considered key to supporting caregivers of an individual experiencing significant dementia-related impairment. There may well be additional caregiving domains that are important to capture in SE assessment (e.g., communicating with other family members, planning for the future). The SE:OR subscale is limited in not applying to caregivers of persons in early-stage dementia who can be safely left alone, or when the patient resides with another family member or care provider. Similarly, the SE:MB subscale is entirely specific to moderate levels of cognitive impairment, and highly questionable for use in other caregiving situations (i.e., level of cognitive impairment that are severe, mild or non-existent.) Although the SE:CT subscale is the least specific to the caregiving situation, and thus the most generalizable, that subscale also comes with limitations and cautions. There is a risk that caregivers may have difficulty understanding instructions and resort to rating the frequency of negative cognitions rather than their ability to control them. For example, Romero-Moreno et al. (2011) [36] recommend paying special attention during interview administration of this subscale, to confirm caregiver understanding of the items. Similarly, Cristancho-Lacroix et al (2015) [12] note that not all items in the SE:CT subscale translated well conceptually for some participants from Asiatic or Maghreb countries. The focus on “controlling” thoughts is also more consistent with second-wave cognitive therapies (e.g., cognitive therapy, Beck’s Cognitive Behavioral Therapy), as opposed to third-wave interventions that focus on changing the function of cognitions rather than the content of the thought (e.g., Acceptance and Commitment Therapy, Mindfulness-based CBT). Thus, future scale development could usefully lead to a cognitively-focused subscale with revised items or a revised instruction that is more compatible with mindfulness-oriented interventions. Overall, given the support for use of the SE-CT subscale with dementia caregivers (Cheng et al., 2013 [5]; Crellin et al., 2014b) and its applicability within other caregiving situations, we continue to see utility for this subscale but call for careful attention to way it is administrated. By virtue of its brevity, short administration time and sensitivity to change following relevant interventions, the RSCSE has utility for a number of clinical applications. The three domains can function as targeted areas within multicomponent interventions. The subscale(s) having the lowest rating can guide therapists or facilitators of intervention groups to the area(s) of focus, while serving as indicators for monitoring responsiveness to the intervention. The literature does not yet support use of a specific cut-off score or clinically meaningful change score. Our tentative recommendation based on experience with samples of help-seeking caregivers is that subscale mean scores below 70 merit attention within treatment settings, with 10-point improvements signifying important gains in confidence to manage important aspects of caregiving. Investigators should explore cut-off scores and indicators of clinically significant change in future research. All these considerations stem from the present review, which, though extensive, has limitations that are worthy of attention. Because our review focused solely on works published in English language journals, we have omitted several translations and adaptations of the RSCSE that may be useful to potential users. Moreover, the inclusion criteria established for our review precluded consideration of adaptations for use with caregivers of other conditions besides dementia. Taking these limitations into account, we must be cautious about generalizing the conclusions to broader samples of caregivers. In summary, the reliability and validity of different translations of the Revised Scale for Caregiving Self-Efficacy appears solid and supports continued use of this measure with cross-national samples of dementia family caregivers. The use of the scale shows significant benefit within the caregiver intervention research literature; this is important given the growth of caregiver interventions across the cross-national community (Gallagher-Thompson et al., 2012). References Anderson, E. S., Winett, R. A., & Wojcik, J. R. (2007). Self-regulation, self-efficacy, outcome expectations, and social support: Social cognitive theory and nutrition behavior. Annals of Behavioral Medicine, 34(3), 304-312. doi:10.1007/BF02874555 Aranda, M. P., & Knight, B. G. (1997). The influence of ethnicity and culture on the caregiver stress and coping process: A socio-cultural review and analysis. The Gerontologist, 37(3), 342-354. doi:10.1093/geront/37.3.342 Au, A., Lai, M., Lau, K., Pan, P., Lam, L., Thompson, L., & Gallagher-Thompson, D. (2009). Social support and well-being in dementia family caregivers: The mediating role of self-efficacy. Aging & Mental Health, 13(5), 761-768. doi:10.1080/13607860902918223 Au, A., Lau, K., Sit, E., Cheung, G., Lai, M., Wong, S. K. A. & Fok, D. (2010a). The role of self-efficacy in the alzheimer's family caregiver stress process: A partial mediator between physical health and depressive symptoms. Clinical Gerontologist, 33(4), 298-315. doi:10.1080/07317115.2010.502817 Au, A., Li, S., Lee, K., Leung, P., Pan, P., Thompson, L., & Gallagher-Thompson, D. (2010b). The Coping With Caregiving group program for Chinese caregivers of patients with Alzheimer's disease in Hong Kong. Patient Education and Counseling, 78(2), 256-260. doi:10.1016/j.pec.2009.06.005 Au, A., Wong, M. K., Leung, L. M., Leung, P. & Wong, A. (2014). Telephone-assisted pleasant-event scheduling to enhance well-being of caregivers of people with dementia: A randomized controlled trial. Hong Kong Medical Journal, 20 (Suppl 3), 30-33. Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY, US: W H Freeman/Times Books/ Henry Holt & Co. Bandura, A. (2002). Social cognitive theory in cultural context. Applied Psychology: An International Review, 51(2), 269-290. doi:10.1111/1464-0597.00092 Bandura, A. (2006), Guide to constructing self-efficacy scales. In F. Pajares & T. Urdan (Eds.), Self-efficacy beliefs of adolescents (pp. 307-337). Charlotte: Information Publishing. Bandura, A. (2012). On the functional properties of perceived self-efficacy revisited. Journal Of Management, 38(1), 9-44. doi:10.1177/0149206311410606 Betz, N. E. (2013). Assessment of self-efficacy. APA handbook of testing and assessment in psychology, Vol. 2: Testing and assessment in clinical and counseling psychology. K. F. Geisinger, B. A. Bracken, J. F. Carlson et al. Washington, DC, US, American Psychological Association: 379-391. Charlesworth, G., Burnell, K., Beecham, J., Hoare, Z., Hoe, J., Wenborn, J., . . . Orrell, M. (2011). Peer support for family carers of people with dementia, alone or in combination with group reminiscence in a factorial design: Study protocol for a randomised controlled trial. Trials, 12 doi:10.1186/1745-6215-12-205 Cheng, S.T., Fung, H. H., Chan, W. C., & Lam, L. W. (2016). Short-term effects of a gain-focused reappraisal intervention for dementia caregivers: A double-blind cluster-randomized controlled trial. The American Journal of Geriatric Psychiatry, 24(9), 740-750. doi:10.1016/j.jagp.2016.04.012 Cheng, S.T., Kwok, T., & Lam, L.C.W. (2014). Dimensionality of burden in Alzheimer caregivers: confirmatory factor analysis and correlates of the Zarit Burden interview. International Psychogeriatrics, 26 (9), 1455-1463. Cheng, S.T., Lam, L. W., Kwok, T., Ng, N. S., & Fung, A. T. (2013). Self-efficacy is associated with less burden and more gains from behavioral problems of Alzheimer's disease in Hong Kong Chinese caregivers. The Gerontologist, 53(1), 71-80. doi:10.1093/geront/gns062 Cheng, S.T., Mak, E.P., Fung, H.H., Kwok, T., Lee, D.T. & Lam, L.C. (2017). Benefit-finding and effect on caregiver depression: A double-blinded randomized controlled trial. Journal of Consulting and Clinical Psychology. doi: 10.1037/ccp0000176. [Epub ahead of print] Choi, E. S., & Kim, K. S. (2010). Factors affecting on caregiving self-efficacy among dementia caregivers. Journal of Korean Academy of Community Health Nursing, 21(2), 210-219. Coon, D. W., Thompson, L., Steffen, A., Sorocco, K., & Gallagher-Thompson, D. (2003). Anger and Depression Management: Psychoeducational Skill Training Interventions for Women Caregivers of a Relative With Dementia. The Gerontologist, 43(5), 678-689. doi:10.1093/geront/43.5.678 Crellin, N., Charlesworth, C., & Orrell, M. (2014a). Measuring family caregiver efficacy for managing behavioral and psychological symptoms in dementia: A psychometric evaluation. International Psychogeriatrics, 26(1), 93-103. Crellin, N. E., Orrell, M., McDermott, O., & Charlesworth, G. (2014b). Self-efficacy and health-related quality of life in family carers of people with dementia: A systematic review. Aging & Mental Health, 18(8), 954-969. doi:10.1080/13607863.2014.915921 Crespo, M., & Fernández-Lansac, V. (2014). Factors associated with anger and anger expression in caregivers of elderly relatives. Aging & Mental Health, 18(4), 454-462. doi:10.1080/13607863.2013.856857 Crespo, M. & Fernández-Lansac, V. (2015). Resiliencia en cuidadores familiares de personas mayores dependientes [Resilience in caregivers of elderly dependent relatives]. Anales de Psicología, 31, 19-27. doi: 10.6018/analesps.31.1.158241 Crespo, M., Fernández-Lansac, V. & Soberón, C. (2014). Adaptación española de la “Escala de Resiliencia de Connor-Davidson” (CD-RISC) en situaciones de estrés crónico [Spanish application of the Connor-Davidson Resilience Scale in chronic stress situations]. Psicología Conductual, 22, 217-236. Cristancho-Lacroix V, Wrobel J, Cantegreil-Kallen I, Dub T, Rouquette A, Rigaud AS. (2015). A Web-based psycho-educational program for informal caregivers of patients with Alzheimer’s disease: results of a pilot randomized controlled trial. JMIR, 17: e117. doi:10.2196/jmir.3717 Depp, C., Sorocco, K., Kasl-Godley, J., Thompson, L., Rabinowitz, Y., & Gallagher-Thompson, D. (2005). Caregiver Self-Efficacy, Ethnicity, and Kinship Differences in Dementia Caregivers. The American Journal of Geriatric Psychiatry, 13(9), 787-794. doi:10.1176/appi.ajgp.13.9.787 Ducharme, F. C., Lachance, L. M., Lévesque, L. L., Kergoat, M. & Zarit, S. H. (2012). Persistant and delayed effects of a psycho-educational program for family caregivers at disclosure of a dementia diagnosis in a relative: A six-month follow-up study. Healthy Aging Research, 1(2), 1-11. Ducharme, F., Lachance, L., Kergoat, M., Coulombe, R., Antoine, P., & Pasquier, F (2015a). A comparative descriptive study of characteristics of early- and late-onset dementia family caregivers. American Journal of Alzheimer’s Disease and Other Dementias, 1-9. doi:10.1177/1533317515578255 Ducharme, F., Lachance, L., Lévesque, L., Zarit, S. H., & Kergoat, M. (2015b). Maintaining the potential of a psycho-educational program: Efficacy of a booster session after an intervention offered family caregivers at disclosure of a relative's dementia diagnosis. Aging and Mental Health, 19(3), 207-216. doi:10.1080/13607863.2014.922527 Ducharme, F., Lévesque, L., Lachance, L., Kergoat, M., & Coulombe, R. (2011a). Challenges associated with transition to caregiver role following diagnostic disclosure of Alzheimer disease: A descriptive study. International Journal Of Nursing Studies, 48(9), 1109-1119. doi:10.1016/j.ijnurstu.2011.02.011 Ducharme, F. C., Lévesque, L. L., Lachance, L. M., Kergoat, M., Legault, A. J., Beaudet, L. M., & Zarit, S. H. (2011b). "Learning to become a family caregiver" efficacy of an intervention program for caregivers following diagnosis of dementia in a relative. Gerontologist, 51(4), 484-494. doi:10.1093/geront/gnr014 Easom, L. R., Alston, G., Coleman, R. (2013). A rural community translation of a dementia caregiving intervention. Online Journal of Rural Nursing and Health Care, 13(1), 66-91. Fortinsky, R. (2001). Health care triads and dementia care: integrative framework and future directions. Aging & Mental Health, 5 (Supplement 1); S35-S48. Gallagher-Thompson, D., Gray, H. L., Tang, P. C. Y., Pu, C. Y., Leung, L. Y. L., Wang, P. ., . . . Thompson, L. W. (2007). Impact of in-home behavioral management versus telephone support to reduce depressive symptoms and perceived stress in Chinese caregivers: Results of a pilot study. American Journal of Geriatric Psychiatry, 15(5), 425-434. doi:10.1097/JGP.0b013e3180312028 Gallagher-Thompson, D., Tzuang, Y., Au, A., Brodaty, H., Charlesworth, G., Gupta, R., & ... Shyu, Y. (2012). Cross-national perspectives on nonpharmacological best practices for dementia family caregivers: A review. Clinical Gerontologist: The Journal of Aging And Mental Health, 35(4), 316-355. doi:10.1080/07317115.2012.678190 Gant, J. R., Steffen, A. M., & Lauderdale, S. A. (2007). Comparative outcomes of two distance-based interventions for male caregivers of family members with dementia. American Journal of Alzheimer's Disease and Other Dementias, 22(2), 120-128. doi:10.1177/1533317506298880 George, N. R., & Steffen, A. (2014). Physical and mental health correlates of self-efficacy in dementia family caregivers. Journal of Women & Aging, 26(4), 319-331. doi:10.1080/08952841.2014.906873 Gilliam, C. M., & Steffen, A. M. (2006). The relationship between caregiving self-efficacy and depressive symptoms in dementia family caregivers. Aging and Mental Health, 10(2), 79-86. doi:10.1080/13607860500310658 Glueckauf, R. L., Ketterson, T. U., Loomis, J. S. & Dages, P. (2004). Online support and education for dementia caregivers: Overview, utilization and initial program evaluation. Telemedicine Journal and E-Health, 10(2), 223-232. Doi: 10.1089/tmj 2004.10.223. Glueckauf, R. L., Sharma, D., Davis, W. S., Byrd, V., Stine, C., Jeffers, S. B., . . . Martin, C. (2007). Telephone-based cognitive-behavioral intervention for distressed rural dementia caregivers: Initial findings. Clinical Gerontologist, 31(1), 21-41. doi:10.1300/J018v31n01_03 Goddard, E., Macdonald, P., Sepulveda, A. R., Naumann, U., Landau, S., Schmidt, U., & Treasure, J. (2011). Cognitive interpersonal maintenance model of eating disorders: Intervention for carers. The British Journal of Psychiatry, 199(3), 225-231. doi:10.1192/bjp.bp.110.088401 Gonyea, J. G., López, L. M., & Velásquez, E. H. (2016). The effectiveness of a culturally sensitive cognitive behavioral group intervention for Latino Alzheimer’s caregivers. The Gerontologist, gnu045. Grano, C., Lucidi, F., Crisci, B., & Violani, C. (2013). Validazione italiana della Revised Scale for Caregiving Self-Efficacy: un contributo preliminare basato su un campione di caregiver di familiari con Alzheimer. = Italian validation of the Revised Scale for Caregiving Self-Efficacy: A preliminary contribution based on a sample of caregivers of family members with Alzheimer's. Rassegna Di Psicologia, 30(3), 9-30. Grano, C., Lucidi, F., & Violani, C. (2017). The relationship betweeen caregiving self-efficacy and depressive symptoms in family caregivers of patients with Alzheimer disease: A longitudinal study. International Psychogeriatrics, 29(7), 1095-1103. Doi: 10/1017/S1041610217000059 Guillamón, N., Nieto, R., Pousada, M., Redolar, D., Muñoz, E., Hernández, E., & ... Gómez‐Zúñiga, B. (2013). Quality of life and mental health among parents of children with cerebral palsy: The influence of self‐efficacy and coping strategies. Journal of Clinical Nursing, 22(11-12), 1579-1590. doi:10.1111/jocn.12124 Haccoun, R. R. (1987) Une nouvelle technique de vértification de l’équivalence de mesures psychologiques traduites = A new technique for verifying the equivalence of translated psychological measures. Revue Québécoise De Psychologie, 8 (3) 30-39. Hambleton, R. K. & Patsula, L. (1998). Adapting tests for use in multiple languages and cultures. Social Indicators Research, 45, 153-171. Harvey, K., Catty, J., Langman, A., Winfield, H., Clement, S., Burns, E., & ... Burns, T. (2008). A review of instruments developed to measure outcomes for carers of people with mental health problems. Acta Psychiatrica Scandinavica, 117(3), 164-176. doi:10.1111/j.1600-0447.2007.01148.x Haccoun, R.R., (1987). Une nouvelle technique de ve´ rification de l’e´ quivalence de mesures psychologiques traduites.(A new method for verifying equivalence between translated psychological measures). Revue que´be´ coise de psychologie 8 (3), 30–39. Holland, J. M., Thompson, L.W., Tzuang, M., & Gallagher-Thompson, D. (2010). Psychosocial factors among Chinese American women dementia caregivers and their association with salivary cortisol: Results of an exploratory study. Ageing International, 35, 109-127. doi:10.1007/s12126-010-9057-0 Hou, R. J., Wong, S. Y., Yip, B. H. Hung, A. T. F., Lo, H. H., Chan, P. H. S.&, . . . Ma, S. H. (2014). The effects of mindfulness-based stress reduction program on the mental health of family caregivers: A randomized controlled trial. Psychotherapy and Psychosomatics, 83(1), 45-53. doi:10.1159/000353278 Kwok, T., Au, A., Wong, B., Ip, I., Mak, V., & Ho, F. (2014). Effectiveness of online cognitive behavioral therapy on family caregivers of people with dementia. Clinical Interventions in Aging, 9, 631-636. doi:10.2147/CIA.S56337 Kwok, T., Wong, B., Ip, I., Chui, K., Young, D., & Ho, F. (2013). Telephone-delivered psychoeducational intervention for Hong Kong Chinese dementia caregivers: A single-blinded randomized controlled trial. Clinical Interventions in Aging, 8, 1191-1197. Liu, H., & Huang, L. (2016). The relationship between family functioning and caregiving appraisal of dementia family caregivers: Caregiving self-efficacy as a mediator. Aging & Mental Health, 1-10. Doi: 10.1080/13607863.2016.1269148. López, J., Romero-Moreno, R., Márquez-González, M., & Losada, A. (2012). Spirituality and self-efficacy in dementia family caregiving: trust in God and in yourself. International Psychogeriatrics, 24(12), 1943-1952. doi: 10.1017/S1041610212001287. Lorig, K., Thompson-Gallagher, D., Traylor, L., Ritter, P. L., Laurent, D. D., Plant, K., . . . Hahn, T. J. (2012). Building better caregivers: A pilot online support workshop for family caregivers of cognitively impaired adults. Journal of Applied Gerontology, 31(3), 423-437. doi:10.1177/0733464810389806 Losada, A., Márquez-Gonzalez, M., Knight, B. G., Yanguas, J., Sayegh, P., & Romero-Moreno, R. (2010). Psychosocial factors and caregivers' distress: Effects of familism and dysfunctional thoughts. Aging & Mental Health, 14(2), 193-202. doi:10.1080/13607860903167838 Losada, A., Shurgot, G. R., Knight, B. G., Márquez, M., Montorio, I., Izal, M., & Ruiz, M. A. (2006). Cross-cultural study comparing the association of familism with burden and depressive symptoms in two samples of Hispanic dementia caregivers. Aging & Mental Health, 10(1), 69-76. doi:10.1080/13607860500307647 MacDougall, M., & Steffen, A. (2016). Self-efficacy for controlling upsetting thoughts and emotional eating in family caregivers. Aging & Mental Health, 1-7. Maneesriwongul, W., & Dixon, J. K. (2004). Instrument translation process: a methods review. Journal of advanced nursing, 48(2), 175-186. Márquez-González, M., Losada, A., López, J., & Peñacoba, C. (2009). Reliability and validity of the Spanish version of the Revised Scale for Caregiving Self-Efficacy. Clinical Gerontologist: The Journal of Aging And Mental Health, 32(4), 347-357. doi:10.1080/07317110903110419 Marrón, E. M., Redolar-Ripol, D., Boixadós, M., Nieto, R., Guillamón, N., Hernández, E., & Gómez, B. (2013). Burden on Caregivers of Children with Cerebral Palsy: Predictors and Related Factors. Universitas Psychologica, 12(3), 767-777. Marziali, E., & Garcia, L. J. (2011). Dementia caregivers' responses to 2 internet-based intervention programs. American Journal of Alzheimer's Disease and Other Dementias, 26(1), 36-43. doi:10.1177/1533317510387586 McKechnie, V., Barker, C., & Stott, J. (2014). Effectiveness of computer-mediated interventions for informal carers of people with dementia—A systematic review. International Psychogeriatrics, 26(10), 1619-1637. doi:10.1017/S1041610214001045 Montoro-Rodriguez, J., & Gallagher-Thompson, D. (2009). The role of resources and appraisals in predicting burden among latina and non-hispanic white female caregivers: A test of an expanded socio-cultural model of stress and coping. Aging and Mental Health, 13(5), 648-658. doi:10.1080/13607860802534658 Nogales-González, C., Romero-Moreno, R., Losada, A., Márquez-González, M., Zarit, S. H. (2015). Moderating effect of self-efficacy on the relation between behavior problems in persons with dementia and the distress they cause in caregivers. Aging & Mental Health, 1-9. doi: 10.1080/13607863.2014.995593 Oettingen, G. (1995). Cross-cultural perspectives on self-efficacy. In A. Bandura (Ed.), Self-efficacy in changing societies (pp. 149-176). New York: Cambridge University Press. Peñacoba, C, Losada A, López J, Márquez-González M. (2008). Confirmatory factor analysis of the Revised Scale for Caregiving Self-efficacy in a sample of dementia caregivers. International Psychogeriatrics, 20, 1291-1293.doi: 10.1017/S104161020800759X. Plotnikoff, R. C., Lippke, S., Courneya, K. S., Birkett, N., & Sigal, R. J. (2008). Physical activity and social cognitive theory: A test in a population sample of adults with type 1 or type 2 diabetes. Applied Psychology: An International Review, 57(4), 628-643. doi:10.1111/j.1464-0597.2008.00344.x Rabinowitz, Y. G., Mausbach, B. T., Thompson, L. W., & Gallagher-Thompson, D. (2007). The relationship between self-efficacy and cumulative health risk associated with health behavior patterns in female caregivers of elderly relatives with Alzheimer's dementia. Journal of Aging And Health, 19(6), 946-964. doi:10.1177/0898264307308559 Rabinowitz, Y. G., Saenz, E. C., Thompson, L. W., & Gallagher-Thompson, D. (2011). Understanding caregiver health behaviors: Depressive symptoms mediate caregiver self-efficacy and health behavior patterns. American Journal of Alzheimer's Disease And Other Dementias, 26(4), 310-316. doi:10.1177/1533317511410557 Rabinowitz, Y. G., Mausbach, B. T., & Gallagher-Thompson, D. (2009). Self-efficacy as a moderator of the relationship between care recipient memory and behavioral problems and caregiver depression in female dementia caregivers. Alzheimer Disease and Associated Disorders, 23(4), 389-394. doi:10.1097/WAD.0b013e3181b6f74d Romero-Moreno, R., Ḿarquez-Gonźlez, M., Mausbach, B. T., & Losada, A. (2012). Variables modulating depression in dementia caregivers: A longitudinal study. International Psychogeriatrics, 24(8), 1316-1324. doi:10.1017/S1041610211002237 Romero-Moreno, R., Losada, A., Mausbach, B. T., Márquez-González, M., Patterson, T. L., & López, J. (2011). Analysis of the moderating effect of self-efficacy domains in different points of the dementia caregiving process. Aging and Mental Health, 15(2), 221-231. doi:10.1080/13607863.2010.505231 Séoud, J. N., & Ducharme, F. (2015). Factors associated with resilience among female family caregivers of a functionally or cognitively impaired aging relative in Lebanon: A correlational study. Journal of Research in Nursing, 20(7), 567-579. doi: 10.1177/1744987115599672. Shaffer, K. M., Riklin, E., Jacobs, J. M., Rosand, J., & Vranceanu, A. (2016). Psychosocial resiliency is associated with lower emotional distress among dyads of patients and their informal caregivers in the neuroscience intensive care unit. Journal of Critical Care, 36154-159. doi:10.1016/j.jcrc.2016.07.010 Stansfeld, J., Stoner, C. R., Wenborn, J., Vernooij-Dassen, M., Moniz-Cook, E., & Orrell, M. (2017). Positive psychology outcome measures for family caregivers of people living with dementia: a systematic review. International Psychogeriatrics, 1-16. Steffen, A. M. (2000). Anger management for dementia caregivers: A preliminary study using video and telephone interventions. Behavior Therapy, 31 (2), 281-299. doi: 10.1016/S0005-7894(00)80016-7. Steffen, A. M., & Gant, J. R. (2015). A telehealth behavioral coaching intervention for neurocognitive disorder family carers. International Journal of Geriatric Psychiatry, doi:10.1002/gps.4312 Steffen, A. M., McKibbin, C., Zeiss, A. M., Gallagher-Thompson, D., & Bandura, A. (2002). The Revised Scale for Caregiving Self-Efficacy: Reliability and validity studies. The Journals of Gerontology: Series B: Psychological Sciences And Social Sciences, 57(1), P74-P86. doi:10.1093/geronb/57.1.P74 Tan, S., Lee, K., Chao, Y. C., Hsu, L., & Lin, P. (2015). Effects of a family involvement program in patients with central-line insertion. Clinical Nursing Research, 24(3), 253-268. doi:10.1177/1054773813516789 Waelde, L. C., Meyer, H., Thompson, J. M., Thompson, L., & Gallagher-Thompson, D. (2017). Randomized trial of inner resources meditation for family dementia caregivers. Journal of Clinical Psychology. doi:10/1002/jclp.22470 Waelde, L. C., Thompson, L., & Gallagher-Thompson, D. (2004). A pilot study of a yoga and meditation intervention for dementia caregiver stress. Journal of Clinical Psychology, 60(6), 677-687. doi:10.1002/jclp.10259 Wang, P. C., Yip, P. K., & Chang, Y. (2016). Self-Efficacy and Sleep Quality as Mediators of Perceived Stress and Memory and Behavior Problems in the link to Dementia Caregivers’ Depression in Taiwan. Clinical Gerontologist, 39(3), 222-239. doi: 10.1080/07317115.2015.1128503 Wawrziczny, E., Berna, G., Ducharme, F., Kergoat, M., Pasquier, F., & Antoine, P. (2017a). Modeling the Distress of Spousal Caregivers of People with Dementia. Journal of Alzheimer's Disease: JAD, 55(2), 703-716. Wawrziczny, E., Berna, G., Ducharme, F., Kergoat, M., Pasquier, F., & Antoine, P. (2017b). Characteristics of the spouse caregiver experience: Comparison between early- and late-onset dementia. Aging & Mental Health, doi: 10.1080/13607863.2017.1339777 Williams, V. P., Bishop-Fitzpatrick, L., Lane, J. D., Gwyther, L. P., Ballard, E. L., Vendittelli, A. P., . . . Williams, R. B. (2010). Video-based coping skills to reduce health risk and improve psychological and physical well-being in alzheimer's disease family caregivers. Psychosomatic Medicine, 72(9), 897-904. doi:10.1097/PSY.0b013e3181fc2d09 World Health Organization:  Process of translation and adaptation of instruments.  Retrieved Jan. 16, 2017 from https://www.who.int/substance_abuse/research_tools/translation/en/ Yeo, G., & Gallagher-Thompson, D. (2006). Ethnicity and the dementias (2nd edition). New York: Routledge. Zeiss, A., Gallagher-Thompson, D., Lovett, S., Rose, J., & McKibbin, C. (1999). Self-efficacy as a mediator of caregiver coping: Development and testing of an assessment model. Journal of Clinical Geropsychology, 5(3), 221-230. doi:10.1023/A:1022955817074 Figure 1. Flow Chart of Review Process Records identified though database searching (N = 650) Caregiving Self-Efficacy 46 Excluded works from books/conference proceedings/ dissertations or theses (n = 139) Full-text articles excluded (n = 59) · Scale not used in study (n = 30) · No dementia family CGs (n = 2) · Case studies/small N (n = 4) · Protocol descriptions (n = 4) Abstracts excluded (n =184) · Additional duplicates (n = 112) · No dementia family Cgs (n = 37) · Non-English works (n = 28) · Reviews/editorials (n = 7) Studies included in qualitative synthesis (N = 58) Full-text articles assessed for eligibility (N = 117) Titles and abstracts screened (N = 301) Records after duplicates removed by Endnote (N = 440) Table 1 Predictive studies and RCTs using interview format of Revised Scale for Caregiving Self-Efficacy (n = 48) Author (Publication Year) Country/ Language Sample Use of Measure Alpha (α) Findings* 1. Au et al. (2009) China (Hong Kong)/ Chinese N = 134; 75% female; 58% adult children Predict depressive symptoms SE:OR α = .89; SE:MB α = .91; SE:CT α = .90 *RSCSE subscales partially mediated the path between social support and depression. 2. Au et al. (2010a) China (Hong Kong)/ Chinese N = 134; 75% female; 58% adult children Predict depressive symptoms SE:OR α = .89; SE:MB α = .91; SE:CT α = .90 *SE:CT mediated link between perceived physical health support and depression. 3. Au et al. (2010b) China (Hong Kong)/ Chinese/Cantonese N = 27;100% female; 34% spouses/SO; 52% adult children RCT outcome SE:OR α = .92; SE:MB α = .95; SE:CT α = .86 *SE:MB and SE:CT improved in treatment group compared to control group. 4. Au et al. (2014) China (Hong Kong)/ Chinese/Cantonese N=60; 76.7% female; 38.3% spouses; 60% adult children RCT outcome Not reported No differences in SE:OR or SE:CT change following intervention, relative to comparison group. 5. Cheng et al. (2013) China (Hong Kong)/ Chinese N = 99; 71% female; 55% adult children Measurement refinement and validation SE:ORα = .92; SE:MB α = .86; SE:CT α = .75 *CFA of shortened scale supported 3-factor model (2 = 29.09, df = 23, ns; RMSEA = .05) SE:CT moderated relationship between challenging behaviors and role overload & burden. 6. Cheng et al. (2014) China (Hong Kong)/ Chinese N = 395; Data originating from 2 studies; 86% female; 27% spouse/sibling; 73% intergenerational To support concurrent validity of Zarit Burden Interview SE:ORα = .95; SE:MB α = .87; SE:CT α = .77 *RSCSE subscales negatively correlated with 3 of the 4 factors for Zarit Burden Interview 7. Cheng et al. (2016) China (Hong Kong)/ Chinese N = 129; 81% female; 27% spouse; 71% adult children Mediate outcome of RCT SE:ORα = .94; SE:MB α = .88; SE:CT α = .80 *3-item version of SE:CT subscale was primary mediator of outcome for a benefit-finding intervention. 8. Cheng et al. (2017) China (Hong Kong)/ Chinese N = 96; 87% female; 24% spouse; 76% younger generation Mediate outcome of RCT SE:ORα = .96; SE:MB α = .84; SE:CT α = .75 *3-item version of SE:CT subscale was mediator of outcomes for a benefit-finding intervention. 9. Coon et al. (2003) USA/ English N = 169; 100% female; 57% spouse; 43% adult children RCT outcome Not reported *Intervention effect for both SE:MB and SE:CT relative to waitlist control. SE:CT partially mediated intervention impact on both anger and depressed mood. 10. Crellin et al. (2014a) England (UK)/ English N=245; 71% female; 62% spouse; 29% adult children To support concurrent validity of Caregiver Efficacy Scale Not reported *RSCSE subscales significantly correlated with Caregiver Efficacy Scale assessing confidence in dealing with behavioral and psychological symptoms of dementia. 11. Crespo & Fernandez-Lansac, (2014) Spain/ Spanish N = 111; 74% female; 51% adult children Predict well-being SE:ORα = .87; SE:MB α = .93; SE:CT α = .90 *Support for convergent and discriminant validity, with predicted varying relationships between the 3 subscales and depression, anxiety, anger, burden and self-esteem. 12. Cristancho-Lacroix et al. (2015) France/ French N = 49; 65% female; 59% adult children RCT outcome Not reported No intervention effect for RSCSE subscales 13. Depp et al. (2005) USA/ English & Spanish N=238; 100% female; 42% spouses/SOs; 58% adult children Impact of ethnicity and kinship status on self-efficacy Caucasian: SE:OR α = .89; SE:MB α = .90; SE:CT α = .89 Hispanic/Latino: SE:OR α = .88; SE:MB α = .88; SE:CT α = .85 * Level of acculturation did not relate strongly with self-efficacy. Hispanic/Latinos higher on 2 of the 3 self-efficacy scales than Caucasian caregivers. 14. Ducharme et al. (2011a). Canada (Québec) French N=122; 78% female; 36% spouses/SOs; 64% adult children Descriptive study of caregiving characteristics within 9 months of Alzheimer’s diagnosis α = .86-.90 *Self-efficacy differences by gender (lower scores for women) and by kinship (lower scores for spouses). 15. Ducharme et al. (2011b) Canada (Québec) French N=111; 79% female; 34% spouses/SOs; 52% adult children RCT outcome α = .86 *Intervention effect for a total RSCSE score relative to waitlist control. 16. Ducharme et al. (2012) Canada (Québec) French N=97; 81% female; 36% spouses/SOs; 55% adult children RCT outcome at 6 months Baseline α = .89 Follow-up α = .91 *Intervention effect for a total RSCSE score relative to waitlist control, p2 = .04. 17. Ducharme et al. (2015a) Canada (Québec) French N=96; 79% female; 66% spouses/SOs; 25% adult children Comparison of caregivers for early- and late-onset dementia patients α = .74-.92 No differences as hypothesized between caregivers of early- and late-onset caregivers in the 3 RSCSE subscales 18. Ducharme et al. (2015b) Canada (Québec) French N=89; 80% female; 49% adult children RCT outcome α = .90 *Intervention effect for a total RSCSE score relative to waitlist control, for participants with and without an added booster session. 19. Gallagher-Thompson et al. (2007) USA/ Mandarin, Cantonese and English N = 45; 100% female; 31% spouse RCT outcome Reported Mean α = .90 *SE moderated treatment impact. Participants low in SE improved most for in-home behavior management intervention. 20. Gant et al. (2007) USA/ English N = 32; 100% male; 88% spouse RCT outcome Not reported Improvement pre to post for both conditions. No differential improvement for more intensive intervention. 21. George & Steffen (2014) USA/ English N=52; 100% female; 57% spouses/SO; 38% adult children Longitudinal model predicting physical and mental health Not reported *SE:CT predicted better SF-12 physical health indices and lower psychoactive medication usage at 18 months post-intervention. 22. Gilliam & Steffen (2006) USA/ English N=74; 100% female; 52% spouses/SO; 43% adult children Predict depressive symptoms SE:MB α = .88 *SE-MB negatively correlated with depressive symptoms, after controlling for number of behavior problems and level of cognitive impairment. 23. Gonyea, López & Velásquez (2016) USA/Spanish N=67; 95% female; 25% spouse; 57% adult children RCT outcome Total score α = .86 *CBT Intervention effect for a total RSCSE score relative to psychoeducational control. 24. Grano et al. (2017) Italy/Italian N=108;57% female; 50% spouse; 47% adult children Predict depressive symptoms using SEM w/ longitudinal data SE:OR α = .86; SE:MB α = .92; SE:CT α = .86 *SE:CT partially mediated link between perceived physical health support and depression. 25. Holland et al. (2010) USA/ Mandarin, Cantonese and English N=47; 100% female; 39% spouses/SO; 61% adult children Predict diurnal cortisol patterns Total RSCSE α = .90 *Belief in Asian values associated with more normal cortisol patterns and with higher RSCSE scores 26. Liu & Huang (2016) Taiwan/ Chinese/ Mandarin N=115; 66% female; 26% spouse; 71% adult children Predict burden and self-esteem SE:OR α = .94; SE:MB α = .96; SE:CT α = .96 *SE:OR partially mediated link between family functioning and burden. Other paths were nonsignificant. 27. Lopez et al. (2012) Spain/ Spanish N = 122; 80% female;36% spouses; 57% adult children Interaction with spirituality to predict well-being Cited Peñacoba et al. (2008) CFA which supports 3 factor model, loadings ranged from .45-.94, α = .84. *Spirituality and self-efficacy had additive effect on well-being. High self-efficacy and high spirituality group had lower levels of depression. 28. Márquez-González et al. (2009) Spain/ Spanish N = 180; 78% female; 57% adult children Validation study of Spanish translation SE:OR α = .86; SE:MB α = .79; SE:CT α = .82 *Support for reliability and convergent/discriminant validity of Spanish translation. 29. Marziali et al. (2010) Canada/ English N = 232; 75% female; 56% spouses; 36% adult children Evaluate assessment battery α = .70-.90 *Support for inclusion of scale within standardized assessment battery. SE signficantly predicted self-reported physical and mental health, and plan for institutionalization 30. Montoro-Rodriguez & Gallagher-Thompson (2009) USA/ Spanish and English N = 185; 100% female; 39% spouse/SO Evaluate socio-cultural model of stress and caregiver burden α = .81-85 *SE:CT inversely related to burden scores. Ethnicity had direct and indirect influence on burden via SE:CT. 31. Nogales-González et al. (2015) Spain/ Spanish N = 231; 79% female; 58% adult children Predict well-being SE:MB α = .80 * SE:MB partially moderated the relationship between patient behavior problems and caregiver reactions. High SE caregivers were less upset by increasing number of disruptive and depressive behaviors. 32. Peñacoba et al. (2008) Spain/ Spanish N = 202; 78% female; 36% spouses; 57% adult children Measurement study Not reported *CFA supported 3-factor model (2 = 120.86, df = 87; GFI= 0.93; IFI = 0.97; CFI = 0.97; RMSEA = .04). Factor loadings ranged 0.45 – 0.94. 33. Rabinowitz et al. (2007) USA/ English & Spanish N=256; 100% female; 38% spouses/SOs; 52% adult children Predict cumulative health risk SE:OR α = .84; SE:MB α = .89; SE:CT α = .89 *SE:OR and SE:CT associated with fewer caregiver health risk behaviors; SE:CT associated with improved dietary practices 34. Rabinowitz et al. (2009) USA/ English & Spanish N=256; 100% female; 61% spouses/SOs Test model of caregiver depression SE:OR α = .89; SE:MB α = .89; SE:CT α = .88 *SE:MB and SE:CT had direct inverse relationship with depressive symptoms. SE:MB moderated relationship between patient behavior problems and caregiver depression. 35. Rabinowitz et al. (2011) USA/ English & Spanish N=256; 100% female; 61% spouses/SOs Test model predicting health risk SE:OR α = .89; SE:MB α = .89; SE:CT α = .88 *Depressive symptoms mediated the relationship between self-efficacy (SE:OR, SE:CT) and cumulative health risk 36. Romero-Moreno et al. (2011) Spain/ Spanish N = 167; 77.20 % female; 34.30 % spouses; 60.20% adult children Test SE as moderator of the relationship between stressors and distress. SE:MB α = .80; SE:CT α = .82 *SE:MB did not moderate the relationship between patient behavior problems and burden; SE:CT moderated the relationship between burden and distress (depression and anxiety). Support for construct validity of scale, showing inverse relationships between SE:MB and burden; and between SE:CT and depression/ anxiety 37. Romero-Moreno et al. (2012) Spain/ Spanish N = 130; 83.08 female; 34.62 % spouses; 61.53% adult children; (n = 116 at 3 month f/u; n=82 at 12 month f/u) Conceptual model testing; predict depression longitudinally SE:CT α = .78 (Sole domain used in study) *longitudinal analyses demonstrate that increases in SE:CT predicted decreases in depression over time. 38. Séoud & Ducharme (2015) Lebanon/ Arabic N=140; 100% female; 18.6% wives; 69.3 adult daughters Predict resilience Total RSCSE α = .91 *RSCSE total score associated with a measure of resilience after accounting for control variables. 39. Steffen (2000) USA/ English N=33; 75.8% female; 54.5% spouses; 36.4% adults children RCT outcome SE:MB = .84 *SE:MB scores were improved following both in-home and group-based interventions relative to control condition. 40. Steffen et al. (2002). USA/ English Study 1 N = 169; 100% female; 57% wives; 39% adult daughters Study 2 N = 145;80% female; 46% spouse; 46% adult children Measurement development Study 1: SE:OR α = .88; SE:MB α = .84; SE:CT α = .86 Study 2: SE:OR α = .85; SE:MB α = .82; SE:CT α = .85 *Original measurement development paper. First sample used for scale refinement and exploratory factor analysis. Second sample used for CFA. Support for concurrent and discriminant validity examined with both data sets. 41. Steffen & Gant (2015) USA/ English N = 74; 100% female; 52% wives; 43% adult daughters RCT outcome Not reported *Telehealth behavioral coaching showed greater improvement in SE:OR and SE:MB relative to comparison condition. 42. Waelde et al. (2017) USA/ English N=31; 100% female RCT outcome SE:CT α = .80 SE:CT did not improve in meditation intervention group, relative to comparison condition. 43. Waelde et al. (2004) USA/ English & Spanish N = 12; 100% female; 50% wives; 50% adult daughters ±Quasi-experimental study outcome Not reported *Significant improvement in SE:CT scores following yoga-meditation intervention 44. Wawrziczny et al., 2017a France/ French N=125; 60% female; 100% spouses Modeling distress SE:OR α = .83; SE:MB α = .90; SE:CT α = .83 SE subscales did not show strong relationships with other variables and were excluded from the final model. 45. Wawrziczny et al., 2017b France/ French N=150; 59.3% female; 100% spouses Describe characteristics of cgs for early- and later-onset patients Early onset: SE:OR α = .86; SE:MB α = .86; SE:CT α = .84 Late onset: SE:OR α = .83; SE:MB α = .89; SE:CT α = .83 *Spouse cgs of early onset patients had lower average SE:CT scores compared to spouses of late onset individuals. 46. Williams et al. (2010) USA/ English N = 116; 78% female; 40% spouses; 50% adult children RCT outcome Not reported No improvement in SE subscale scores following video-based skills intervention relative to wait list control. (* indicates findings support hypothesized function of RSCSE in study; ± pre-post design without a comparison group) Table 2 Predictive studies and RCTs using self-report format of Revised Scale for Caregiving Self-Efficacy (n = 12)* Author (Publication Year) Country/ Language Sample Use of Measure Alpha (α) Findings (* indicates findings support hypothesized function of RSCSE in study) 47. Easom et al. (2013) USA/ English N=85; 78% female; 49% adult children ± quasi-experimental study outcome Not reported No intervention effect for a total RSCSE score. Improved SE for worry about future (1 item from SE:CT). 48. Farran et al. (2011) USA/ English N = 82; 77% female; 55% spouse, 35% adult children Support validity of Caregiver Assessment of Behavioral Skill-Self-Report (CAB-SR) Not reported *SE:CT subscale correlated with 4 of the 7 CABS-SR subscales 49. Glueckauf et al. (2004) USA/ English N=21; 86% female; 62% spouses/SO; 38% adult children ± pilot quasi-experimental study outcome Not reported *significant pre-post intervention improvement in all 3 subscales 50. Glueckauf et al. (2007) USA/ English N=14; 71% female; 29% spouses/SO; 57% adult children RCT outcome Not reported *significant pre-post intervention improvement in SE:OR and SE:MB for treatment compared to control 51. Hou et al. (2014) China (Hong Kong)/ Cantonese N=141; 83% female; 40% spouses/SO; 45% adult children RCT outcome Not reported *Mindfulness-based stress reduction intervention showed greater improvement in SE:CT relative to control 52. Kwok et al. (2013) China (Hong Kong)/ Cantonese N=38; 74% female; 10% spouses/SO; 87% adult children RCT outcome SE:OR α = .90; SE:MB α = .93; SE:CT α = .92 *Psychoeducation administered by telephone showed greater improvement in SE:OR relative to control. SE:MB showed nonsignificant trend for intervention impact. 53. Kwok et al. (2014) China (Hong Kong)/ Cantonese N=36; 72% female; 16% spouses/SO; 78% adult children ± quasi-experimental study outcome SE:MB α = .95; SE:CT α = .91 *Dementia severity moderated impact of online CBT intervention on SE:CT. 54. Lorig et al. (2012) USA/English N=60; 82% female; 62% spouses/SO:68% caring for dementia pt ± quasi-experimental study outcome Not reported *Significant improvement in total SE score following online intervention 55. MacDougall & Steffen (2016) USA/ English N=158; 100% female; 17% spouse; 60% adult children Predict emotional eating SE:CT α = .90 *SE:CT predicted lower rates of emotional eating after controlling for other predictors 56. Marziali & Garcia (2011) Canada/ English & French N = 91; 72% female; 74% spouses/SO; 26% adult children RCT outcome Not reported *Significant improvement in total SE score following 2 online interventions. Change in SE scores for video group predicted change in distress 57. Sadak et al. (2015) USA/ English N=130; 80% female; 63% spouse/SO; 25% adult children Support concurrent validity of PBH-LCI:D scale α = .90 Correlation between RSCSE and PBH-LCI:D nonsignificant 58. Wang, Yip & Chang (2016) Taiwan/ Chinese N=72; 78% female; 21% spouse/SO; 79% adult children Test SE as a mediator of the relationship between stressors and depression. Not reported *SE:CT partially mediated relationship between stressors and depression. (* indicates findings support hypothesized function of RSCSE in study; ± pre-post design without a comparison group) Appendix A. Summary of Findings Regarding the Predictive Validity of the Revised Scale for Caregiving Self-Efficacy: Supplemental details for studies presented in Tables 1 & 2. In order to help readers grasp the research findings regarding caregiver outcomes related to the RSCSE, we provide more detailed descriptions of the main findings of the studies listed in Tables 1 and 2. The RSCSE has been included in studies designed to create and/or validate other measures (Farran et al., 2011; Cheng et al., 2014; Sadak, Korpak & Borson, 2015), and has demonstrated concurrent validity for a measure of self-efficacy for dementia caregiving focused on managing behavioral and psychiatric symptoms (Crellin et al., 2014a) [10]. Predictors of self-efficacy The impact of ethnicity and kinship status on self-efficacy was studied in a sample of female Caucasian and Hispanic/Latina dementia caregivers living in the USA (Depp et al. 2005) [13]. When compared to Caucasian participants, Hispanic/Latina caregivers reported higher self-efficacy on two of the three subscales (SE:MB, SE:CT), and daughters reported higher self-efficacy on all three subscales. Among Hispanics/Latinas, acculturation did not relate strongly to self-efficacy (i.e., one difference was found among 6 comparisons). Data from this same study of Spanish and English-speaking caregivers in the USA were used to test a socio-cultural model of stress and coping (Montoro-Rodriguez & Gallagher-Thompson 2009) [30]. Using structural equation modeling, the authors successfully tested a model demonstrating that SE:CT was inversely related to perceived burden, with Latina caregivers reporting on average higher levels of SE:CT than Caucasian caregivers. In two studies of French-speaking Canadian caregivers, responses to the RSCSE were compared across a variety of characteristics. Self-efficacy differences were found across gender (lower scores for women) and kinship (lower scores for spouses) in one study (Ducharme et al., 2011a) [14]. Caregivers of early- and late-onset dementia patients were similar in average responses to the 3 RSCSE subscales in a second study (Ducharme et al. 2015a) [17]. Caregiving self-efficacy and physical health The RSCSE has been found to relate a number of physical health indices, such as perceived physical health, emotional eating, health risk behaviors, and cortisol patterns. A path analytic study of dementia family caregivers was conducted in Hong Kong with a Chinese translation of the scale (Au et al., 2010a) [2]. The results suggested that poorer perceived physical health was directly and indirectly associated with increased depressive symptoms, with the indirect path mediated by SE:CT. These findings indicate that self-efficacy for controlling upsetting thoughts about caregiving may function as a mechanism through which perceived physical health influences depressive symptoms. This mechanism appeared domain-specific as only SE:CT, but not SE:MB or SE:OR, was a significant mediator. Within a sample of English-speaking caregivers, SE:CT at 12 months post-intervention predicted self-reported physical health indices (SF-12 subscales), as well as psychoactive medication usage at 18 months (George & Steffen 2014) [21]. In another study from the same research group, MacDougall and Steffen (2016) [55] demonstrated that SE:CT predicted emotional eating in a sample including caregivers for individuals with either a diagnosed dementia or undiagnosed cognitive impairment, after controlling for other variables relevant to the stress process model. Using data from the California REACH-I site, Rabinowitz and colleagues found that both SE:OR and SE:CT were associated with fewer caregiver health risk behaviors (Rabinowitz et al., 2007) [33]. Later path analyses using the same dataset demonstrated that depressive symptoms fully mediated the relationship between self-efficacy (SE:OR, SE:CT) and cumulative health risk (Rabinowitz et al., 2011) [35]. Studying diurnal cortisol patterns in Chinese American caregivers, Holland et al. (2010) [25] demonstrated that belief in Asian values was associated with more normal cortisol patterns and with higher RSCSE scores. Caregiving self-efficacy and mental health Direct effects of RSCSE. Research findings suggest that the RSCSE is directly related to mental health, including depression and anger. Support for the construct validity of the English version of the RSCSE was demonstrated in a Canadian study developing a standardized assessment battery for use by social service agencies (Marziali et al., 2010) [29]. In this large sample of dementia caregivers, a RSCSE total score significantly predicted better self-reported physical and mental health. In a study of dementia family caregivers from the USA using an English-language version of the RSCSE, the SE:MB subscale was a significant predictor of depressive symptoms, but did not function as a moderator as hypothesized (Gilliam & Steffen, 2006) [22]. A high sense of spiritual meaning and self-efficacy were examined as predictors of depression in caregivers (López, Romero-Moreno, Márquez-González & Losada, 2012) [27]. Social support, caregivers’ appraisal of behavioral problems, and being a caregiver with a high sense of spiritual meaning and high self-efficacy accounted for 21.5 % of the total variance; specifically this combination of high sense of spiritual meaning and self-efficacy accounted for 4% of the total variance. The authors concluded that caregivers with a high sense of spirituality and self-efficacy may be protected from the negative consequences of caregiving through the experience that they are capable of accomplishment, rather than focusing on their past failures. Mediational analyses. Au et al. (2009) [1] used a Chinese translation of the RSCSE to investigate self-efficacy as a mediator of the relationships between social support and depressive symptoms of family caregivers of patients with dementia in Hong Kong. Self-efficacy acted as partial mediator between social support and depressive symptoms; SE:CT had a mediation effect between the other self-efficacy scales (i.e. SE:OR and SE:MB) and depressive symptoms. Results supported the domain-specific nature of caregiving efficacy and the importance of controlling upsetting thoughts (Au et al., 2009) [1]. Investigators from Taiwan conducted a cross-sectional study of depression in dementia caregivers and reported that, along with sleep quality, SE:CT partially mediated the relationship between stressors and depressive symptoms (Wang, Yip & Chang, 2016) [58]. Wawrziczny et al. (2017) [44] included the 3 subscales of the RSCSE in a study modeling distress in French spousal caregivers and did not find that the subscales contributed to the final model of spousal distress (i.e., depression, health problems, disrupted schedule, and psychological distress). Moderation analyses. In a cross-sectional study of self-efficacy, burden and depression in Hong Kong caregivers, Cheng and colleagues (2013) [5] found differential relationships between shortened versions of the three subscales and role overload, burden, depressive symptoms and positive gains. SE:CT moderated the relationship between challenging behaviors on the one hand, and burden, role overload and positive gains on the other; SE-OR and SE:MB had direct effects with psychosocial measures but did not function as moderators. Care-recipient challenging behaviors were positively correlated with burden and role overload only when SE:CT was low. When SE:CT was high, having more challenging behaviors to deal with was actually associated with gains. The authors concluded that caregiving challenges can promote personal growth when caregivers are confident about their ability to manage negative thoughts. The SE:MB subscale was used in its Spanish version (Márquez-González et al., 2009) [28] to assess the moderation effects of self-efficacy for dealing with behavioural and psychological symptoms of dementia (BPSD) (Nogales-González, Romero-Moreno, Losada, Márquez-González & Zarit, 2015) [31]. Significant moderating effects of SE:MB on the relation between the frequency of BPSD and caregiver distress were found for the dimensions of depressive and disruptive behaviours, but not for memory problems, suggesting that caregivers who confronted high frequencies of depressive or disruptive behaviours reported significantly lower levels of distress when their self-efficacy was higher. In a comparable test of the relationship between RSCSE subscales, caregiving stressors, and depression (Rabinowitz et al., 2009) [34], data for Latina and white caregivers were used from the Bay Area site for the REACH study conducted in the USA. For the pooled sample, SE:MB and SE:CT had direct inverse relationships with depressive symptoms, and SE:MB moderated the relationship between behavior problems in the care recipient and caregiver depression. Caregivers with lower levels of SE:MB and encountering higher levels of disruptive behaviors were at greater risk for reporting depressive symptoms. Following a stress and coping model, Romero-Moreno et al. (2011) [36] analyzed the moderating effect of two self-efficacy domains in different points of the caregiving process: (1) SE:MB in the relationship between frequency of behavioral problems and burden; and (2) SE:CT in the relationship between burden and distress (depression and anxiety). A Spanish version (Márquez-González et al., 2009) [28] was used in face-to-face interviews. Results revealed the moderator role of SE:CT in the relationship between burden and distress, and supported the multidimensionality of the self-efficacy construct. Although the hypothesis that SE:MB would moderate the relationship between behavioral problems and burden was not supported, SE:MB was shown to benefit caregivers who reported both high and low frequency of behavioral problems. Intervention Research Individual-focused RCTs with RSCSE as a primary outcome In a randomized, experimental study, Ducharme et al. (2011b) [15] assessed the efficacy of Learning to Become a Family Caregiver (LBFC), a psychoeducational program focused on easing the transition into the caregiving role for adults assisting a recently diagnosed relative with Alzheimer’s disease. A French Canadian translation of the RSCSE was used as one of the primary outcome measures at baseline, end of treatment, and 3 months after the 7 week-long program. Among other findings, caregivers in the experimental group showed greater self-efficacy both at the intervention completion time, as well as at the 3-month follow-up, than control group caregivers. In analyses of six-month follow-up data, differential impact of the experimental program on self-efficacy was non-significant (Ducharme et al., 2012) [16]. Following these findings, Ducharme et al. (2015b) [18] evaluated the efficacy of adding a booster session to the LBFC intervention, a 90-minute session for caregivers to consolidate what they learned. Their French Canadian translation of the RSCSE was again utilized as an outcome measure to assess differences between those caregivers receiving the booster session, those who participated in LBFC without a booster session, and a control group who received regular care from memory clinics. As compared to the control group, self-efficacy was greater for caregivers who received the intervention, regardless of the booster session. Two interventions for male family dementia caregivers (Gant et al., 2007) [20] were similarly examined suing the RSCSE as an outcome measure. These interventions were compared to explore potential differences between an educational versus a video and workbook intervention. The educational and check-in-call condition included a booklet with information on dementia and biweekly telephone calls, whereas the video condition involved 10 sessions of videos, a workbook specifically for men, and weekly telephone calls. No differences were found between the two conditions, although pre- to post-intervention improvements were found for both conditions on RSCSE scores, as well as on other mental health and psychosocial outcomes. A culturally sensitive CBT group intervention for Spanish-speaking dementia caregivers was compared to a more general psychoeducational group in the USA (Gonyea et al., 2016) [23]. The two interventions had the same structure of 5-week, 90-minute group sessions with telephone coaching and homework assignments. Repeated measures analyses of variance (pre-, post-, 3-month follow up) showed a modest yet significant Condition x Time effect on total RCSE score. Compared with caregivers in the psychoeducational group, those in the CBT condition reported significant improvements in self-efficacy from baseline to postintervention, and these gains were maintained at the three months. A telephone-based psychoeducational program for family dementia caregivers was shown to decrease burden and increase self-efficacy in a sample of Chinese caregivers in Hong Kong (Kwok et al., 2013) [52]. Caregivers were randomized to receive either the psychoeducational intervention, which included telephone-delivered consultation from social workers, or were placed in the control group that provided participants with an educational DVD. SE:OR increased for the intervention group as compared to the control group (who experienced a slight decline), whereas SE:CT and SE:MB improved for both the experimental and control group participants. Williams et al. (2010) [46] assessed a video-based coping skills (VCS) intervention to reduce distress in caregivers of a relative with Alzheimer’s disease or related dementia. Caregivers were assigned either to the VCS training, which involved coping skills training through video illustrations and phone coaching, or to a waitlist control condition. No differences in the self-efficacy subscales were found between the conditions; VCS training, however, led to improvements in depressive symptoms, anxiety, perceived stress, and average systolic and diastolic blood pressure. Group-based RCTs with RSCSE as a primary outcome Au et al. (2010b) [3] evaluated the effectiveness of the Coping and Caregiving psychoeducational group-based program (Gallagher-Thompson et al., 2007) [19] for Chinese family caregivers of patients living with Alzheimer’s disease. Female primary caregivers were randomized to join the treatment group or a waitlist control group. The caregivers in the treatment group participated in thirteen weekly group sessions that taught specific cognitive-behavioral strategies to handle caregiving stress. As compared to the waitlist control group, caregivers in the treatment group were found to demonstrate significant increases in their SE:CT and SE:MB scores. Results supported the potential of the self-efficacy scales in gauging therapeutic changes in caregivers (Au et al., 2010b) [3]. Glueckauf et al. (2007) [50] evaluated the effects of a telephone-based cognitive-behavioral intervention on caregiver’s self-efficacy, as well as on psychological distress and caregiving specific problems. Rural family caregivers of older adults with dementia were randomized to receive either the cognitive-behavioral (CB) intervention, which included 12 weekly sessions of telephone group and individual sessions, or to routine education and support (ES). Caregivers in the telephone-based CB intervention had significant improvements in their SE:OR and SE:MB scores, as well as their total RCSE scores as compared to ES control group. Individual-focused RCTs with RSCSE as a secondary outcome Cristancho-Lacroix and colleagues first described (Cristancho-Lacroix et al., 2013) and then evaluated (Cristancho-Lacroix et al., 2015) [12] the efficacy of a web-based psychoeducational program for informal caregivers in an unblinded randomized clinical trial. The French Canadian translation of the RSCSE (Marziali and Garcia, 2011) [56] was employed in this study as a secondary outcome, but no intervention effects for self-efficacy beliefs were found. Two telehealth interventions for women caregivers of adults with neurocognitive disorders were developed and evaluated (Steffen & Gant, 2015) [41]. Participants were randomized into either the behavioral coaching intervention, which included video segments, weekly telephone calls, and maintenance calls, or into a basic education individual condition. The participants in the telehealth coaching intervention showed greater improvements in SE:OR and SE:MB scores, as well as in their depressive symptoms, upset, and negative mood states. A group mindfulness-based stress reduction (MBSR) intervention was used with Chinese caregivers of people with chronic conditions including cognitive impairment; outcomes were caregiver improvements in depression, anxiety, quality of life, self-efficacy, self-compassion, and mindfulness (Hou et al., 2014) [51]. Caregivers who were randomly assigned to the MBSR group received eight weekly sessions teaching skills such as meditation, mindfulness, and body scanning, as well as CDs to guide a daily home practice, and caregivers in the control group received self-help materials. A validated Chinese translation of two RSCSE subscales, SE:OR and SE:CT, was used and significant improvements in SE:CT were found for the MBSR group compared to the control group. Results support the differential abilities of the subscales to measure intervention outcomes. RSCSE as a mediator of intervention outcome The RSCSE has also been found to have mediating effects on a range of intervention outcomes, including within psychoeducational and positive psychology based interventions. A RCT of psychoeducational skill training groups in the USA (Coon et al., 2003) [9] resulted in higher self-efficacy scores in both SE:MB and SE:CT for intervention participants. SE:CT was found to partially mediate treatment impact on depressed mood, hostility, and state anger. In two separate double-blinded RCTs examining benefit finding interventions for Hong Kong caregivers, SE:CT was the primary mediator of significant intervention effects (Cheng et al., 2016, 2017) [7-8]. These two studies, utilizing group (Cheng et al., 2016) [7] and individual-focused (Cheng et al., 2017) [8] interventions are noteworthy in their attention to intervention strategies grounded in positive psychology. Similarly within a multisite and bilingual (English and French) Canadian study, Marziali and Garcia (2011) [56] evaluated the impact of two internet-based interventions on dementia caregivers’ distress and health status. Caregivers experienced significant increases in their total SE scores following both Chat Group and Video Group interventions. Within the Video Group, however, increases in total RSCSE scores were associated with declined stress response in caregivers leading to a significant mediation effect. RSCSE as a moderator of intervention outcome The effectiveness of an in-home behavioral management program (IHBMP) for female Chinese American caregivers was compared to a telephone support condition (TSC) by Gallagher-Thompson and colleagues (Gallagher-Thompson et al., 2007) [19]. Caregivers randomly assigned to the IHBMP received aspects of CBT in a psychoeducational format, and showed less bother and depression following the intervention than caregivers assigned to TSC. Self-efficacy, as measured with Mandarin, Cantonese, and English versions of the RSCSE, was found to moderate treatment impact, such that caregivers with low levels of SE:OR showed improvement in the IHBMP, but not in the TSC. These results show how the RCSE subscales can be used to understand differential treatment outcomes. Quasi-experimental studies with RSCSE as an outcome Due to the lack of control or comparison groups, the results of the following studies should be interpreted with caution. We present them as pilot studies worth some consideration due to the novel components of either the sample or approach to intervention delivery. The REACH intervention was revised and implemented for use with a rural population of dementia caregivers in the USA. Participants received up to nine in-home sessions and three telephone support group sessions providing information and support; there was no control group used in this demonstration study. Although participants reported decreased depression and burden over the course of the intervention, within group changes in a total RSCSE score were non-significant (Easom et al., 2013) [47]. Two subscales, SE:CT and SE:MB, of the Chinese version of the RSCSE were used to assess within group pre-post changes following an online cognitive behavioral therapy intervention for dementia family caregivers (Kwok et al., 2014) [53]. The online intervention lasted nine weeks and offered individualized support within a cognitive behavioral therapy framework. Both the perceived behavioral and psychological symptoms of dementia (BPSD) in care-recipients, as well as the BPSD-related distress in caregivers declined after the intervention. Within group SE:CT scores significantly improved from baseline to postintervention for caregivers assisting family members with moderate to severe stages of dementia. An online skills-based workshop for individual caregivers involved with the United States Department of Veteran Affairs was developed and evaluated, using the RSCSE as one outcome measure (Lorig et al., 2012) [54]. The Building Better Caregivers (BBC) program involved six weeks of workshops aimed at improving skills such as action planning, medication management, and stress management. Following the intervention, caregivers showed improvements from baseline in total SE scores as well as in burden, depression, pain, and perceived stress. Alzheimer’s Caregiver Support Online, an online and telephone intervention, was created for dementia family caregivers; within group changes from baseline to postintervention were assessed by Glueckauf et al. (2004) [49]. The intervention provided education for caregivers, as well as problem-solving and coping skills; participants reported significant increases on all three RSCSE subscales after receiving the intervention. The SE:CT subscale was used as one of the outcome measures to evaluate the impact of a group yoga-meditation intervention, Inner Resources, for female dementia family caregivers (Waelde et al., 2004) [43]. Latina and Caucasian caregivers in the USA participated, and study materials, including the SE:CT subscale, were translated to and interviewed with in Spanish for those who preferred it. Caregivers participated in six sessions of meditation, hatha yoga, guided imagery, and breathing techniques, and showed significant improvements in SE:CT, along with improvements in depression, and anxiety.