We developed and tested an intervention using web-based technology to conduct professionally led psychoeducational support groups with the spouses of male SSs. The goal was to reduce depression in both members of the CG-SS dyad by encouraging CGs to better attend to their emotional needs, as well as to those of the SS. We hypothesized that outcomes for CGs and SSs receiving the intervention would be superior when compared to dyads assigned to an information only control condition. According to the SPM (Pearlin et al., 1995
), we further hypothesized that increases in mastery, self-esteem, and social support would be associated with decreased depression for SSs and CGs alike. The conditions were also compared on measures of treatment credibility, effort, and perceived benefit.
Our findings suggest that the intervention reduced the primary outcome of depression for CGs at levels reflecting statistical and clinical significance. The practical impact of the intervention was demonstrated on several levels. First, it is noteworthy that about 40 percent of CGs receiving the intervention demonstrated a 50 percent decrease from CESD baseline scores, given that this type of change is widely used as the critical end point for defining improvement in depression treatment studies (Keller, 2003
). We also looked at the proportion of participants who dropped from baseline scores exceeding the CESD clinical cut off of 16 to scores less than 16 at posttest, which is another recommended approach for judging the clinical impact of treatment studies (Frank et al., 1991
). Not only did the intervention condition favor this type of change at posttest, a similar pattern was found at the one month follow-up as well. These patterns were true in both the intent-to-treat and per protocol analyses.
The clinical impact of the intervention in reducing CG depression is further suggested by the standardized ES (−.79 for intent-to treat and −.81 per protocol) associated with posttest mean differences on the CESD. This is especially evident when the effect sizes observed across other caregiver intervention studies are considered. For instance, in a meta- analysis of interventions for improving the mental health of CGs of SSs (as measured by change on the Short Form Health Survey; SF-36), Lee, Soeken, and Picot (2007)
reported that four high quality studies yielded varied effects with an overall mean weighted ES of 0.28. Pinquart and Sörensen (2006)
, in their meta-analysis of psychosocial interventions for CGs of dementia patients, concluded that ESs in the range of −.70 to be large and meaningful with respect to improving CG mental health outcomes. Although there is not full agreement on what magnitude of effect is necessary to establish practical significance, it has been advised that the most informative interpretation occurs when the effect size is compared to other effects involving the same or similar variables within related contexts (Ferguson, 2009
Although depression was not similarly reduced for SSs at clinically and statistically significant levels (as it was for the CGs), the overall pattern of change was in the predicted direction. However, reduced depression for SSs did not appear until one month after treatment, as evident in both the intervention and control. Thus, although the efficacy of the intervention for reducing depression in SSs was in the expected direction, it was not convincingly supported.
One possible explanation for lower intervention efficacy with SSs is that they were not directly involved with the intervention (apart from interacting with the CG on the homework assignments meant to benefit both dyad members). In turn, it could be that either CGs poorly implemented these assignments, or put insufficient effort into completing them. Similarly, CGs receiving the intervention may have ineffectively showed increased respect and concern for SSs’ emotional well-being as targeted by the intervention. In retrospect, quality assurance checks regarding homework completion and skill implementation seem advisable. Attempts to involve SSs more directly with the intervention might also be needed. For example, even SSs with significant communication impairments could participate more fully in the future by receiving reminders on a Smart Phone device to use relaxation techniques or to engage in pleasant activities. Such control enhancing techniques yield higher mastery and reduced depression (Landreville, Desrosiers, Vincent, Verreault, & Boudreault, 2009
Although our intervention did not produce significant change in outcomes other than depression for SSs or CGs, the pattern of zero-order correlations across the change scores for study measures lend modest support to the conceptual framework of the SPM (Pearlin et al., 1995
). This was mostly true for SSs where decreased depression was associated with increased mastery, self-esteem, and social support. Moreover, these correlations were large in magnitude. Although scholars have applied the SPM in studies of the well-being of family CGs of chronically ill adults (see, for example, Paoli, 2010
), the present study is unique in demonstrating its relevance to CRs.
For CGs in our sample, diminished depression was correlated solely with increased mastery. Although this finding alone is not highly supportive of the SPM, it is consistent with prior research where perceived mastery mediated the relationship between stressors and CGs’ psychological well-being for chronic illnesses beyond stroke (Gaugler et al., 2009
; Shirai, Koermer, & Kenyony, 2009
). Thus, perhaps the main goal of psychoeduational programs should be to increase feelings of mastery in route to improving the overall well-being of the primary CG. However, the exact causal relationships between self-esteem, mastery, social support, and well-being remain an active area of investigation within family caregiving research. Consistent with our results, Shirai et al. (2009)
found the impact of social support on CGs’ well-being to be mediated by perceived mastery in a non-intervention study with CGs of dependent older adults.
It is important to consider why our intervention did not yield significant changes on outcomes beyond depression. Because both CGs and SSs scored high on the other measures at baseline, there may have been insufficient opportunity for improvement to occur in a short 11 week period. In contrast, dyads were screened for elevated depression permitting a greater opportunity for change on this outcome. In addition, although prominent global measures of mastery, self-esteem, and social support were used (given their well-known reliability and validity), situation specific measures may have shown greater sensitivity to change (Paoli, 2010
Our findings also provide initial evidence that stroke families can benefit from a web-based intervention and that they are willing to use it. Even though CGs in our intervention condition found the program to be more useful than did controls, and were more confident in recommending it to others, there were no significant differences by condition in amount of reported effort devoted to the online programs.
Given the paucity of online intervention studies with stroke families, it is worth considering why the present findings are dissimilar from those of Pierce et al. (2009)
, whose intervention did not reduce CG depression. One possibility is that there was little room for change on this outcome in their sample where there was no initial screening for elevated depression. The two interventions also were based on different conceptual underpinnings, with Pierce et al. relying on Friedemann’s (1995)
framework of systemic organization. In turn, the primary outcome intended for SSs in their study was reduced use of services without corresponding attention given to quality of emotional care and its relationship to psychological well-being within the CG-SS dyad. Pierce et al. (2009)
also did not include enacted video support groups and real life chat sessions in their intervention. Thus, they did not provide the potentially therapeutic exposure to other CGs that was present in our intervention. Future research is needed to compare different varieties of online programs with stroke families and to identify specific therapeutic components that are most beneficial to psychological well-being.
Our findings should be interpreted cautiously in view of the exploratory and developmental nature of this project where the primary aim was to examine initial feasibility and efficacy of the intervention. Subsequent research is required to refine this intervention further, as well as more rigorously test its efficacy (ability to positively affect clinical outcomes) and effectiveness (applicability on a wide scale basis; Wells, 1999
). A comparison of the efficacy of our web-based intervention to a more traditional in-person format is also an important next step.
Our RCT involved only a small number of dyads that were almost entirely Caucasian. Thus, statistical power was compromised, potential moderators of treatment change (e.g., comorbidity, stroke severity, caregiving duration) could not be considered, mediational analyses based on the SPM were limited to zero-order correlations, differential treatment affects across racial and ethnic groups went unexplored, and characteristics of SSs (e.g., level of functional impairment) and CGs (e.g., amount or duration of care) that might influence treatment efficacy could not be meaningfully considered as covariates.
Given the very strict eligibility associated with the RCT, generalization of these findings across a wider spectrum of stroke care dyads is unknown. Furthermore, a limited timeline did not permit conducting long-term follow-ups. This limitation, coupled with the small sample size, restricted a fuller examination of collateral treatment changes at the dyadic level over time as predicted by the SPM. Our exclusive use of self-report measures points to the need to include more objective outcome indices in the future.
The major limitation, however, involves the specific control condition used. As Schulz et al. (2009)
pointed out, “The most appropriate control condition for this type of intervention… is under considerable debate. Options include treatment as usual, minimal support, or attention control” (p. 13). In turn, we reasoned that our control condition involved elements of both “treatment as usual” and “minimal support,” given that it provided access to large amounts of relevant information. Nevertheless, CGs receiving the intervention interacted both with each other and the Professional Guide, whereas those in the control condition did not. Therefore, in the absence of an attention control condition, we cannot conclude if the observed treatment differences were the result of anything beyond interacting with and gaining attention from others. Our control condition did not exclude the possibility that the opportunity to express feelings in a supportive atmosphere was the underlying therapeutic agent in the intervention condition.
Despite these limitations, we successfully developed and tested a theoretically derived web-based psychoeducational program that shows promise for enhancing the psychological well-being of SSs and CGs alike. Our findings also suggest that CGs perceived the intervention as credible and were willing to devote considerable effort to it. Because telehealth interventions for caregiving families are in their infancy, developmental initiatives like this are important and timely. As Glueckauf and Noel (2011)
pointed out, web-based videoconferencing is likely to become the preferred medium for obtaining CGs’ information and support as the technology-savvy baby boomers become increasingly involved in family care. The Internet provides economic advantages in providing education and support to family CGs as compared to standard face-to-face treatment, which is meaningful in the context of health care finance reform initiatives.