Through careful collection of TI data (Burgio et al., 2001
), we showed that interventionists can apply multicomponent treatments accurately and that CGs are receptive to receiving up to eight home visits and two therapeutic phone calls over a 6-month period. CGs in the MSC group were somewhat less receptive to the brief phone contacts offering nonspecific support, with calls lasting approximately only 10 of the 15 scheduled min. Moreover, African Americans were significantly less receptive to the MSC phone contacts, with calls lasting an average of 2 fewer min in duration than those to Whites. Note that our treatment delivery data indicate that interventionists were equally accurate in delivering this intervention to African American and White caregivers; thus, this finding cannot be attributed to TI differences. Interventionists’ evaluations of treatment enactment suggest that 79% of the CGs showed moderate to good adherence to the skills training intervention. Notably, except for the racial difference found for duration of MSC phone contacts, our interventions, designed to be culturally sensitive, were applied and accepted similarly by African American and White CGs.
The outcome data show no change in distal outcomes of depression and anxiety over the 6-month period. Results do show significant therapeutic changes over time for three proximal targets of intervention: number of problem behaviors, average bother per behavior problem, and satisfaction with leisure activities. More specifically, CGs in both intervention groups reported significantly fewer problem behaviors, less behavioral bother, and an increase in satisfaction with leisure activities. Because of the absence of group differences, we do not know whether these therapeutic changes are related to participation in treatment or whether they are due to extraexperimental factors (e.g., regression to the mean or more experience in the CG role). However, studies that have used a no-treatment control group report either no change or worsening in number of problem behaviors and behavioral bother over similar time intervals (Ostwald et al., 1999
; Quayhagan et al., 2000
). Similarly, researchers have not reported therapeutic changes in leisure activities over time.
In addition, Goode, Haley, Roth, and Ford (1998)
and Roth, Haley, Owen, Clay, and Goode (2001)
studied White and African American dementia CGs in Birmingham by using many measures similar to those in the current project, and they found increased numbers of problem behaviors and no significant changes in appraisals or social activities over a 1-year period, further suggesting that the positive changes found in the present project are due to intervention and not the passage of time.
When race and relationship of CG were added to the analyses, an interesting pattern of results emerged. shows a treatment by race interaction for behavioral bother, with African American CGs in the more active STC group reporting less behavioral bother over time compared with White CGs in the STC and African Americans in the MSC. suggests that, for the number of problem behaviors, the differential treatment effects were most pronounced for spouse CGs. White spouse CGs in the MSC reported the largest decrease in number of problem behaviors; African American spouse CGs in the MSC actually reported an increase in problem behaviors.
On the basis of our clinical observations, we believe that African Americans were more responsive than Whites to the therapeutic relationship established in the one-on-one STC sessions. Although the psychotherapy literature clearly shows the importance of establishing a therapeutic alliance in achieving positive outcomes (Wampold et al., 1997
), racial differences have not been examined. It is also possible that Whites were more willing or able to use the written information provided in the MSC, or they may have been more responsive to the brief non-specific support offered by phone. Our finding that the duration of phone contacts was significantly longer for Whites offers some support for this latter point. The hypothesis that Whites might have been more able to use written information is not supported by the finding of similar education levels for our White and African American CGs (M
= 13.3 years, SD
= 2.1 and M
= 12.7 years, SD
= 2.5, respectively).
Regarding the differential treatment effects for spouses and nonspouses, Schulz, O’Brien, Bookwala, and Fleissner (1995)
suggest that spouse CGs provide greater levels of personal care and are more adversely affected by the caregiving experience than nonspouse CGs. Spouses might have the most to gain from an intervention they find to be helpful. Receiving an intervention not perceived to be therapeutic could add one more source of burden to an already burdensome situation. Data in show that White CGs are most responsive to the MSC; however, the MSC offered no therapeutic effects for African Americans. In this context, one would predict that White spouse CGs in the STC group—the individuals with the most to gain from a therapeutic intervention—would perceive the largest decrease in number of problem behaviors (). Similarly, it is not surprising that African American spouse CGs in the MSC group—the individuals with the most to lose from receiving what was, for them, an ineffective intervention—perceived an increase in number of problem behaviors over time.
Our data also uncovered interesting main effects for race. Numerous studies have shown that African American CGs report more benefits or gains from the caregiving experience than Whites (Rapp & Chao, 2000
). The African American CGs in our study reported a significant increase in positive aspects of caregiving over time, whereas Whites showed stable values. A possible interpretation is that, for African Americans, receiving an intervention can render the caregiving experience more positive and hopeful.
Prior research has also established that White CGs are more likely to place their impaired relatives in a nursing home than African Americans. A component of both of our interventions was to supply CGs with information to facilitate nursing home placement if they requested this information. Provision of this information might have resulted in a significant increase for Whites in the desire to institutionalize their relative over time. Any effects of this information on African Americans could have been suppressed by the strong cultural expectation against nursing home placement.
Finally, and unexpectedly, African American CGs reported a decrease in satisfaction with social support, with stability of White CGs over time. The results also showed a decrease in social network, but only for African American spouse caregivers. As already discussed, increasing social support was a direct aim of this study. Several previous longitudinal studies have shown significant declines in caregiver social networks and supports over time (Goode et al., 1998
; Kiecolt-Glaser, Dura, Speicher, Task, & Glaser, 1991
), suggesting that the stability found in White CGs may represent a preventive effect of the intervention for these CGs.
We believe that this home-based intervention can be administered with minimal modification through home health care agencies by either social workers or nurses. We are examining this strategy in an ongoing study utilizing social workers (MSWs), working through home health care agencies, to deliver a combined cognitive behavior therapy and problem-solving intervention to improve the quality of life of rural, medically fragile elders (Scogin, Kaufman, Burgio, Rohen, & Fisher, 2000
A weakness of the current study was our inability to blind study personnel to group assignment. Maintaining blinding in psychosocial intervention trials is notoriously difficult because participants often spontaneously discuss their intervention experiences with assessors. In addition, intervention materials such as external memory aids and written instructions can be present in the home during assessment. Research has shown that even when attempts are made to blind assessors, 86% can accurately guess which participants have received active intervention in a randomized trial, but that only subjective assessor clinical rating measures (not used in this study) are affected by knowledge of group assignment (Carroll, Rounsaville, & Nich, 1994
). Nevertheless, the issue of how to effectively blind assessors in studies of this type, and the impact of blinding on outcomes, deserves greater attention in future caregiver intervention studies.
In conclusion, our results suggest that both interventions, skills training (STC) and brief supportive phone calls plus written information (MSC), can reduce the number of problem behaviors and the bother associated with these problems; they can also increase satisfaction with leisure activities. Substantial prior research by the REACH team and other investigators indicates that none of these outcomes improve without intervention over a 6-month period of time.
However, the results suggest that the interventions were differentially effective based on these race and relationship factors. We believe that it is overly simplistic to think that interventions that are successful with CGs of one particular ethnic or cultural background would be equally effective with those from very different circumstances. Thus, the results of this study suggest the need to develop interventions with multiple components that are appropriately targeted to individuals who might benefit most from such interventions, with appropriate modifications made to maximize their relevance to subgroups of CGs based on relevant CG characteristics.