Cultural adaptation of an intervention for caregivers of young autistic children: Community members' perspectives

Caregivers of autistic children in low-to-middle-income countries experience many barriers to access resources to support their child's development. Caregiver training is considered an evidence-based practice and may be a cost-effective way to support caregivers of autistic children in such settings. This study focuses on the cultural adaptation of Parents Taking Action (PTA; Magaña et al., Family Process, 56, 57-74, 2017) to support caregivers of autistic children in Paraguay. We conducted focus groups and individual interviews with 28 caregivers, autistic individuals, and professionals in Paraguay to understand caregivers' needs and to explore needed cultural adaptations of PTA to achieve contextual fit. Participants identified caregivers' need for accurate and reliable information, strategies to support children's growth, and emotional support and strategies to manage stress. Additionally, participants provided recommendations for adapting PTA considering the dimensions within the Cultural Adaptation Checklist (Lee et al., International Journal of Developmental Disabilities, 2023). This study is the first step in the iterative process of culturally adapting an intervention and the process described in this study may be appropriate for culturally adapting other interventions.

Comprehensive Older Adult and Caregiver Help (COACH): A person-centered caregiver intervention prevents elder mistreatment

BACKGROUND

Elder mistreatment (EM) harms individuals, families, communities, and society as a whole. Yet research on interventions is lagging, and no rigorous studies demonstrating effective prevention have been published. This pilot study examines whether a first-of-its-kind coaching intervention reduced the experience of EM among older adults with chronic health conditions, including dementia.

METHODS

We used a double-blind, randomized controlled trial to test a strengths-based person-centered caregiver support intervention, developed from evidence-based approaches used in other types of family violence. Participants (n = 80), family caregivers of older adults who were members of Kaiser Permanente, completed surveys at baseline, post-test, and 3-month follow-up. The primary outcome was caregiver-reported EM; additional proximal outcomes were caregiver burden, quality-of-life, anxiety, and depression. Nonparametric tests (Mann-Whitney U, Fisher's Exact, Wilcoxon Signed Rank, and McNemar's) were used to make comparisons between treatment and control groups and across time points.

RESULTS

The treatment group had no EM after intervention completion (assessed at 3-month follow-up), a significantly lower rate than the control group (treatment = 0%, control = 23.1%, p = 0.010).

CONCLUSIONS

In this pilot study, we found that the COACH caregiver support intervention successfully reduced EM of persons living with chronic illness, including dementia. Next steps will include: (1) testing the intervention's mechanism in a fully powered RCT and (2) scaling the intervention for testing in a variety of care delivery systems.

I see, I learn, I do: Development and evaluation of a video-enhanced nasogastric tube feeding training programme for caregivers

AIM

We examined the effectiveness of a video-enhanced education package in improving caregiver outcomes (number of steps at first feeding attempt, time to achieve competency and knowledge) compared to the current institutional training approach.

DESIGN

Quasi-experiment.

METHODS

From August 2016-June 2017, we recruited 112 caregivers in a Singaporean tertiary hospital. We allocated 72 and 40 caregivers to video-enhanced and standard education, respectively. Median values are reported with interquartile ranges (IQR), and analysed using Mann-Whitney U test.

RESULTS

Caregivers taught with our video-enhanced package performed a median of 7.0 (IQR = 3.5-7.5) out of eight steps correctly at their first attempt, a 40% increase. There was no change in the median number of training sessions but the 75th percentile dropped to 9.3 from 6.0, a 35% reduction. Post-training knowledge improved from a median of 0.5 (IQR = 0-2.0) to 1.0 (IQR = 0-3.0). The video-enhanced package can improve caregivers' knowledge and accelerate their skill competency.

Evaluation of a Telehealth Training Package to Remotely Teach Caregivers to Conduct Discrete-Trial Instruction

The present study evaluated the effectiveness of using telehealth technologies to remotely train caregivers of children with ASD to conduct discrete-trial instruction (DTI). We used a multiple-baseline-across-participants design to evaluate caregiver correct implementation of the DTI procedures and child emission of independent correct tacts as dependent measures. We observed robust and immediate improvements for all three caregivers and two of three children. Treatment effects were maintained during follow-up and generalization probes. We discuss the benefits of telehealth technologies and other remote treatment applications.

Outcomes and Acceptability of Telehealth-Based Coaching for Caregivers in Asian Countries

Recent studies evaluating the effectiveness of using telehealth to train caregivers across large geographical distances in the United States and internationally indicate that this modality can increase families' accessibility to evidence-based interventions for problem behavior. In this study, experimenters and interpreters in the United States remotely coached nine caregivers of children with disabilities residing in three countries in Asia to implement functional analyses (FA) and functional communication training (FCT). Five of the nine families were culturally matched to either the experimenter or the interpreter. Problem behavior was reduced to near-zero levels for all but one participant. Furthermore, all caregivers implemented the procedures with high levels of integrity and rated the assessment and treatment as highly acceptable, regardless of cultural matching or use of interpreters. Overall, findings suggest telehealth-based caregiver coaching and caregiver-implemented FA plus FCT is feasible and acceptable in Asia.

Evaluating the Use of Video Modeling With Voiceover Instructions to Train Therapists to Deliver Caregiver Training Through Telehealth

Caregiver training is an important component of behavioral intervention; however, many barriers exist for in-person training. Alternatively, behavioral therapists may use telehealth as a service delivery method. To effectively train caregivers through telehealth, therapists should receive explicit training, but there has been limited research on effective methods for teaching this skill. The purpose of the current study was to evaluate video modeling with voice-over instruction (VMVO) to train therapists to implement 11 component skills of caregiver training through telehealth to teach confederate caregivers to implement a guided compliance procedure. We measured the therapist's implementation of the component skills during a scripted role-play before and after video-model training within a multiple baseline design across participants. We also conducted maintenance and generalization probes to a novel skill. All seven therapists learned the skill, but three therapists required a feedback component in addition to the VMVO. The results suggest that VMVO may be an efficient and effective method for training therapists to conduct caregiver training via telehealth. Furthermore, results indicate that component skill analyses may be valuable to monitor skills that require remediation.

A shared reading intervention: Changing perceptions of caregivers in a semi-rural township

BACKGROUND

 Many caregivers from low-middle income (LMI) households consider that preschool children are too young for shared book reading. Thus, many caregivers are unaware of their potentially powerful role in their children's emergent literacy and communication.

OBJECTIVES

 To describe (1) caregivers' perceptions of shared reading, (2) caregivers' perceptions of barriers to shared reading and (3) changes in these perceptions following a short intervention.

METHOD

 A qualitative methodology was used to understand the perceptions of 40 caregivers from a semi-rural South African township. Two semi-structured interviews were conducted before and after intervention. The intervention was a short training video about shared reading.

RESULTS

 Caregivers described the unfamiliar reading culture and viewed reading as an educational activity that they knew little about. Barriers to shared reading included lack of time, few reading materials and low levels of literacy or lack of exposure to this type of activity. Following the intervention, they acknowledged the importance of shared reading, described growing confidence in their shared reading abilities and closer relationships with their children.

CONCLUSION

 Speech-language therapists (SLTs) have a pivotal role to play in caregiver training of emergent literacy skills and can make a marked impact in guiding caregivers' shared reading. A short video-based intervention can alter caregiver perceptions and practices, which may be the first step in changing behaviours.Contribution: The study provides an example of a simple and cost-effective intervention that changed caregiver perception and caregivers' reported shared reading practice.

Examining the perceptions of needs, services and abilities of Czech and North Macedonian caregivers of children with autism and trainers

Effective practices for supporting families with autistic children ensure a match between their needs and the expectations and competencies of the clinician. Applied behavior analysis (ABA) services are a common provision for serving autistic individuals. However, in regions where ABA is in its infancy, like the Czech Republic and North Macedonia, culturally relevant resources, regulations for practice, and standardized coursework are missing. In their absence, it is necessary to investigate the degree to which practitioners in the regions are meeting the behavioral needs of families. Assessing this match can set the stage for establishing more stable and effective services in the areas, as well as neighboring countries with similar historical foundations. Therefore, a survey was conducted to examine the perceptions of caregivers and trainers (those who self-identified as providing support to families with autistic children). A total of 233 caregivers and 204 trainers participated. Analysis of the survey responses verified the lack of behavioral knowledge on the part of the trainers, the apparent lack of access to ABA services for families in both regions, a potential misalignment between family needs and training targets, and the disparities between the two countries. The information evaluated here can be used to guide preservice training, dissemination efforts, and regulations surrounding behavioral practices.

Improving Cancer Caregiver Communication and Health Literacy with a Brief Online Training Module

This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Discharge Practices for Children with Home Mechanical Ventilation across the United States. Key-Informant Perspectives

Rationale: In 2016, the American Thoracic Society released clinical practice guidelines for pediatric chronic home invasive ventilation pertaining to discharge practices and subsequent management for patients with invasive ventilation using a tracheostomy. It is not known to what extent current U.S. practices adhere to these recommendations.Objectives: Hospital discharge practices and home health services are not standardized for children with invasive home mechanical ventilation (HMV). We assessed discharge practices for U.S. children with HMV.Methods: A survey of key-informant U.S. clinical providers of children with HMV, identified with purposeful and snowball sampling, was conducted. Topics included medical stability, family caregiver training, and discharge guidelines. Close-ended responses were analyzed using descriptive statistics. Responses to open-ended questions were analyzed using open coding with iterative modification for major theme agreement.Results: Eighty-eight responses were received from 157 invitations. Eligible survey responses from 59 providers, representing 44 U.S. states, included 49.2% physicians, 37.3% nurses, 10.2% respiratory therapists, and 3.4% case managers. A minority, 22 (39%) reported that their institution had a standard definition of medical stability; the dominant theme was no ventilator changes 1-2 weeks before discharge. Nearly all respondents' institutions (94%) required that caregivers demonstrate independent care; the majority (78.4%) required two trained HMV caregivers. Three-fourths described codified discharge guidelines, including the use of a discharge checklist, assurance of home care, and caregiver training. Respondents described variable difficulty with obtaining durable medical equipment, either because of insurance or durable-medical-equipment company barriers.Conclusions: This national U.S. survey of providers for HMV highlights heterogeneity in practice realities of discharging pediatric patients with HMV. Although no consensus exists, defining medical stability as no ventilator changes 1-2 weeks before discharge was common, as was having an institutional requirement for training two caregivers. Identification of factors driving heterogeneity, data to inform standards, and barriers to implementation are needed to improve outcomes.

An Evaluation of Dementia Dialogues®: A Program for Informal and Formal Caregivers in North and South Carolina

In 2019, the University of South Carolina's Office for the Study of Aging (OSA) remodeled the curriculum for the nationally registered Dementia Dialogues^® program that delivers high-quality education to formal and informal caregivers of persons who exhibit signs and symptoms of Alzheimer's disease and related dementias (ADRD). This study evaluated new knowledge acquired and program satisfaction by North and South Carolina program participants (N = 235) after completing updated modules. Pre/post module survey data were analyzed using means and percentiles, McNemar's test, and paired t tests. Results demonstrated significant positive increases in caregiver knowledge attainment, with differences in overall knowledge change in specific modules among caregivers and noncaregivers (p < .0001-<.05). Dementia Dialogues^® may serve as a useful tool in providing important information that increases caregiver knowledge of persons living with ADRD. Further research is recommended to examine how knowledge improvement translates into caregiving practices.

Safe to sleep: Community-based caregiver training

Annually, thousands of infant deaths are classified as sudden unexpected infant deaths (SUIDs). In an effort to reduce the risk of SUIDs, the American Academy of Pediatrics has made a number of recommendations to educate caregivers, childcare providers, and healthcare professionals on safe infant sleep practices. The purpose of the current study was to extend the literature on safe infant sleep practices by teaching caregivers to arrange safe infant sleep environments using a mannequin and common infant items. We partnered with community-based agencies to evaluate the effectiveness of behavioral skills training delivered in a single training session as part of the ongoing pre- or postnatal care these agencies provided. Following training, all participants demonstrated a substantial change in responding and returned favorable social validity ratings. We discuss these outcomes in light of previous studies, limitations, and future directions.

Remote Coaching of Caregivers Via Telehealth: Challenges and Potential Solutions

The use of telehealth technologies to provide clinical services to families of children with autism and other developmental disabilities is a rapidly growing area of research. In particular, remote training of caregivers via video conferencing appears to be a promising approach for disseminating behavior-analytic interventions (Neely, Rispoli, Gerow, Hong, Hagan-Burke, 2017; Tomlinson, Gore, & McGill, 2018). Although remote training offers a number of advantages, it brings a variety of challenges that are unique to this modality. The field would benefit from information on problems that practitioners may encounter when providing these services and how to train caregivers effectively. In this paper, we report on the experiences of 18 practitioners who provided caregiver training via telehealth from four different sites across a 4-year period. We describe a variety of technical and clinical issues that arose during service delivery, suggest strategies for preventing and remediating problems, and include case descriptions and data to illustrate our experiences. This information may help prepare practitioners to deliver telehealth services and guide further research in this area.

Coping strategies of family caregivers in spinal cord injury: a qualitative study

Purpose: To identify the coping strategies used by family caregivers of persons with spinal cord injury (SCI) in Switzerland in order to develop tailored support programs.Materials and methods: Purposive sample of >18 years participants, speaking an official Swiss language fluently, being family caregivers of persons with SCI for at least 4 years, and perceiving either a high or low burden in relation to caregiving. Data were collected through face-to-face semi-structured interviews (N = 22). Thematic analysis was performed.Results: Four main coping strategies were identified: reappraisal, active acceptance, setting limits to the caregiver role, and seeking support. These strategies can be used one at a time or combined, and at different times of a caregiver pathway. Our analysis highlighted that caregivers need skills to implement these strategies (e.g., self-evaluation skills).Conclusions: Caregivers of persons with SCI develop cognitive coping strategies to make sense of the situation and establish a "new normal" and problem-focused coping strategies to deal with their new tasks and role. These strategies do not seem to be typical only of SCI caregivers. Hence, interventions that worked for caregivers in other fields could be adapted. Rehabilitation centers should systematically integrate programs targeted to caregivers into their offerings.IMPLICATIONS FOR REHABILITATIONHealthcare systems need to develop educational and support measures for both persons with a health condition and their caregivers.Caregivers should become long-term partners in rehabilitation and a regular and structured needs assessment should be offered.Interventions that worked for caregivers in other fields can be adapted to support also caregivers in SCI.Educational and support programs dedicated to caregivers should teach not only how to perform caregiving tasks but also how to balance between responding to the care recipient's needs and their own needs.

Caregivers can implement play-based instruction without disrupting child preference

Young children diagnosed with autism spectrum disorder often require systematic teaching to learn new skills, and caregivers can teach their children by embedding learning opportunities in a play-based context. However, researchers have not evaluated procedures to train caregivers how to implement a combination of strategies designed to establish rapport and early language skills while maintaining play as a preferred context. Caregiver-child dyads composed of 2 mothers and their sons were recruited to participate. A multiple-probe design across strategies was used to demonstrate the efficacy of behavioral skills training on the mothers' integration of parallel play, child-directed interaction, teaching requests (mands), and teaching labels (tacts). Both children acquired the target requests and labels as a function of their mothers' teaching. By assessing the children's preferences, we confirmed the teaching strategies did not decrease toy engagement or the value of playing with their mother. We obtained stimulus generalization of the mothers' implementation of the strategies from a clinic to their home and maintenance of mother and child performance across a month.

Early Childhood Development Caregiver Training and Neurocognition of HIV-Exposed Ugandan Siblings

OBJECTIVE

Early childhood development (ECD) programs can enhance neurocognitive development outcomes through caregiver training. This study explores whether school-age siblings benefited from a program provided to HIV-infected caregivers and their preschool-aged target children.

METHODS

Siblings of target 2- to 3-year-old children in ECD intervention households were evaluated at school age (5-12 years) on neurocognitive outcomes with the Kaufman Assessment Battery for Children (KABC), computerized Test of Variables of Attention, Behavior Rating Inventory for Executive Function (BRIEF; parent), and attention-deficit/hyperactivity disorder rating inventory (ADHD-R)-IV (parent). Households from 18 geographic clusters in eastern Uganda were randomized to individualized biweekly sessions of either (1) Mediational Intervention for Sensitizing Caregivers (MISC) training emphasizing cognitive stimulation/enrichment or (2) health/nutrition/development [Uganda Community-Based Association For Women & Children Welfare (UCOBAC)] program. Siblings with baseline and at least 1 follow-up assessment (n = 216) were included in the analysis. Three repeated postbaseline measures of sibling neurocognitive outcomes were analyzed using the linear mixed-effects model while adjusting for socioeconomic status and behavioral outcome at baseline.

RESULTS

Siblings in the MISC arm had better performance on KABC sequential processing at 6 months (p = 0.02) and simultaneous processing at 12 months (p = 0.03). MISC mothers rated their children as having significantly more problems on the BRIEF and ADHD-RS-IV (p < 0.01) than UCOBAC mothers across all time points.

CONCLUSION

Mediational Intervention for Sensitizing Caregivers training resulted in some short-term neurocognitive benefits for school-aged siblings, but these differences were not sustained at 1-year follow-up. Exploring potential impacts of parenting programs on other children in the home is an important development for the field.

Teaching caregivers to implement mand training using speech generating devices

Individuals with developmental disabilities often do not develop vocal repertoires, thus requiring the use of augmentative devices. Teaching caregivers to conduct communication training with their children may be one way to foster communication with their device in the natural environment. This study replicates Rosales, Stone and Rehfeldt (2009), but using an augmentative device. Behavioral skills training was used to teach caregivers to implement mand training procedures. Caregivers quickly learned to implement mand training with their children and independent mands increased from pretraining to posttraining observations for 2 out of 3 children.

Transfer of treatment effects from combined to isolated conditions during functional communication training for multiply controlled problem behavior

Functional communication training (FCT) is highly effective for treating socially maintained problem behavior when based on the results of functional analyses (FA). Research suggests that combining relevant antecedents and consequences of problem behavior during FCT can be an efficient approach to treatment for behavior that is multiply controlled. However, no studies have evaluated whether treatment effects under combined conditions would transfer to single, or isolated, conditions. Participants were 5 children with autism, aged 3 years to 6 years, who engaged in problem behavior maintained by both escape from demands and access to tangibles. An experimenter coached their caregivers via video conferencing to implement FA and FCT in their homes. All participants received FCT under a combined condition, followed by brief exposure to sessions with isolated antecedents and consequences. Treatment effects for just 1 of the 5 participants immediately persisted under isolated conditions. These results suggest that, when caregivers combine variables relevant to multiple functions during FCT, exposure to isolated conditions may at least temporarily produce treatment failures.

Family Caregiving for Cancer Patients: the State of the Literature and a Direction for Research to Link the Informal and Formal Care Systems to Improve Quality and Outcomes

OBJECTIVES

Based on recent shifts in reimbursement for cancer treatment from fee-for-service to bundled and value-based payment, this concluding article summarizes data from these papers and the large body of literature on caregiving to suggest how caregiving research might be redirected to link the formal with the informal systems to achieve higher-quality and lower-cost care. Caregiver dyads, the tasks of care, and strategies for training are presented.

DATA SOURCES

Articles in this issue of Seminars in Oncology Nursing, the larger body of caregiving literature, and the Oncology Care Model driving bundled payments and value-based care.

CONCLUSION

Research on informal caregiving for cancer patients should begin to reframe the rich body of evidence available toward a focus on caregivers reactions to the tasks of care, the training necessary for caregivers to perform them, and how each contributes to quality care at lower costs and appropriate outcomes given patients' stage of disease and goals of treatment.

IMPLICATIONS FOR NURSING PRACTICE

Oncology systems must take a more active role in including patients and their families as partners to manage treatments and side effects to achieve the best possible patient outcomes. They must be able to evaluate the patient and the caregiver to determine what tasks they will be able to perform, and then make sure they have the training and resources to carry out those tasks. Training could be done by social media and through communication using patient portals that could be expanded through the electronic medical records to include caregiver portals, enabling caregiver questions and reports of patients' conditions.

Feasibility of a multidisciplinary caregiving training protocol for young caregivers in families with ALS

Feasibility of a multidisciplinary caregiving training protocol for young caregivers in families with ALS.

OBJECTIVES

To assess the feasibility of a multidisciplinary young caregiver group training protocol for children and youth who provide care to a family member with ALS.

METHOD

Peer group experiential young caregiver model based on theories of self-management and self-efficacy. Training conducted by a multidisciplinary team of therapists in ALS (PT, OT, Speech and social work), as well as assistive device vendors. Demographic data, caregiving tasks and evaluations were collected.

RESULTS

The model is feasible for both youth and therapists. Youth found benefit, skill acquisition, and mastery by asking questions, teaching back skills to the group and engaging with peers.

CONCLUSION

This project demonstrates young caregivers will participate in training, and engage with "like" peer group. Future projects will focus on developing a structured survey and observation, testing efficacy in larger groups.

IMPACT OF A SUPPORT GROUP FOR THE CAREGIVERS AT AN ORPHANAGE IN TURKEY

This study examined the effectiveness of a 20-session training and supervision support group for caregivers working at an orphanage in Istanbul. The support group's goals were to promote sensitive and responsive caregiving in an institutional setting, to decrease the stress level of the caregivers, and to increase the quality of the relationship between caregivers and children. Thirty-six children (15-37 months) and 24 caregivers participated in this study. Comparison of the pre- and posttest measures of the caregiver intervention and control groups indicated that the intervention yielded successful outcomes. Caregivers in the intervention group displayed significant decreases in the amount of psychological symptoms that they reported and in their emotional burnout levels. Their sense of self-efficacy also improved. In addition, at the end of the 5-month training program, positive developments were observed regarding children's development and problem behaviors. Having regular visitors also was found to be a significant predictor for better developmental outcomes for the children under institutional care.

Development of a wheelchair maintenance training programme and questionnaire for clinicians and wheelchair users

Purpose of state: The aims of this study were to develop a Wheelchair Maintenance Training Programme (WMTP) as a tool for clinicians to teach wheelchair users (and caregivers when applicable) in a group setting to perform basic maintenance at home in the USA and to develop a Wheelchair Maintenance Training Questionnaire (WMT-Q) to evaluate wheelchair maintenance knowledge in clinicians, manual and power wheelchair users.

METHODS

The WMTP and WMT-Q were developed through an iterative process.

RESULTS

A convenience sample of clinicians (n = 17), manual wheelchair (n ∞ 5), power wheelchair users (n = 4) and caregivers (n = 4) provided feedback on the training programme. A convenience sample of clinicians (n = 38), manual wheelchair (n = 25), and power wheelchair users (n = 30) answered the WMT-Q throughout different phases of development. The subscores of the WMT-Q achieved a reliability that ranged between ICC(3,1) = 0.48 to ICC(3,1) = 0.89. The WMTP and WMT-Q were implemented with 15 clinicians who received in-person training in the USA using the materials developed and showed a significant increase in all except one of the WMT-Q subscores after the WMTP (p < 0.007).

CONCLUSION

The WMTP will continue to be revised as it is further implemented. The WMT-Q is an acceptable instrument to measure pre- and post-training maintenance knowledge. Implications for Rehabilitation The Wheelchair Maintenance Training Program can be used to educate rehabilitation clinicians and technicians to improve wheelchair service and delivery to end users. This training complements the World Health Organization basic wheelchair service curriculum, which only includes training of the clinicians, but does not include detailed information to train wheelchair users and caregivers. This training program offers a time efficient method for providing education to end users in a group setting that may mitigate adverse consequences resulting from wheelchair breakdown. This training program has significant potential for impact among wheelchair users in areas where access to repair services is limited.

Changes in Caregiver Knowledge and Perceived Competency Following Group Education about Sensory Processing Disturbances: An Exploratory Study

Parents or teachers (n = 10) of children diagnosed on the autism spectrum and exhibiting sensory processing disorders (SPD) attended a series of six weekly educational sessions designed to increase the participants' knowledge of SPD, skills in interacting with children exhibiting SPD and confidence in intervening with children exhibiting undesirable behaviours stemming from SPD. The sessions consisted of group classroom instruction with instructional methods including PowerPoint-assisted lecture/discussion and short video clips. Pre-test and post-test assessment was made of the participants' (a) self-perceived knowledge of sensory processing concepts; (b) actual knowledge of sensory processing concepts; and (c) self-rated competency for dealing with children exhibiting behaviours related to SPD. Statistical analysis revealed significant gains were achieved on all measures. The results were interpreted as indicating that group classroom instruction is an effective means of increasing such caregivers' self-perceived knowledge of sensory processing concepts, actual knowledge of sensory processing concepts and self-rated competency for dealing with children exhibiting behaviours related to SPD. Future research to assess the short-term and long-term impacts of these gains and to gauge the relative effectiveness of various contents for such sessions is recommended. Copyright © 2016 John Wiley & Sons, Ltd.

Implementing a training intervention to support caregivers after stroke: a process evaluation examining the initiation and embedding of programme change

BACKGROUND

Medical Research Council (MRC) guidance identifies implementation as a key element of the development and evaluation process for complex healthcare interventions. Implementation is itself a complex process involving the mobilization of human, material, and organizational resources to change practice within settings that have pre-existing structures, historical patterns of relationships, and routinized ways of working. Process evaluations enable researchers and clinicians to understand how implementation proceeds and what factors impact on intended program change. A qualitative process evaluation of the pragmatic cluster randomized controlled trial; Training Caregivers after Stroke was conducted to examine how professionals were engaged in the work of delivering training; how they reached and involved caregivers for whom the intervention was most appropriate; how did those on whom training was targeted experience and respond to it. Normalization Process Theory, which focuses attention on implementing and embedding program change, was used as a sensitizing framework to examine selected findings.

RESULTS

Contextual factors including organizational history and team relationships, external policy, and service development initiatives, impinged on implementation of the caregiver training program in unintended ways that could not have been predicted through focus on mechanisms of individual and collective action at unit level. Factors that facilitated or impeded the effectiveness of the cascade training model used, whether and how stroke unit teams made sense of and engaged individually and collectively with a complex caregiver training intervention, and what impact these factors had on embedding the intervention in routine stroke unit practice were identified.

CONCLUSIONS

Where implementation of complex interventions depends on multiple providers, time needs to be invested in reaching agreement on who will take responsibility for delivery of specific components and in determining how implementation and its effectiveness will be monitored. This goes beyond concern with intervention fidelity; explicit consideration also needs to be given to the implementation process in terms of how program change can be effected at organizational, practice, and service delivery levels. Normalization Process Theory's constructs help identify vulnerable features of implementation processes in respect of the work involved in embedding complex interventions.

Impact of treatment integrity on intervention effectiveness

Treatment integrity has cogent implications for intervention effectiveness. Understanding these implications is an important, but often neglected, undertaking in behavior analysis. This paper reviews current research on treatment integrity in applied behavior analysis. Specifically, we review research evaluating the relation between integrity failures and the efficacy of behavioral interventions. Avenues for future research are provided.

The effects of training on caregiver implementation of incidental teaching

A brief training package consisting of modeling, rehearsal, and feedback was evaluated to train caregivers to use incidental teaching to teach 3 children with autism to request an item or activity. The training package improved correct implementation of the incidental teaching procedure by caregivers. In addition, probes indicated that caregivers could apply these skills to teach the child an additional skill.

Internet-based program for dementia caregivers

The overall goal of the Internet-Based Savvy Caregiver (IBSC) program was to develop and bring to market an Internet-based psycho-educational program designed to provide dementia caregivers the knowledge, skills, and outlook they need to undertake and succeed in the caregiving role they have assumed. The IBSC program's concept is based on a face-to-face caregiver-training program and curriculum, the previously validated Savvy Caregiver Program (SCP). The project used an iterative design with expert and consumer input to develop the initial prototype. Forty-seven participants completed the IBSC program and follow-up questionnaire. Results of the formative evaluation showed that participants found the program educational, convenient, useful, and interesting. Participants endorsed feeling more confident in caregiving skills and communication with their family members. The evidence points to the feasibility of an Internet-based program to strengthen family caregivers' confidence in caring for persons with dementia.

The effects of behavioral skills training on caregiver implementation of guided compliance

The effectiveness of a behavioral skills training package that consisted of modeling, rehearsal, and feedback was evaluated to increase correct implementation of guided compliance by caregivers of 3 children who exhibited noncompliance. Results showed that the training package improved performance of guided compliance. Generalization probes indicated that the skills learned were exhibited in different settings 3 to 6 weeks after training ended.

Exercise interventions for dementia and cognitive impairment: the Seattle Protocols

Research evidence strongly suggests that increased physical exercise may not only improve physical function in older adults but may also improve mood and slow the progression of cognitive decline. This paper describes a series of evidence-based interventions grounded in social-learning and gerontological theory that were designed to increase physical activity in persons with dementia and mild cognitive impairment. These programs, part of a collective termed the Seattle Protocols, are systematic, evidence-based approaches that are unique 1) in their focus on the importance of making regular exercise a pleasant activity, and 2) in teaching both cognitively impaired participants and their caregivers behavioral and problem-solving strategies for successfully establishing and maintaining realistic and pleasant exercise goals. While additional research is needed, initial findings from randomized controlled clinical trials are quite promising and suggest that the Seattle Protocols are both feasible and beneficial for community-residing individuals with a range of cognitive abilities and impairments.

A randomized, controlled study of an Alzheimer's caregiver skills training program

This study was an attempt to improve the quality of the relationship between dementia caregivers and their loved ones by decreasing the gap between caregivers' expectations and patients' actual functional abilities and by teaching supportive skills. Although a group of 49 caregiver-patient dyads were recruited, the outcome measures of only those dyads (47) that completed the week seven session were used for analysis. Half of the dyads were randomized to an intervention group and the other half to a waiting list. The intervention group (N = 24) completed a four-session caregiver training program in which caregivers first watched investigators administering to their loved ones the Texas Functional Living Scale and later progressed to helping their loved ones by appropriate cueing to perform the tasks involved. Comparisons were made between baseline scores, scores at seven weeks, and scores at the end of 17 weeks on the congruence between caregiver estimates and patients' actual performance on the Independent Living Scale and measures of cognition, function, preillness quality of relationship, caregiver mood, feeling of self-efficacy, and several other measures. We were not able to increase the congruence between caregiver estimates and patients' actual performance and found no change in any other measure. We didfind the expected relationship between depression and caregiver sense of self-efficacy.

A training workshop on late-stage dementia care for family caregivers

Training workshops have been considered a useful intervention in helping family caregivers of people with dementia to cope with the stress of caregiving. However, there are no reports in the literature with regard to training and support of families specifically looking after individuals who are in the late stage of dementia. This paper reports the experience and evaluation of a training workshop aimed at preparing family caregivers for late-stage dementia care. Eighty-eight percent of the participants completed the client satisfaction questionnaire. The results from the questionnaire gave a very positive response, showing 90.9 percent of respondents were satisfied with the workshop, and 77.3 percent of respondents indicated that their caregiving needs were met. Eleven participants who attended this workshop joined a focus group feedback session. The Kruskal-Wallis test found no significant differences between the overall profile of the participants and that of the focus group in terms of age, gender, educational background, whether they were primary caregivers, for whom they cared (e.g., parents or spouse), or whether the care recipient stayed at home or in a nursing home. Findings from the focus group session provide a somewhat different picture from that of the questionnaire. Three focus group participants provided more critical comments of the workshop. Although the majority of the focus group agreed that the workshop had been useful, they disagreed on whether it is necessary to discuss psychosocial issues in this workshop. Findings from the focus group have enabled the project team to reflect on their design and operation of the workshop and provided valuable insight for future development as well as for further study.