As the number of Hispanic elderly is predicted to grow significantly in the next few decades, there will be an increase in need for elderly caregiving. Due to cultural values of familism, Hispanics are more likely to rely on family caregivers. Using a quasi-experimental, single group pre/post-test design, we sought to examine if Spanish caregivers of older adults with dementia (n=61) experienced less depression and caregiver after participating in a monolingual Spanish Caregiver Support/Training Program (CS/TP). While caregiver depression decreased significantly, there was no significant difference in caregiver burden. Future research should examine the cultural context for Hispanic caregivers. Practitioners should continue to focus on multicomponent interventions and develop more targeted interventions that take specific characteristics of Hispanic monolingual informal caregivers into consideration.
Prior to collecting data, approval was obtained from the California State University, Los Angeles Institutional Review Board. A pre-experimental, single group pre-test/post-test design was implemented. It was hypothesized that caregivers who completed the monolingual Spanish Caregiver CS/TP would exhibit a marked improvement in their level of depression and caregiver burden. Monolingual Spanish-speaking adult caregivers for a family or friend who was 60+ years with dementia were recruited through Spanish newspaper announcements and a mass mailing was sent to local adult day care centers, churches, hospitals and medical clinics in the East Los Angeles area. All materials were in Spanish. Eligibility requirements for the study were that participants were monolingual Spanish-speaking adult caregivers for a family or friend who was 60+ years with dementia. At the first session, participants received information about the 8-week CS/TP; they were given the informed consent forms and told about the legal requirement to report elder abuse. They were told that participation in the study was completely voluntary and that they could quit anytime. Participants were given $100 for attending all eight sessions, with each session lasting an hour and a half. There were a total of 61 participants in the study. Trained interventionists included Licensed Clinical Social Workers (LCSWs), psychologists, nurses, physical therapists, and attorneys.
To measure the effectiveness of the intervention, a pre-test and post-test of depression and caregiver burden were given. The two scales that have been widely used to measure the impact of caregiving across a diverse population are the Center for Epidemiological Studies Depression scale (CESD) and the Zarit Burden Index (ZBI). The CESD is a highly popular and frequently used 20-item scale originally designed to measure depression in the general population for epidemiological research [40,41]. The possible score ranges from 0-60, with a higher score representing greater depression. The cutoff score for clinical depression is 16. With high internal consistency with Cronbach’s alpha scores ranging from .85-.92 and high validity with Pearson correlations ranging from .74-.75 [40-42], the CESD has proven to be an accurate and valid measure of depression. One of the most commonly used measures at the international level, the ZBI is a 22-item scale designed to measure feelings of burden experienced by caregivers of older adults with dementia . The possible range is from 0-88, with a higher score meaning greater caregiver burden . Argue that the longer version is better for longitudinal studies in detecting change compared to the shorter 4 or 12 questions ZBI. Like the CESD, the ZBI has also shown strong psychometric properties; the Cronbach’s alpha score shows a high internal consistency at .93 and test-retest reliability is .89 . Both of these scales have been translated into Spanish and have demonstrated adequate internal consistency and test-retest reliability within the Latino population [46,47]. The Spanish version of the CESD and ZBI has an internal consistency of .93 and .92, respectively . A questionnaire that included socio-demographic information relating to age, gender, ethnicity, marital status, years in the US, education and income was taken at the first session. In order to measure for functional limitations of the caregiver and care recipient, ADLs and IADLs for each were measured at the first session as well.
Descriptive statistics were used to provide a demographic profile of the sample. Using SPPSS v. 22, a paired samples t-test was used to examine if the monolingual Spanish CS/TP produced an effect by lowering participant’s level of depression and their degree of caregiver burden from pre-test to post-test. The P-value used to consider significance was .05.
As shown in table 1, there were a total of 61 participants, with the majority being female (82%), Hispanic ethnicity (49.2%), and married (50.8%). The average age of the caregiver was 54.1 years old. With respect to ethnicity, Mexican Americans made up the next largest group (37.7%), followed by Latinos (11.5%). The average number of years in the U.S. was 32.5, with a range from 6 to 77 years. With respect to education, one-third had a high school diploma and one-third had a college degree or more. The majority made between $10,000-$24,999 (49.2%) and the least amount making over $55,000 (3.3%). The majority were the primary caregivers (59 %).
|Refused to answer||1||1.6|
|Refused to answer||1||1.6|
|Years in US|
|Amount of Education|
|High School Diploma||19||31.1|
|College Degree or more||63||31.66|
|Refused to answer||6.5|
Table 1: Socio-demographic Characteristics of Caregivers (N=61).
In order to get a sense of overall health of caregiver and care recipient, ADLs and IADLs were measured, as shown in table 2. The majority of caregivers did not report any difficulties performing ADLs (85.2%) or IADLs (50.8%). However, the vast majority of care recipients reported difficulties performing ADLs and IADLs, with only 13.1% and 1.6% reporting no difficulties respectively.
|ADLs (difficulty performing)||Caregiver (%)||Care recipient (%)|
|Using the toilet||0||47.5|
|Transferring from bed to chair||0||45.9|
|IADLs (difficulty performing)|
|Using the telephone||1.6||52.4|
|Lifting 10-15 pounds||11.5||68.9|
|Lifting 25 pounds||24.6||75.4|
|Doing light housework||8.2||57.4|
|Doing heavy housework||29.5||86.9|
Table 2: Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).
As shown in table 3, with respect to the psychosocial measures, there was clear improvement in depression as seen by a significant decrease in the CESD from the pre-test (M=19.5, sd=13.1) and the post-test (M=17.6, sd= 2.6); t (60)=1.93, p<0.05. Notably, the mean scores for both the pre-test (M=19.5) and post-test (M=17.6) for the CESD met the cut off score of 16 or higher, which classifies individuals as having elevated levels of depression. For the ZBI, there was no significant difference in caregiver burden from the pre-test (M=37.1, sd=19.4) and the post-test (M=34, sd=15.5); t (60)=.85, p>0.05. The mean caregiver burden scores for pre-test (M=37.0) and post-test were moderate (M=34.0).
|CESD (Possible Range:0-60)||Pre-test||Post-test||t(60)=1.93, p=.039|
|ZBI (Possible Range: 0-88)||t(60)=.85, p=.058|
Table 3: Depression (CESD) and Caregiver Burden (ZBI).
Overall, the multicomponent Spanish Caregiver Support/Training Program (CS/TP) showed mixed results. Depression levels decreased as predicted. The program’s psychoeducational skills taught problem-solving skills through a cognitive behavioral framework. Participants were taught to identify the event that is causing them distress (e.g., behavior of the care recipient), brainstorm options and weigh the advantages and disadvantages of each. Additionally, participants were taught how to discriminate between the event and the emotions that they are feeling due to the event. This is an important distinction because participants were taught that while they may not be able to change the event, they can change how they feel toward the event. Another skill that was taught was to reward oneself for caregiving tasks; therefore, individuals focused on small pleasant activities throughout the week.
There was no significant change with respect to caregiver burden. This is similar to the original Caregiver Support/Training program in which only depression was significantly lowered . While the original intervention included all racial and ethnic groups, approximately two-thirds were Hispanics. Therefore, it is not surprising that these findings would be similar. These findings also mirror the literature; Pinquart & Sorenson’s  meta-analysis of interventions found that the intervention effect sizes for caregiver burden were smaller when compared to those for depression. Specifically, the effect size for caregiver burden was 0.12 (small), while the effect size for depression was 0.24 (medium). Another explanation may be that a large number of participants were adult children, who were married with their own families. The ZBI refers specifically to the elder care recipient, but in this study, participants may also be caregiving for their children. Multigenerational caregivers often experience a different form of burden that may not be captured by the ZBI . Also, poorer caregiver physical health is correlated with greater caregiver burden [20,21]; and the majority of caregivers did not have functional limitations. Thus, it is possible that as their difficulty in performing ADLs and IADLs increased, caregiver burden would increase. Finally, ethnicity and culture also play a key role in the caregiver relationship and caregiver burden . The cultural expectations of taking care of one’s parents lead to more acceptance of the caregiving role, and hence, less perceived caregiving burden [24,29,49]. Findings regarding Hispanics and caregiving burden were similar to the findings of this study. Both studies found Hispanic familism values to be associated with less perceived burden, but familism was not significantly related to depressive symptoms. The view of caregiving impacts the level of perceived burden; thus because Hispanics may have a greater sense of responsibility and commitment to caregiving, they have less reported caregiver burden . While this study did not measure cultural values, the fact that burden did not change may speak to the fact that burden was initially at a moderate level may be related to cultural values of caregiving.
There are several limitations to the study that must be addressed. One of the limitations was the lack of a control group and randomization. The original plan was to have one track serve as the control group; however, given the limited availability of the trainers, training room, and participants, two separate 8-week sessions was not possible. Therefore, the second track started before the first track was complete. Another limitation is that while the study used a longitudinal study design to look at the effect of the intervention, data was not collected after the program in order to measure sustained effects. Additionally, the small sample size (n=61) limited the ability to generalize the findings. Another impact of the small sample size is that it would limit the power the find potentially significant associations . Meta-analysis of interventions for caregivers found that the median number of study participants was 45. Therefore, this sample size may be typical to, if not slightly greater than, similar caregiver intervention studies. Given the limitations, the results of this study should be interpreted cautiously. However, the study does underscore the importance of looking at the monolingual Hispanic caregiving population and consider their unique needs, especially given the number of growing Hispanic older adults with dementia. Future studies should specifically look at cultural values and how they influence caregiver burden.
The physical, emotional, and financial costs to caregivers are immense. Caregiver health has a direct impact on the level of care that caregivers offer. Hence, interventions that reduce caregiver stress and facilitate caregivers’ quality of life are needed. This study tested a multicomponent program that incorporated knowledge about caregiving, psycho-education, and mutual support with the goal of decreasing participants’ level of depression and caregiver burden. Moreover, this study adds to the limited literature on Hispanic caregivers for older adults, specifically monolingual Spanish speaking.
As the number of Hispanic older adults proliferates, the demand for programs that support, educate, and assist informal Hispanic caregivers will only increase. It is imperative that long term care programs and services target the needs of in-home caregivers with multicomponent programs that provide education, support, as well as respite. The Evercare and NAC study underscored the importance of availability of Spanish language caregiving information . By designing programs that meet the needs of caregivers we can begin to forestall and perhaps reverse the health and mental health vulnerabilities associated with providing care over time. Furthermore, taking into consideration the unique cultural needs of the Hispanic population is needed and this includes providing more intervention programs targeted at monolingual caregivers. Future research should also consider the caregivers’ and care recipients’ level of acculturation, which impacts their language, belief systems, and comfort with the U.S. health care system, and include culturally specific indicators to measure these factors.
Citation: Huynh-Hohnbaum ALT, Villa VM (2016) Evaluating a Multi-Component Spanish Caregiver Monolingual Intervention. J Community Med Public Health Care 3: 015.
Copyright: © 2016 Anh-Luu T Huynh-Hohnbaum, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.