Evaluation of Training Program for Caregivers to Aging Adults

Introduction

Over 33 million Americans are age 65 or older, and the number of seniors in the U.S. is expected to double over the next 30 years (Novelli, 2004). However, longevity comes at a cost (Aldwin, 2004).  Eighty percent of seniors have at least one chronic health condition, and 50% have at least two. 

Three million older adults say they cannot perform basic activities of daily living, such as bathing, shopping, dressing, or eating (Centers for Disease Control and Prevention, 1995). Many need personal care assistance to  stay in their own homes and experience the highest possible quality of life as they age.

Estimates suggest more than 1.5 million adults in California have disabilities that require ongoing assistance with day-to-day activities (Scharlach, 2001). Sacramento County in California responded to the need for in-home caregivers by establishing the In-Home Supportive Services (IHSS) Public Authority.

At the time of this study, Sacramento County IHSS had approximately 12,000 county-funded in-home caregivers who collectively provided 1.2 million hours of service per month. Of approximately 12,000 IHSS recipients, 52% were age 65 or older, and 10% were 85 or older. Approximately 85% needed assistance with personal care. Personal care refers to the activities of daily living (ADL): eating, bathing, grooming, dressing, and toileting (Lynch, 2002).

In 2002, the IHSS Public Authority contracted with University of California Cooperative Extension, Sacramento County to design, deliver, and evaluate a training program for the in-home caregivers. This article reports an evaluation of the Caregiver Training Program, a new Extension program designed and delivered by Extension academic advisors to enhance the skills and knowledge of the in-home caregivers.

Description of the Caregiver Training Program

Design

The Cooperative Extension advisor designed a training program based on a needs assessment of 1,000 in-home caregivers from the IHSS registry and a review of related literature. The resulting Caregiver Training Program included eight 2-hour lessons in three subject-matter areas: health promotion/activities of daily living (3 lessons), nutrition (3 lessons), and resource management (2 lessons).

The health promotion unit included:

• Wound care,
• Bowel and bladder care,
• Diabetes,
• Infection control,
• Dementia/memory loss,
• Preventing falls, and
• Self-neglect (by the care recipient).

Nutrition sessions covered:

• The food guide pyramid,
• Meal planning and food shopping, and
• Food safety.

Resource management lessons included:

• Finding and keeping a job and
• Community assets.

Delivery

Fifty training workshops were held from September 2002 through May 2003. Lessons were self-contained and could be taken independently of the others. Training was optional, and classes were free.

Teaching methods were varied to maintain interest. Participatory learning strategies included hands-on activities, such as preparing a nutritional meal, and interactive activities, such as small group discussion about changes caregivers could make in the kitchen to keep their client safe. Occasionally the trainer also provided supplemental take-home material, such as information from the Alzheimer's Foundation or a diabetes self-assessment.

Evaluation of the Caregiver Training Program

A Caregiver Training Evaluation form was adapted from an evaluation tool designed by Kay Rockwell (1999) to assess four aspects of the training program:

• Instructional methods
• Training outcomes
• Appropriateness of the training facility
• Suggestions for future programming

Variables

The training variables were:

1. Training facilities,
2. Presentation objectives,
3. Appropriateness of objectives,
4. Relevance of content,
5. Organization of content,
6. Supportiveness of the instructional aids, and
7. Overall evaluation of the training.

The five participant outcome variables were:

1. Knowledge,
2. Skill/ability,
3. Attitude,
4. Interest, and
5. Confidence.

Evaluation Instrument

The evaluation form was a simple, 1-page English-language survey with 14 items. The 12 training and participant change variables were measured by Likert-type items, with "5" as the highest score. A closed-ended question (yes/no) asked whether participants would recommend this training to others, and the last item asked for recommendations for future trainings.

Data Collection

At the end of each training session, the trainer reminded participants about the purpose of a training objective and asked them to review the specific objectives (on their class handout) for the evening. Each participant completed a Caregiver Training Evaluation form before leaving.

Data Analysis

• Descriptive statistics were calculated for all Likert-type items.

• Regression analysis was used to analyze participant change by the training variables.

• Multiple regression analysis was used to determine which training variables predicted various types of participant change.

Findings

A total of 143 caregivers attended one or more of 50 training classes offered from September 2002 through May 2003. Collectively, they completed 526 evaluation surveys providing the data for this evaluation. Training participants were predominantly female (83%), and ethnically diverse: White (40.5%), African American (22.6%), Asian (19.0%), Hispanic (17.3%), and American Indian (0.6%).

Training Outcomes

Participants (N= 143) reported positive changes in knowledge (M = 4.62, SD = .72), skill/ability (M = 4.58, SD = .76), attitude (M = 4.73, SD = .60), interest (M = 4.71, SD = .68), and self-confidence (M = 4.67, SD = .70) as a result of Caregiver Training classes. Over half of participants earned a Certificate of Completion; 20 caregivers received all three certificates (nutrition, health promotion, and resource management).

Participant Change

To assess overall program effectiveness, mean scores for self-reported changes in knowledge, skill/ability, attitude, interest, and confidence were averaged to create the new composite variable, participant change (M = 4.68, SD = .60). We used a multiple regression analysis using participant change as the dependent variable and the seven training variables as independent variables. The overall regression was significant (F_7,394 = 63.63, p<.001). Of seven independent variables, four variables significantly predicted participant change:  presentation of objectives (β = .19, p<.01), appropriateness of objectives (β = .19, p<.01), relevance of content (β = .19, p<.05), and organization of content (β = .16, p<.05). See Table 1.

Participant Reaction to the Training

Participants were satisfied with the training facilities. They would recommend the training to other caregivers and suggested that future training should include information about high blood pressure and CPR, and be offered in Spanish, Russian, and Hmong. Other participants' comments:

• "I would like to recommend the training to other caregivers because they will benefit from it."

• "It will help them to cope with their problems facing the job. I got a lot out of this class and am looking forward to the next class!"

• "This was a very good class--covered material needed to help with clients."

• "I really enjoy the training sessions. They have improved my skill and thinking."

• "I like coming to the class so I can learn to help."

Discussion

Training Evaluation

Participants evaluated the Caregiver Training Program highly, which was validated by the fact that many attended multiple training sessions to earn subject-matter certificates. Caregivers voluntarily attended training on their own time and did not receive additional pay or promotions for attending training or earning certificates.

Instructional Factors Related to Training Effectiveness

The evaluation indicated four training variables were related to the perceived effectiveness of the Caregiver Training Program:

• Appropriate objectives
• Clearly stated objectives
• Relevant and timely content
• Well-organized content.

Appropriate Objectives

Training effectiveness was related to instructional objectives that were "problem-focused" rather "information-focused" (Levine, 2001). Caregivers regularly confront problems related to physical care, disease treatment, injury protection, and patients with dementia. Training objectives concerned concrete aspects of preventing and solving problems, rather than abstract information about problems. For example, in the session on "Preventing Falls," one objective was to assess the care recipient's home for hazards and identify how to eliminate or reduce hazards their care recipient faced.

Clearly-Stated Objectives

Training effectiveness was related to clearly stated objectives that were identified and explained at the beginning of each session. This helps students understand the lesson structure and sequence; facilitates efficient learning: and reduces student anxiety because they understand where the training is going and what they will learn (Diamond, 1998). This was important in the Caregiver Training Program because many caregivers have limited educational experience, and may feel uncomfortable in a classroom.

Relevant and Timely Content

Training was effective because it met the needs of caregiver participants. While not surprising, this is a reminder that adults (caregivers) seek learning to meet specific and current information needs. Adult learners are "most interested in information and ideas that solve problems they are currently faced with" and "can be applied immediately" (Levine, 2001). In this case, a caregiver needs assessment guided curriculum development.

Well-Organized Content

Class organization also influenced training effectiveness. All lessons were organized in a linear format, beginning and ending with a statement of objectives. Each session offered multiple opportunities for participants to share their insights and act as peer "consultants." This approach recognized and utilized learners' knowledge and experience, an important adult education principle.

Limitations

Training participants were self-selected, and outcomes may be biased toward learners who are comfortable in a classroom setting. Conclusions were based on self-reported data, rather than objective outcome measures. Respondents may not have understood some terms on the evaluation form.

Conclusions and Implications

Now, more than ever, cooperative extension must meet community needs and document measurable impact. The Caregiver Training Program designed and delivered by Sacramento County Cooperative Extension met a community need for need for better-qualified in-home caregivers to the elderly. According to self-reported data, participants felt the training improved their knowledge, skill/ability, attitude, interest, and self-confidence as in-home caregivers. This is in contrast to previously reported caregiver support and training programs (Whittier, Goon, & Aaker, 2004).

Extension is distinctive in its emphasis on science-based training methods and materials. The effectiveness of the Caregiver Training Program was related to appropriate and clearly stated objectives and relevant, timely, and well-organized content. While this may seem simplistic, the findings correspond to adult learning principles described in the literature and can provide guidance for other Extension training programs.

Extension is uniquely qualified and positioned to provide training for the emerging caregiver workforce. Extension professionals have a wealth of research-based information and expertise in nutrition, activities of daily living, and resource management. Extension also has the expertise in adult education and outcome-oriented training that leads to measurable changes in knowledge attitudes, skills, and behaviors.

Extension can also use its expertise to assist families and other volunteer caregivers. We can design and deliver training for family caregivers, drawing on science-based knowledge of human development, family dynamics, and issues facing aging families.

Future evaluation of the Caregiver Training Program should:

• Measure the validity and reliability of the survey instrument.

• Use objective measures to validate self-reported changes.

• Use a pre-test/post-test control group design or a pre/post retrospective evaluation tool.

References

Administration of Aging. (2003). A profile of older Americans. Available at: http://www.aoa.gov/prof/statistics/profile/2003/17.asp

Aldwin, C. & Gilmer, D. (2004). Health, illness and optimal aging.  Sage Publication: Thousand Oaks.

Centers for Disease Control and Prevention. (1995). National Center for Health Statistics supplement on aging study. Available at: http://www.cdc.gov/nccdphp/aag/aag_aging.htm

Diamond, R. (1998). Designing & assessing courses & curricula. Jossey-Bass Publishers: San Francisco.

Levine, J. (2001). The challenges of helping adults learn: characteristics of adult learners & implications for teaching technical information. LearnerAssociates.net

Lynch, B. (2002). The first report. Sacramento County In-Home Supportive Services.  Unpublished.

Novelli, W. (2004). The health and economic effects of an aging society. Available at: http://www.cdc.gov/nccdphp/aag/aag_aging.htm

Rockwell, K. (1999). Does Extension make a difference: Measuring program outcomes. Unpublished, West Virginia University Jackson's Mill Conference Center.

Scharlach, A., & Santo, T. (2001). Family caregivers in California: Needs, interventions and model programs. Center for the Advanced Study of Aging Services, University of California: Berkeley.

Whittier, S., Goon, D., & Aaker, J. (2004). Caregiver support interventions. Available at: http://cssr.berkeley.edu/aging/pdfs/famcare_04.pdf