Copyright 1992 by The Cerontological Society of America The Cerontologist Vol.32, No. 3, 382-390

We examined the effectiveness of a multicomponent group program for spouses of frail aging veterans that included support, education, problem solving, and stress reduction. Compared with caregivers who received no intervention, those in the group program showed significant increases in use of active behavioral coping strategies, knowledge of community resources, perceived independence in the marital relationship, and personal changes in the caregiving relationship. They also experienced significant decreases in subjective burden and the stress and severity of caregiving problems. Key Words: Spouse caregivers, Burden, Support groups

An Evaluation of a Group Program for Spouses of Frail Elderly Veterans1

Numerous recent studies of the efficacy of psychosocial intervention programs for caregivers of frail elderly persons have been undertaken as a result of the increasing awareness of the potential negative effects of caregiving on the physical, social, and psychological well-being of the caregiver (see, for example, Greene & Monahan, 1987, 1989; Haley, Brown, & Levine, 1987; Lovett & Gallagher, 1988; Montgomery & Borgatta, 1989; Toseland, Rossiter, & Labrecque, 1989a, b, c; Zarit, Anthony, & Boutselis, 1987). Much less attention, however, has been paid to spousal caregivers than to adult children caregivers, and almost no attention to caregivers of frail aging veterans, a large and rapidly growing group of individuals. In addition, few evaluations of caregiver support programs have been focused on spousal caregivers and none have focused on caregivers of aging veterans (Toseland & Rossiter, 1989). Spouses differ from other types of caregivers in important ways, including providing more total hours of care, using fewer formal care resources, experiencing greater reductions in health and physical stamina, and increased isolation (Brody, 1981; Johnson, 1983; John-

1 This research was supported by the Department of Veterans Affairs, Health Services Research & Development #IIR 86-071. 2 Director, Ringel Institute of Gerontology, and Professor, School of Social Welfare, Rockefeller College of Public Affairs and Policy, University at Albany, State University of New York, Albany, NY 12222. 'Director, Managed Care Research (151K), Stratton VA Medical Center, Albany, NY, and a doctoral candidate in the Psychology Department, University at Albany, State University of New York, Albany, NY. 4 Past Project Director, and currently Program Director, Adult Day Health Care (122), Social Work Service, Stratton VA Medical Center, Albany, NY. 5 Associate Professor, Department of Anthropology, Sociology, and Social Work, North Adams State College, North Adams, MA, and a docloral student in the School of Social Welfare, Rockefeller College of Public Affairs and Policy, University at Albany, State University of New York, Albany, NY.

382

son & Catalano, 1981,1983; Montgomery & Borgatta, 1989; Soldo & Myllyluoma, 1983). Research on caregiver support programs has evolved from case studies of single support groups to experimental and quasiexperimental studies that include a number of groups and the measurement of a broader range of outcomes (Toseland & Rossiter, 1989). Results of the more recent, better-controlled studies of caregiver support programs are more equivocal than the glowing accounts of program effectiveness reported by the earlier case studies (Toseland & Rossiter, 1989). These results suggest that additional studies of new and improved psychosocial intervention programs are needed. Methodology Hypotheses In this study, no significant changes were expected in the physical health status and functioning of caregivers and care receivers. These variables were included primarily as descriptive control variables. Significant positive changes were hypothesized in the "micro-outcomes" measures of pressing problems, perceived self-efficacy, knowledge and use of community resources, informal social supports, and self-ratings of personal change. In contrast, less change was expected in the "macro-outcomes" measures of burden, coping, depression, stress, anxiety, and marital relationship. These predictions were made because previous research on adult children caregivers indicated that it is not reasonable to expect dramatic improvements in macro-outcomes such as depression, anxiety and marital relationship; improvements in specific objectives, or micro-outcomes, are more likely (Toseland, Rossiter, & Labrecque, 1989c). The Gerontotogist

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Ronald W. Toseland, PhD,2 Mark S. Labrecque, BA,3 Sarah T. Coebel, MSW,4 and Myles H. Whitney, MSW5

Participants

Table 1. Demographics by Condition in Study of Support Group Intervention

Vol. 32, No. 3,1992

Variable

Control (n = 47)

Support (n = 42)

Monthly income

Household $1,460

$1,413

Caregiver 67.6 8.1

64.2 5.8

100.0% 0.0% 0.0%

88.1 % 9.5% 2.4%

51.1% 40.4% 4.3% 4.3%

61.9% 28.6% 2.4% 7.1 %

How religious Not at all Somewhat Moderately Very Extremely

4.3% 10.6% 31.9% 46.8% 6.4%

4.8% 7.1 % 42.9% 42.9% 2.4%

Highest grade

11.3

11.9

Employment status Full-time Part-time Unemployed Retired Disabled Never worked

14.9% 4.3% 2.1 % 61.7% 0.0% 17.0%

14.3% 7.1 % 2.4% 42.9% 4.8% 28.6%

Age How long caregiving Race White Black Hispanic Religion Catholic Protestant Jewish Other

Age Race White Black Hispanic

t = .32

r = 2.12* r = 1.34 X2 = 5.93

X2 = -92

X2 = .90

r = -1.30 X2 = 7.39

Care Receiver 70.6

69.3

r = .87 X2 = 4.93

100.0% 0.0% 0.0%

88.1 % 9.5% 2.4% X2 = -92

Religion Catholic Protestant Jewish Other None

51.1% 40.4% 6.4% 2.1 % 0.0%

54.8% 33.3% 2.4% 4.8% 4.8%

How religious Not at all Somewhat Moderately Very Extremely

17.0% 14.9% 25.5% 38.3% 4.3%

14.3% 16.7% 40.5% 28.6% 0.0%

Highest grade

10.7

11.0

Employment status Retired Disabled

Statistics

X2 = 4.08

t = - .45

x2 = o.oo 42.6% 57.4%

42.9% 57.1 %

*p < .05.

Design A single blind, randomized, control group design was used. Initial screening of potential participants occurred over the telephone. In order to keep control subjects blind to the existence of the support group, as participants were recruited, each phone call was alternated on a predetermined basis to recruit either a control or support group participant. To keep all participants blind to the existence of an 383

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Potential participants were recruited through referrals from outpatient clinic staff and through the use of a computerized medical record system in one VA hospital. The wives of veterans who (1) resided in the community, (2) were over 59 years of age, (3) named their wife as next of kin, and (4) lived in counties within 100 miles of the VA hospital were sent a cover letter explaining the research project and a questionnaire to assess the kind of daily care they performed for their husbands. To obtain a sample of caregivers who were highly stressed and in need of support services, wives who expressed interest in participating and were actively providing care were further screened for level of burden by the project director using a telephone protocol developed for the study. Level of burden was determined by individual items assessing (1) the husband's medical condition, (2) the husband's functional abilities, (3) the husband's psychological needs, (4) the wife's ability to cope with the situation, and (5) an overall rating of the situation. Each of the five items was rated for its impact on the caregiver by the project director on a 3-point scale: 0 = low burden, 1 = medium burden, and 2 = high burden. To be accepted for the study, potential participants had to have a burden level greater than 4 where the maximum score was 10. The mean burden level for those accepted was 6.2. Originally, 108 caregivers agreed to participate in the study — 53 in the control condition and 55 in the support condition. A total of 13 participants assigned to the support group condition were dropped from the study due to difficulties that ranged from arranging for respite care (n = 7), lack of transportation to the meetings (n = 3), being unavailable to complete posttest interviews (n = 1), on further assessment not meeting the criteria for study participants (n = 1), and poor health (n = 1). A total of six participants assigned to the control group condition were dropped from the study because of impaired mental abilities (n = 1), language difficulties (n = 1), being unavailable to complete posttest interviews (n = 2), and being found to be ineligible for participation based on the criteria described above during the pretest interview (n = 2). Thus, there were a total of 89 participants in this study with 47 in the control condition and 42 in the support condition. At posttest one control group and two support group participants' husbands had died, and one support group participant's husband had been institutionalized. Demographic data for these participants is included in Table 1; however, they were dropped from all other analyses so that sample sizes reported in subsequent tables are 46 for the control condition and 39 for the support condition. Analyses of the demographic data indicate that the typical caregiver in the study was a white, married woman, age 66, with a high school education, who had been caring for her husband for more than 7 years. The typical care receiver was a 70-year-old white man, a disabled veteran, who had an eleventh grade education.

tered at both pretest and posttest, but some measures were administered at posttest only.

alternative condition, potential control group participants were only asked to agree to be interviewed four times during the course of the study. Potential support group participants were asked to agree to be interviewed and to agree to attend the support group meetings. This procedure introduces a potential selection bias in the randomization. However, this bias was considered less potentially confounding than the bias that would arise had control group participants been informed about the availability of a support group. The procedure was repeated over the course of approximately 8 months, until six support groups and six control groups were developed. Groups ranged in size from 5 to 9 individuals. To control for the potential confounding effects of different leaders, all groups were led by the same person, an MSW with approximately 8 years of experience in individual and group interventions with chronically ill and elderly persons. Throughout the study, participants were kept blind to the existence of the alternative intervention condition. However, because participants in the support group were asked additional questions at posttest to assess their participation, interviewers collecting posttest data could not be kept blind to the condition to which participants had been assigned. Therefore, single blind rather than double blind methodology was used in this study.

Care Receiver's Health Status and Functional Status. — Two measures were also used to rate care receivers' health and functional status at pretest and posttest. Caregivers were asked to rate their husbands' present physical health on a 5-point scale fromO = very poor to 4 = excellent. The measures of care receiver functional status were adapted from the Patient Assessment Tool for Home Care (PATH), a measure of client functioning and need for services/ care developed for the New York State Department of Health (RPI Home Care Classification Project, 1986). These included seven activities of daily living (ADLs) measured on 5-point scales ranging from 1 = independence (i.e., requires no supervision or assistance) to 5 = dependence (i.e., another person must help with all aspects of the ADL), and ten instrumental activities of daily living (lADLs) measured on 5point scales (responsibility for own medications had a 3-point scale) ranging from 1 = independent performance of the activity to 5 = not engaging in the activity at all. Good reliability and validity data are available on the PATH and it is able to accurately classify patients by disability level (RPI Home Care Classification Project, 1986).

Conditions

Support Group Condition. — Support groups met for eight weekly 2-hour sessions. Each session included four components: support, education and discussion, problem solving, and stress reduction. (A manual for leaders of support groups entitled ''Caregiver's Support Croup Manual" describing the intervention program in detail is available from Terry Harbert, Chief, Social Work Service [122], ColmeryO'Neil Department of Veterans Affairs Medical Center, 2200 Gage Boulevard, Topeka, KN 66622.)

Burden. — Caregiver burden was assessed in two ways. Participants were asked to estimate the total number of hours they spent providing care each day at pretest, and whether there had been any changes at posttest using a 5-point scale ranging from 1 = a lot fewer hours to 5 = a lot more hours. They were also asked to complete the Montgomery and Borgatta Burden Scale (MBBS), which assesses objective and subjective caregiver burden on ten 5-point items ranging from 1 = a lot less burden to 5 = a lot more burden. Because the scale asks caregivers to rate changes in burden it was given at posttest only. According to Montgomery and Borgatta (1986), the objective burden subscale has a Chronbach alpha of .94, and the subjective burden subscale has a Chronbach alpha of .73.

Control Condition. — Members of the control condition received no support group intervention. However, if they requested information or help with a problem they were referred to appropriate resources and services. Measures Personal interviews averaging IV2 hours were conducted with each participant within 2 weeks of their participation in the support or control group condition, and again within 2 weeks after intervention. Interviews were conducted either in participants' homes or at the VA, whichever was more convenient for them. A total of 330 interviews were conducted (control = 172; support = 158). Overall, 73% of interviews were conducted in participants' homes and the remaining interviews were conducted at the VA. This percentage was approximately the same for control (76%) and support (67%) groups. Most of the measures in the interview protocol were adminis-

Psychological Variables. — Caregivers were assessed for depression, anxiety, perceived selfefficacy, and coping skills. Because of the prevalence of depression as a symptom of caregiving (see, for example, Coppel et al., 1985; Gallagher, Nies, & 384

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Intervention

Caregiver's Physical Health Status. — Two measures were used to assess caregivers' health at pretest and posttest. Caregivers were asked to rate their present physical health on a global 5-point scale from 0 = very poor to 4 = excellent. Physical well-being was also assessed using the Physical Symptoms Index of the Adult Health and Daily Living Form (HDL) (Moos et al., 1987). This index lists 16 health symptoms (plus an "other" category), which the caregiver rated on a 5-point scale ranging from 0 = never to 4 = always. Good internal consistency among items is reported (Chronbach's alpha = .80).

Thompson, 1982; Myers et al., 1984), two measures of depression, the Beck Depression Inventory (BDI), and the Geriatric Depression Scale (GDS) were administered at pretest and posttest. The BDI contains 21 items, each with a 4-point scale ranging from 0 = not depressed to 3 = severely depressed. The BDI has demonstrated good reliability (r = .78 to .93), good to excellent validity, and sensitivity to clinical changes (Beck, 1967). Depression was also measured by the GDS, a 15-question yes/no instrument designed for elderly populations. The GDS has been assessed to have excellent reliability (r = .94), and good concurrent validity (Yesavage et al., 1983). Anxiety was assessed by the Spielberger State-Trait Anxiety Inventory (STAI), Forms X-1 and X-2 (Spielberger, Gorsuch, & Lushene, 1970), which assessed 20 state and 20 trait anxiety items on 4-point scales ranging from 0 = not at all to 3 = very much so. The STAI has high internal consistency (Chronbach's alpha range from .83 to .92) and reasonably high testretest correlations (range from .73 to .86). Concurrent validity is supported by acceptably high correlations (r = .41 to .83) with other anxiety measures. Perceived self-efficacy was measured at pretest and posttest by a 3-item index, developed by Duncan and Liker (1981), which assessed 1) how sure participants were that their lives would work out the way they wanted, 2) to what extent they carry out plans made ahead, and 3) to what extent they finish things once they start them. Responses were made using 5-point scales ranging from 1 = high to 5 = low self-efficacy. Help seeking and coping were assessed at pretest and posttest using indices from the Health and Daily Living Form (Moos et al., 1987). To assess help seeking behavior, participants were administered the eight-item Help Seeking Coping Index, which assessed whether they had sought help from the sources listed. To assess coping behavior, participants were asked to complete a 33-item Index of Coping Responses (ICR). Participants were asked to respond to the items on 5-point scales ranging from 0 = never to 4 = always. Reliability for the ICR subscales ranges from .44 to .80 (Billings & Moos, 1984; Holahan & Moos, 1987).

member of the network on a 5-point scale ranging from 1 = a lot less to 5 = a lot more, with 3 = about the same. Additionally, participants identified the type of support (e.g., emotional, regular instrumental, intermittent instrumental, and informational) received from children and others. Marital Relationship. — Two items were used to assess the quality of the marital relationship. Overall satisfaction was measured at pretest and posttest by a 5-point scale ranging from 0 = not at all to 4 = extremely. Change in spousal independence was measured at posttest on a 5-point scale ranging from 1 = a lot less to 5 = a lot more, with 3 = about the same.

Personal Change. —Two measures developed for this study assessed personal changes resulting from participation in the study. A four-item Personal Change Scale assessed the way caregivers' knowledge, feelings, thoughts, and behaviors changed regarding the caregiving situation. Each item was rated on a 5-point scale ranging from 0 = not at all to 4 = very much. A 12-item Self-Appraisal of Change Scale assessed changes in self-confidence, anger, isolation, enjoyment, and related areas. Responses were recorded on a 5-point scale ranging from 1 = a lot less to 5 = a lot more, with 3 = about the same.

Caregivers' Knowledge and Use of Community Services. — Participants' knowledge and use of community services were assessed at pretest and posttest. Eight services were assessed: (1) respite care, (2) adult day health care (ADHC), (3) hospital-based home care (HBHC), (4) meal programs, (5) homemakers/home health aides, (6) visiting nurses, (7) senior/ handicapped transportation, and (8) information and referral. Caregiver's Informal Support Network. — Informal social support networks of caregivers were measured through a series of questions. Participants named the people in their network, which included all their children, others (e.g., siblings, friends, neighbors), and, at posttest, new others. They also rated at posttest any change in satisfaction with each Vol. 32, No. 3,1992

385

Satisfaction. — Participant satisfaction was assessed at posttest by asking caregivers to rate how satisfied they felt with the help they had received on a 5-point scale ranging from 0 = not at all to 4 = extremely. All participants were also asked to respond to an open-ended question about what they found most helpful about their participation in the research project. Data Analysis Pretest to posttest change was assessed for the main effects of condition, time, and the interaction of condition and time, by multivariate repeatedmeasures analysis of variance. Pillai's criterion was used to evaluate the significance of main effects and interactions. Pillai's is more robust with unequal ns, and in cases where the assumption of homogeneity of variance is violated (Olsen, 1979). Significant multivariate effects were followed up with univariate ANOVAs. Significant interaction effects were followed by a simple effects analysis. These post-hoc

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Pressing Problems. —At pretest, participants were asked to identify pressing problems related to caregiving. At posttest, participants were asked to rate (1) how stressful the problem had been in the preceding month from 0 = not at all stressful to 4 = extremely stressful, (2) how self-confident the caregiver felt in coping with or accepting the problem from 0 = not at all self-confident to 4 = extremely self-confident, and (3) if there was a change in the problem from - 3 = much worse to 4 = completely better, with 0 = no change.

scores as measured bytheADLand IADL inventories. At pretest, care receivers had an average of one or more ADL impairments and two to three IADL impairments.

comparisons included both the between-subject effect (within time and across condition) and the within-subject effect (within condition and across time). The Games and Howell procedure is recommended for between-subject post-hoc comparisons when there are unequal ns and heterogeneous variances in order to maintain family-wise Type I error (Games & Howell, 1976; Jaccard, Becker, & Wood, 1984; Keselman & Rogan, 1977). Within-subject comparisons for the simple effects analysis were conducted using contrasts specified within MANOVA. Posttest only data were analyzed by multivariate analyses of variance (MANOVA). In situations where only a single dependent variable was used to measure a concept, univariate rather than multivariate tests were used to analyze the data. Categorical variables were analyzed using chi square. In addition to quantitative analyses, audiotapes of group sessions were reviewed to assess treatment integrity, major themes in group discussions, and sources of beneficial group outcomes.

Burden

Results

Health Status As shown in Table 2, there was no significant multivariate effect for condition, time, or condition-bytime interaction for caregiver's physical health. Tihis means that there was no change in caregivers' global health rating scores or in their Physical Symptoms Index scores from pretest to posttest. Similarly, there were no significant changes in care receivers' global physical health scores or in their functional status

Psychological Variables As can be seen in Table 2, there was a significant condition-by-time interaction for the psychological

Table 2. Effects of Support Group Intervention According to Multivariate Analyses of Variance

Effect

Pillai's

Exact F

Hypothesis DF

Error DF

Significance

Caregiver's physical health Condition Time Condition by time

.02501 .05047 .00112

1.05188 2.17915 .04598

2.00 2.00 2.00

82.00 82.00 82.00

.354 .120 .955

Care receiver's physical health and functional status Condition .05667 .08580 Time .06514 Condition by time

1.62186 2.53415 1.88144

3.00 3.00 3.00

81.00 81.00 81.00

.191 .063 .139

Psychological variables Condition Time Condition by time

.10697 .15980 .25231

1.13793 1.80687 3.20587

8.00 8.00 8.00

76.00 76.00 76.00

.348 .089 .003

Knowledge of community services Condition .10536 .50529 Time Condition by time .24500

1.29552 11.23530 3.56953

7.00 7.00 7.00

77.00 77.00 77.00

.264 .000 .002

.49997 1.96972 .77406

7.00 7.00 7.00

77.00 77.00 77.00

.832 .070 .611

2.00

82.00

.026

3.00

75.00

.024

2.00

76.00

.000

Use of community services Condition Time Condition by time

.04348 .15187 .06574

Change in caregiver's burden at posttest 3.82907 Condition .08541 Caregiver's evaluation of pressing problems at posttest Condition .11801 3.34497 Caregiver's evaluation of personal change at posttest Condition .19333 9.10748

386

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There was a significant main effect of condition and a significant condition-by-time interaction for the hours of caregiving. Post-hoc comparisons revealed no significant difference in hours of caregiving across conditions at pretest. There was, however, a significant difference across conditions at posttest [V (81) = 2.96, p < .05]. There was also a significant difference from pretest to posttest for control group participants [F (1,83) = 9.01, p = .000], but not for support group participants [F (1,83) = .70, p = .405]. As can be seen from the means presented in Table 5, caregivers in the control condition estimated their posttest hours of caregiving to be greater than support group participants, and they estimated their hours increased from pretest to posttest. Table 2 reveals a significant multivariate main effect for change in caregiver burden. Univariate ANOVAs for objective and subjective burden revealed that the significant difference was in the subjective [F (1,83) = 7.07, p = .009] rather than the objective burden subscales[F (1,83) = 3.89, p = .052] of the MBBS. Support group participants experienced significantly more change in subjective burden at posttest than did control group participants.

variables that were measured. Univariate ANOVAs were significant for three measures: the BDI [F(1,83) = 11.19, p = .001], perceived self-efficacy [F = (1,83) = 4.76, p = .032], and active behavioral coping [F (1,83) = 3.99, p = .049]. The only post-hoc comparison across conditions that was significant was active behavioral coping at posttest [V(83) = 2.49, p < .05]. The contrast revealed that there was significantly more use of active behavioral coping at posttest. Post-hoc comparisons over time were significant for the support group condition [F (1,83) = 6.41, p = .013] but not for the control condition. Support and control group participants scored similarly on the use of active behavioral coping at pretest; however, the support group participants increased their use of this strategy from pre- to posttest and control group participants did not. The post-hoc comparison over time for the BDI was significant [F (1,83) = 17.39, p = .000] for the control condition but not for the support condition. The means (shown in Table 5) reveal that control group participants reported being less depressed on the BDI at posttest than at pretest. There was no significant difference in depression over time reported for support group participants, nor was there any significant difference between support and control groups on the BDI at either pre- or posttest. The post-hoc comparisons for perceived selfefficacy were not significant across condition or over time.

Marital Relationship Table 3 reveals a significant main effect for marital satisfaction overtime. Participants in both conditions were less satisfied at posttest. There was also a significant increase in feelings of independence experienced by support group participants but not by control group participants, with over 20.5% of participants in the support groups reporting feeling a lot more independent compared with only 2.3% in the control group. Pressing Problems

Personal Change A significant multivariate main effect of condition was found in caregivers' evaluation of personal changes related to caregiving. Univariate ANOVAs revealed a significant effect for personal change [F(1,77) = 17.26, p = .000] but not for self-appraisal of change. The means presented in Table 5 indi-

Caregivers' Knowledge and Use of Community Services A significant multivariate main effect of time and a significant condition-by-time interaction were found for knowledge of community services. Univariate ANOVAs indicated significant interaction effects for knowledge of ADHC [ f (1,83) = 21.94,p = .000] and HBHC [F (1,83) = 5.23, p = .025]. There were no significant univariate effects for knowledge of any of the other community services. Post-hoc comparisons revealed significantly greater knowledge by support group participants at posttest of ADHC [V (79) = 3.349, p < .05] and HBHC [V (83) = 2.09, p < .05]. Post-hoc comparisons revealed a significant increase in support group participants' knowledge of ADHC [5(1,83) = 40.55, p = .000] and HBHC [F (1,83) = 17.39, p = .000] over time. However, no similar increase was found in control group participants' knowledge of ADHC or HBHC. Table 2 reveals that there were no significant multivariate effects for use of community services. Service utilization was not different and did not increase for control or support group participants from pre- to posttesting.

Table 3. Effects of Support Group Intervention According to Univariate Repeated Measures Analysis of Variance

Effect Hours of caregiving Condition Time Condition by time

DF

MS

F

Significance

84.05 3.10 10.84

1 1 1

84.05 3.10 10.85

5.61 2.01 7.02

.020 .160 .010

1 1 1

.11 5.59 .22

.05 12.62 .50

.830 .001 .483

Quality of marital relationship Condition .11 Time 5.59 .22 Condition by time

Table 4. Posttest Outcomes of Support Group Intervention

Variable (at posttest) Stress of pressing problems Self-confidence in ability to cope with pressing problems Change in severity of pressing problems Personal Change Scale Self-Appraisal of Change Scale Change in satisfaction with children with others

Caregiver's Informal Support Network Only two participants identified a new person as part of their informal support network at posttest. There was no change in satisfaction with either children or others at posttest. Vol. 32, No. 3,1992

SS

Control Support (n = 46) (n = 39) 2.31

1.83

F=

4.83'

1.91

2.09

F=

0.91

- .28 1.89 3.08

.67 4.26 3.13

F =

10.04**

F =

17.26**'

3.03 3.00

t= t=

3.00 2.96

*p< .05; **p< .01; ***p < .001. 387

Statistics

F=

1.78 -1.05 -1.44

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Table 4 indicates there was a significant multivariate main effect for condition in caregivers' evaluation of the pressing problems they were experiencing. Univariate ANOVAs revealed significant differences for the stress of pressing problems [F (1,77) = 4.83, p = .031] with the support group condition participants reporting less stress, and greater improvement in pressing problems [F 0,77) = 10.04, p = .002] at posttest. Participants in the control condition indicated that their pressing problems became somewhat worse at posttest.

Table 5. Means and Standard Deviations for All Measures in Study of Support Group Interventions Control (n = 47) Variable

Time Mean SD

Caregiver's physical health

Pre

Caregivers' physical symptoms Care receivers' physical health Care receivers' ADLs

Post Pre Post Pre Post Pre Post

Care receivers' lADLs

Pre Post

Hours of caregiving

Pre

Geriatric Depression Scale State Anxiety Scale Trait Anxiety Scale Perceived self-efficacy Professional help seeking Active cognitive coping Active behavioral coping Avoidance coping

Post Post Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre

Post Pre Post Pre Post

Knowledge of community services Respite care Pre Post Adult day health care Pre Post

.54 .70 .57 .57

.51

.58 .52 .51 .81 .95

7.13 7.21 8.88 7.94 2.99 3.46 .52 .46

7.89 6.37 3.28 3.01 7.68 7.60 7.55 8.57 .78 .76 .95 1.04 6.12 5.62 7.01 7.82 2.51 3.18 .50 .47 .50 .50

Control (n = 47)

Mean SD

Variable

2.56 2.49 .68 .63 1.87 1.62 13.15 14.39 34.77 35.05 3.63 3.40 3.09 2.91 9.18 9.69 3.05 2.97 30.64 30.28 30.15 30.51 2.26 2.11 .64 1.08 26.15 27.82 25.95 28.64 7.62 7.56

Knowledge of community services (continued) .44 Pre Hospital-based home care Post .50 .65 Home health aides/ Pre homemakers Post .72 Pre Visiting nurse association .87 .94 Post .76 Transportation Pre .83 Post Pre .48 Information and referral .83 Post

.62 .92 .46 .87

.72 .64 .48 .43 .92 .93 5.70 7.45 7.92 8.12 2.25 2.51 .55 .58 .58 6.04 2.13 3.42 7.46 7.89 8.26 8.19

Use of community services Respite care Adult day health care Hospital-based home care Home health aides/ homemakers Visiting nurse association Transportation

.60

.73 .74 .93 6.64 6.67 6.62 6.90 3.61 3.32

Information and referral Change in satisfaction with children Change in satisfaction with others Marital satisfaction Stress of pressing problems Coping with pressing problems Severity of pressing problems Personal Change Scale Self-Appraisal of Change Scale

.49 .27 .51 .34

cate greater personal change for support group participants. Satisfaction Support group participants rated their satisfaction with their participation significantly higher than did control group participants (M = 3.19 vs. M = 2.72, F = 7.13, p < .01). In response to the open-ended question about what they liked most about the group, support group members frequently mentioned: they learned how to cope with the stress and how to relax; the counselor helped them to think out their problems rather than offer solutions; they were not alone with their concerns; they could say things that they couldn't tell family or friends; they could vent their feelings without guilt; they learned they were doing a good job; their self-confidence increased; and resources and services were available to help them with their caregiving responsibilities. Control group participants also made many positive 388

Time Mean SD

Pre

Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post

.02 .11

.24 .26 .15 .15 .04 .13 .04 .02 .28 .33 .11 .15

.50

Support (n = 42) Mean SD

.43 .38

.46 .72 .74 .87 .87 .90 .72 .82

.51 .38

.41 .74

.51 .48 .46 .34 .25

.51 .46 .44 .34 .34 .31

.46 .39 .50 .44

.15

.03

.16

.32 .43 .44 .36 .36 .21 .34 .21 .15 .46 .47 .32 .36

.08 .10 .13 .13 .15 .10 .10 .05 .05 .13 .26 .03 .15

.27 .31 .34 .34 .37 .31 .31 .22 .22 .34 .44 .16 .37

Post

3.00 0.0

3.03 1.48

Post Pre Post Post Post Post Post Post

2.96 2.67 2.22 2.31 1.91 -.28 1.89 3.08

3.00 2.51 2.24 1.83 2.09 .67 4.26 3.13

.16 1.21 1.33 1.01 .77 1.35 2.31 .18

0.0 1.02 1.16 .93 .95 1.33 2.88 .19

comments including: just being able to tell someone about my situation; helped me think about things I hadn't before; realizing that other people were in similar situations; knowing that there was someone I could turn to for assistance; and having someone listen to my concerns. Discussion The results of this study suggest that participation in a support group has some short-term benefit for spouses of aging veterans. Support group participants experienced significant decreases in the stress and severity of pressing problems related to caregiving and in subjective burden. They also experienced significant increases in use of active coping strategies, knowledge of community resources, perceived independence in the marital relationship, and personal changes in their ability to cope with the caregiving situation. However, no changes were found in the health status of the caregiver or care receiver, or The Gerontologist

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Objective burden Subjective burden Beck Depression Inventory

2.67 2.59 .75 .69 1.91 1.89 16.04 17.00 36.70 38.57 4.54 5.31 2.87 3.21 11.59 8.80 3.87 3.83 31.50 31.22 29.76 30.17 2.02 2.23 .94 .98 25.67 26.83 24.98 24.67 6.65 7.46

Support (n = 42)

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group participants, but not an increase in use of these services, is supported by previous research evaluating group intervention for daughters caring for their frail parents (see, for example, Toseland, Rossiter, & Labrecque, 1989a, b, c). In contrast, the finding that there was no change in the size of the informal support networks of caregivers participating in the groups is not supported by the previously cited research. This may point to another difference in the way female spouses and female adult children respond to group programs for caregivers. Spouses, who tend to be more isolated than adult children, may find it more difficult to reach out and develop new friendships even with the help of a support group. In fact, unlike adult daughters who participated in similar psychoeducational support groups (Toseland, Rossiter, & Labrecque, 1989c), spouses did not name their fellow participants in the support group as new members of their informal support networks at posttest. In the future, support group programs for caregivers may want to place special emphasis on helping spouses to increase their social support networks by encouraging them to reach out to group members and to others who are not currently part of their friendship network. Additional research is also needed to confirm data from this study and our previous studies, which indicate spouses may have a more difficult time than adult children in strengthening their informal support network through group intervention. The fact that caregivers in the support group condition experienced significant reductions in the stress and severity of pressing problems (some of these problems included feelings of depression and anxiety), but not in standardized measures of anxiety and depression, supports our original hypotheses about the sensitivity of micro- vs. macro-outcome measures for assessing changes brought about by psychoeducational programs for caregivers. Changes in the use of active behavioral coping strategies, knowledge of ADHC and HBHC, and in personal changes related to caregiving can be viewed as additional evidence for the greater sensitivity of micro measures of change. Based on these findings, future researchers may want to develop measures designed to assess the specific goals of a particular caregiver intervention program, rather than relying solely on global measures of change. Participants expressed satisfaction with their participation in a support group, underscoring the beneficial impact of the intervention. Additional research is needed to determine whether the impact of the intervention persists over time. Perhaps more interesting, however, are the responses from control group participants. It is clear from their satisfaction levels, as well as their spontaneous replies to open-ended questions at posttest, that merely talking with someone about their situation during screening and pretest interviews was perceived as beneficial. Therefore, to control for the reactive effects of testing, and to assess the full impact of group programs for spousal caregivers conducted in community settings without extensive

in caregivers' objective burden, anxiety, or use of community resources and social support networks. Audiotapes of the group meetings revealed that, after hearing others' situations, members often expressed the feeling that "their situation was not so bad." Caregivers' efforts to provide the best possible care to their frail spouses were validated by the leader and their fellow members during group meetings. It is also clear from the tapes that members received much encouragement and support from each other and the group leader in grappling with difficult caregiving issues, problems, and concerns. This, in turn, may have helped caregivers in the groups to feel less burdened, and to take the steps necessary to make changes in problematic caregiving situations. At first, we found the significant change in hours spent caregiving rather puzzling in the absence of a significant change in the health status of the care receivers. It may be that those in the control group became sensitized to their caregiving responsibilities and duties as a result of the screening and pretest interview. However, unlike participants in the groups who were educated about the importance of taking care of themselves by engaging in physical exercise, leisure pursuits, and other stress reduction activities, those in the control group may have used their heightened awareness to engage in even more caregiving activities. In fact, those in the control group reported that the number of hours they spent caregiving per day increased rather dramatically during the short time frame between pretest and posttest. Since a significant change in hours spent caregiving was not found in a recent evaluation of a caregiver support program for daughters of the frail elderly (Toseland, 1990), the finding may also reflect a difference in response to psychoeducational interventions by spouses and adult children. Unless specifically instructed to spend time in stress-reduction exercises such as exercising or pursuing a leisure activity, spousal caregivers, who already do more than adult children, may increase the number of hours they spend caregiving per day as a result of attending a support group program, whereas adult children may not. An increase in the already extensive hours spousal caregivers spend in caregiving activities may have the unwanted effect of reducing attention to their own needs, increasing their isolation, and increasing the dependency of the care receiver. Therefore, those who plan and conduct intervention programs for spousal caregivers may want to ensure that their programs include a focus on helping caregivers to set aside time for their own needs. The finding that there was a significant increase in knowledge of ADHC and HBHC may indicate that these resources were the most salient for caregivers. These two resources address caregivers' needs for relief from the 24-hour-a-day, 7-days-a-week feeling of responsibility that caregivers frequently mentioned during group interaction as one of the most stressful aspects of caregiving. The finding that there was a significant increase in knowledge of community services on the part of

screening and pretest interviewing, future researchers should consider including a posttest-only control group in their evaluation designs. References

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An evaluation of a group program for spouses of frail elderly veterans.

We examined the effectiveness of a multicomponent group program for spouses of frail aging veterans that included support, education, problem solving,...
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