Barriers to and Strategies for Engaging Extension Educators in Family Caregiver Education

Introduction

Extension strives to use the best theory and evidence for development, delivery, and assessment of educational programs (Gagnon & Pettigrew, 2018). In recent years, there has been a significant push in the development of prepackaged evidence-based programming to foster efficiency in outreach efforts (Olson, Welsh, & Perkins, 2015). However, despite detailed descriptions for how programs should be conducted, levels of actual adherence to these plans vary immensely (Duerden & Witt, 2012). Herein we report on a study we conducted to investigate barriers experienced by county agents that mitigated their participation in a program designed to enhance the skills and knowledge of family caregivers and medical professionals. We also explored strategies for overcoming such barriers.

Caregiver Education Program

Program Design

Upon receiving associated grant funding, we designed an educational program to address knowledge and skills needed among caregivers. The resulting Caregiver Education Program (CEP) included the following six 1-hr sessions:

• Caregiving 101—introduction to caregiving and an aging resources network;
• Healthy Caregiving—exploration of strategies for maintaining healthy relationships with care recipients and implementing self-care;
• Nutrition—discussion of nutritional needs of older adults;
• Home Safety—discussion of strategies for ensuring that older adults' homes remain safe to inhabit;
• Elder Abuse and Exploitation—identification of types of abuse and common symptoms of such; and
• Finances—discussion of various federal and state programs that help fund caregiving expenses.

Each session reflected the scientific literature, applications of the socioecological approach (i.e., examining both micro and macro influences on the care family), and proposed solutions. For each session, lesson-specific resources (e.g., fact sheets) and various marketing materials (e.g., flyers, social media posts) were available for use by Extension educators presenting the program.

Extension Educator Training

The program lessons were self-contained and could be delivered independent of one another. Extension educator trainings for Caregiving 101 and Healthy Caregiving were mandatory as the knowledge and skills addressed had been added to family and consumer sciences (FCS) educators' core competency requirements. Trainings for the other four lessons were optional.

Initial in-services were offered during June 2017 at five locations across the state, with at least one training occurring in each Extension district. We designed each of those in-services as an all-day event to allow for adequate time to train educators on Caregiving 101 and Healthy Caregiving. We offered 10 additional online in-services during July 2017 to train educators on the remaining lessons.

We held a second round of in-services from January 2018 through March 2018 to train educators on all six lessons. Educators were given the option of either attending the in-services in person or telecommuting. We recorded these in-services to allow educators on-demand access to the trainings.

We posted all in-services in Oklahoma Extension's Program Activity Reporting System to allow agents to enroll. CEP staff and district FCS program specialists also notified educators of all in-services via email. Despite required program attendance, only 29% of Oklahoma's FCS educators participated in the initial trainings.

Purpose of Study

The purpose of our study was to explore (a) what barriers kept educators from participating in the program and (b) what strategies could be employed to better aid the educators in participating in the trainings and delivering the program.

Method and Sample

In March 2018, all Oklahoma FCS educators received an email from CEP staff asking for their participation in a voluntary phone interview at a time convenient to their schedules. The interviews were conducted by telephone 1 month following the second round of in-services, and responses to the interview questions were transcribed verbatim. We conducted the interviews by telephone rather than in person to increase efficiency of data collection. Of the 55 educators, 31 (56%) participated in the interviews. We had planned to interview all 55 educators but discontinued the interviews after 31 were completed as it was evident data saturation (Patton, 2015) had been reached. The study had prior approval from Oklahoma State University's Institutional Review Board.

We designed the interview questions to assess educators' perceptions of barriers related to training for and delivery of the program, strategies for better engaging educators across the program, and additional assistance educators needed from program staff to increase efficiency of program adherence (see appendix). We developed three sets of structured, open-ended interview questions to align with the following varying degrees of experience educators had with the program:

• educator had been trained on and had presented to the public at least one lesson (n = 4),
• educator had received only training (n = 13), or
• educator had had no participation in the program (n = 14).

Using structured, open-ended interview questions allowed for in-depth exploration of topics and greater understanding of processes (Weller et al., 2018) and reduced research bias (Turner, 2010). Interviews lasted an average of 13 min 51 s (Mdn = 11 min 47 s).

The average participant was a 50-year-old (SD = 10.41) female. Twenty-four participants identified their ethnicity as White, five identified as Native American, and two identified as multiracial (Caucasian and Native American). Participants ranged from having been in their current positions from 1 year to 34 years (M = 13.25, SD = 10.87) and with Extension from 2 years to 34 years (M = 15.50, SD = 10.90).

Results

To enhance reliability of the study, we analyzed the recorded responses to the interview questions using the constant-comparative method (Lincoln & Guba, 1985). Codes were developed separately by two members of our research team; after coding individually, the two coders compared their identified codes and discussed any discrepancies until agreement was reached. All interviewees identified barriers to implementing the caregiver education program that could be organized into four themes: staff shortages, program prioritization, development of a public audience, and communication with the program team. Representative examples of each theme as stated in participants' own words are presented in Table 1.

Table 1.
Barriers to Oklahoma Family and Consumer Sciences (FCS) Extension Agents' Implementation of Caregiver Education Program

Theme	Example comment
Staff shortages	"I am 50% FCS, 50% 4-H, and I am also county director, and I also take care of rural development stuff too. There is a limit to what I can do." (Interviewee 3) "I am the only educator in my county, and I am trying to keep the ag going, 4-H going, and FCS going, trying to keep my office running." (Interviewee 11) "When I first did the training, I was full-time FCS educator in my county. Now because of budget cuts, I am 60% FCS and 40% 4-H, so I have added duties now." (Interviewee 23)
Program prioritization	"I just have to find a place in my schedule, where I can shut the door and say, 'Okay, I am in training, this is what I am doing, hold my calls.'" (Interviewee 13) "Advisory teams advise needs . . . I'm not doing caregiving because it wasn't picked by my advisory team." (Interviewee 14) "It is not a high priority on the needs in this community. Also, we have so many other organizations that are doing similar things." (Interviewee 21)
Development of public audience	"Some of the curriculum you require six times, and lot of times, a lot of people, you are going to see them once. So getting them to come four to six times is tough. A lot of them are a one-time audience." (Interviewee 20) "I haven't figured out how I am going to deliver it [programming]. If I do once a week for so many weeks, or if I can get more of an audience, I would take a Saturday and do it all in one time. [With multiple sessions], I am just not sure how I can get the audience to come back every time." (Interviewee 28) "It's just finding the people . . . sometimes they call you with the audience . . . but this one doesn't work that way." (Interviewee 29)
Communication with program team	"Well, a year ago, or less than a year ago, when I took the first training, . . . everything kept changing, and so I had a high frustration level before we ever began because I wanted something right now as I had the audience who needed it, and nothing happened." (Interviewee 2) "We get flooded with emails all the time. I'm not under the impression it's required." (Interviewee 14) "I think if you all will do a follow-up email with a synopsis that this is out there and what kind of time commitment is required, I think that will be helpful." (Interviewee 15)

Discussion and Implications

Our findings indicated that educators perceived numerous barriers to attending training for and implementing the program we had developed. These barriers ranged from lack of time to attend training to challenges in locating an audience for the program.

The process of implementing a new program relies heavily on educators' ability to prioritize their schedules to attend in-services. However, due to budget cuts, educators across Extension are experiencing office restructuring and increased responsibilities that limit their time for trainings and ability to implement new programs (Strong & Harder, 2009). This circumstance applied to the educators who participated in our study as well.

Three themes we identified—staff shortages, program prioritization, and development of a public audience—all relate to one another and in some way to the aforementioned changes in Extension educators' responsibilities. Restructuring of job roles had required educators in our study to choose their programs carefully. With time constraints, many educators relied on their communities and program advisory committees (PACs) to guide those choices. Despite being informed of the needs present in Oklahoma communities, educators did not perceive the caregiving program as a priority because of the perception that their constituents did not perceive the program as a priority, a circumstance related to the educators' challenges in locating audiences. This scenario represents an important hurdle that caregiving program developers must address because research (National Alliance for Caregiving and AARP Public Policy Institute, 2015), policy initiatives (Caregiver Advise, Record, and Enable Act, 2014), and practitioners within communities all continue to identify the need for ongoing support for caregivers.

The educators also reported issues with the program staff, especially related to communication and program delivery. The interview results suggest that streamlining the process of finding program information and being clearer regarding the expectations of the program may help increase the ability of educators to fully participate in the program. It is vital to program success that program staff be as clear as possible when making any types of changes to the program and provide transitory assistance to educators to maintain the necessary trust between themselves and the educators.

Further analysis and delivery of the program will continue, and although the input received from the interviewees was invaluable, a potential limitation of the study is that interviewed educators were not randomly selected. However, data collection remained open until data saturation was reached, thus reducing bias (Patton, 2015; Smith & Noble, 2014). We feel that the responses shared herein may help inform other teams preparing to develop programs and services to support caregiving families in their communities.

Additionally, on the basis of our findings and experience with launching CEP, we can share valuable insights. Every effort should be made to increase awareness of caregiving issues, with particular attention to associated programming through Extension services at the national, state, and local levels. Following are suggested strategies for implementation for CEP and similar programs moving forward.

1. Develop webinars and educational programs for online delivery to allow the public to access programming when doing so is convenient. This strategy will help alleviate some of the time management issues faced by Extension educators, allowing the general public to take part in the educational program and content on their schedules.
2. Develop clear communication among partners and with the public. Contacting potential stakeholders prior to program development for their input on current community needs and dissemination strategies will facilitate personal ownership of the educational program by both educators and the general public.
3. Use established networks to engage stakeholders (e.g., hospitals, home health agencies), and develop associated materials. Using existing social media and electronic mailing list networks can result in time savings in recruiting participants as the lines of communication are already open to potential participants. Development of recruitment materials that are relatable and can be customized to address the concerns of each stakeholder group will allow for direct and understandable communications in the recruitment process.
4. Facilitate clearer prioritization processes for educators regarding identified needed programs. Developing guidelines on how to prioritize needed programs can help educators choose between programs deemed necessary by their PACs and those deemed necessary by their land-grant institutions.

Those involved in disseminating information through Extension should consider the strategies suggested here to adequately prepare educators for successful program delivery in their communities. Doing so for caregiving programs in particular is imperative in order to support positive public health and wellness outcomes for current and future caregiving families.

Disclaimer

Our work was supported by the Rural Health and Safety Education Competitive Grants Program (grant no. 2015-46100-24172) from the U.S. Department of Agriculture National Institute of Food and Agriculture.

References

Caregiver Advise, Record, and Enable (CARE) Act of 2014, 63 OKCS § 3113 (2014).

Duerden, M. D., & Witt, P. A. (2012). Assessing program implementation: What it is, why it's important, and how to do it. Journal of Extension, 50(1), Article 1FEA4. Available at: https://www.joe.org/joe/2012february/a4.php

Gagnon, R. J., & Pettigrew, J. (2018). Examining predictors of implementation quality in an emerging international Extension context. Journal of Extension, 56(4), Article 4RIB4. Available at: https://joe.org/joe/2018august/rb4.php

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage.

National Alliance for Caregiving and AARP Public Policy Institute. (2015). Caregiving in the U.S. 2015. Retrieved from http://www.caregiving.org/caregiving2015/

Olson, J. R., Welsh, J. A., & Perkins, D. F. (2015). Evidence-based programming within Cooperative Extension: How can we maintain program fidelity while adapting to meet local needs? Journal of Extension, 53(3), Article 3FEA3. Available at: https://www.joe.org/joe/2015june/a3.php

Patton, M. Q. (2015). Qualitative research and evaluation methods: Integrating theory and practice (4th ed.). Thousand Oaks, CA: Sage.

Smith, J., & Noble, H. (2014). Bias in research. Evidence Based Nursing, 17(4), 100–101. doi:10.1136/eb-2014-101946

Strong, R., & Harder, A. (2009). Implications of maintenance and motivation factors on Extension agent turnover. Journal of Extension, 47(1), Article 1FEA2. Available at: https://www.joe.org/joe/2009february/a2.php

Turner, D. W. (2010). Qualitative interview design: A practical guide for novice investigators. The Qualitative Report, 15, 754–760. Retrieved from https://nsuworks.nova.edu/tqr/vol15/iss3/19/

Weller, S. C., Vickers, B., Bernard, H. R., Blackburn, A. M., Borgatti, S., Gravlee, C. C., & Johnson, J. C. (2018). Open-ended interview questions and saturation. PLoS ONE, 13, e0198606. doi:10.1371/journal.pone.0198606

Appendix

Caregiver Education Program Implementation Study Interview Protocols

Protocol for Educators Who Had Presented at Least One Module to the Public

1. Please tell me about your experiences with the Caregiving Curriculum.
   1. What did the planning process look like for you prior to delivering the modules?
   2. How did the process of preparing for these Caregiving modules differ from other workshops you have delivered?
   3. How many workshops have you led regarding the Caregiving Curriculum?
2. Explain the process of how you recruit rural caregivers for the Caregiving Curriculum modules.
3. What are some of the challenges you are facing in delivering the curriculum?
   1. What feedback do you have for us regarding recruitment materials?
   2. What feedback do you have for us regarding the module assessments?
   3. What feedback do you have for us regarding the Caregiving Pre-Test/survey instruments?
   4. What feedback do you have for us regarding evaluating programs through extension in general?
4. What is one thing you wish you would have known prior to delivering your first Caregiving module?
5. What is the greatest take away you hope other FCS Educators leave with regarding delivery of the Caregiving Education curriculum?
6. Is there anything else we should know about your experiences with the Caregiving Education curriculum?
7. Is there anything that you are surprised that we did not ask you about?

Protocol for Educators Who Had Completed an In-Service but Had Not Presented to the Public

1. Please tell me about your experiences with the Caregiving Curriculum.
   1. What does the planning process look like for you prior to delivering the modules?
   2. How does the process of preparing for these Caregiving modules differ from other workshops you have delivered?
2. Explain the process of how you will recruit rural caregivers for the Caregiving Curriculum modules.
3. What are some of the challenges you are facing in preparing to deliver the curriculum?
   1. What feedback do you have for us regarding recruitment materials?
   2. What feedback do you have for us regarding the module assessments?
   3. What feedback do you have for us regarding the Caregiving Pre-Test/survey instruments?
   4. What feedback do you have for us regarding evaluating programs through extension in general?
4. What is the greatest take away you hope other FCS Educators leave with regarding delivery of the Caregiving Education curriculum?
5. Is there anything else we should know about your experiences with the Caregiving Education curriculum?
6. Is there anything that you are surprised that we did not ask you about?

Protocol for Educators Who Had Not Completed an In-Service or Presented to the Public

1. Please explain your experiences/perceptions of the Caregiving Curriculum to date.
2. Have you completed any of the 6 in-services for the Caregiving Curriculum?
   1. Were you aware that there were 6 in-service opportunities at the beginning of this year?
3. Are you aware that the two of the Caregiving Curriculum modules are part of your core competencies?
   1. What barriers have kept you from completing these in-services?
   2. What strategies do you have for overcoming these barriers?
   3. What feedback do you have for us in helping educators overcome these barriers?
      1. (Follow-up, if necessary) What feedback do you have for us in helping make sure educators have everything they need to complete the in-services?
4. Do you have any other comments for us regarding the Caregiving Curriculum?