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Testing Self-Efficacy as a Pathway That Supports Self-Care Among FamilyCaregivers in a Psychoeducational InterventionMarie Y. Savundranayagama; Mary Brintnall-Petersonb

a University of Wisconsin-Milwaukee, Milwaukee, Wisconsin b University of Wisconsin-Extension,Madison, Wisconsin

Online publication date: 18 March 2010

To cite this Article Savundranayagam, Marie Y. and Brintnall-Peterson, Mary(2010) 'Testing Self-Efficacy as a PathwayThat Supports Self-Care Among Family Caregivers in a Psychoeducational Intervention', Journal of Family Social Work,13: 2, 149 — 162To link to this Article: DOI: 10.1080/10522150903487107URL: http://dx.doi.org/10.1080/10522150903487107

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Testing Self-Efficacy as a Pathway ThatSupports Self-Care Among Family Caregivers

in a Psychoeducational Intervention

MARIE Y. SAVUNDRANAYAGAMUniversity of Wisconsin–Milwaukee, Milwaukee, Wisconsin

MARY BRINTNALL-PETERSONUniversity of Wisconsin-Extension, Madison, Wisconsin

This study investigated the extent to which a psychoeducationalintervention supports family-centered care by influencing healthrisk and self-care behaviors of caregivers of individuals withAlzheimer’s disease (N¼ 325). Moreover, this study investigatedthe extent to which changes in self-efficacy explained changes inhealth risk and self-care behaviors. Data were analyzed usingrepeated measures and multivariate analysis of variance andmultiple regression. Qualitative written accounts of the impact ofthe intervention augmented the quantitative findings. The study’sfindings revealed that family caregivers experienced reductionsin health risk behaviors and improvements in exercise, stressmanagement, and relaxation activities as a result of participatingin the psychoeducational intervention. Improvement in self-efficacy was linked with reductions in health risk behaviors andincreased involvement in stress management and relaxationactivities. Implications are discussed in terms of the need to under-stand the mechanisms by which interventions influence familycaregivers and the role these mechanisms play in supportingfamily-centered care.

The authors acknowledge financial support from grants to M. Y. Savundranayagam fromthe Hartford Foundation’s Geriatric Social Work Faculty Scholars Program and the Center onAge and Community at the University of Wisconsin–Milwaukee.

Address correspondence to Marie Y. Savundranayagam, Helen Bader School of SocialWelfare, University of Wisconsin–Milwaukee, P. O. Box 786, Milwaukee, WI 53201. E-mail:[email protected]

Journal of Family Social Work, 13:149–162, 2010Copyright # Taylor & Francis Group, LLCISSN: 1052-2158 print=1540-4072 onlineDOI: 10.1080/10522150903487107

149

Downloaded At: 06:32 25 November 2010

KEYWORDS Alzheimer’s disease, family caregivers, family-centeredcare, psychoeducational interventions, self-care, self-efficacy

Family members caring for an individual with Alzheimer’s disease (AD) facemultiple challenges due to the various cognitive, functional, behavioral, andcommunication impairments that are symptoms of the illness (Bedard,Pedlar, Martin, Mallott, & Stones, 2000; Pinquart & Sorenson, 2003;Savundranayagam, Hummert, & Montgomery, 2005). The rigorous caredemands and exhaustive stressors associated with AD require exceptionalvigilance. They can threaten the familial relationships and negatively affectthe caregiver’s mental and physical health. Caregivers who provide care topersons with AD reported higher levels of anxiety, stress, and depressionthan those caring for persons with physical disabilities and cancer (Clipp& George, 1993; Hooker, Monahan, Bowman, Frazier, & Shifren, 1998;Ory, Hoffman, Yee, Tennstedt, & Schulz, 1999). Mental health conse-quences have also been linked with elevated stress hormones (Vitaliano,Zhang, & Scanlan, 2003) and increased risk for death among caregivers(Schulz & Beach, 1999). Negative health outcomes associated with caregiv-ing have been linked with reduced self-care and greater numbers of healthrisk behaviors, such as poor diet and exercise and not getting enoughrest (Gallant & Connell, 1997; Vitaliano et al., 2002). Therefore, a family-centered approach to the care of individuals with AD requires a closeexamination of the benefits of self-care and a strong effort to reinforcethis information with family caregivers. More importantly, it is vital thatfamily caregivers are educated, empowered, and supported in their effortsto engage in positive self-care behaviors as they continue in their caregiv-ing role.

OVERVIEW OF POWERFUL TOOLS FOR CAREGIVING

A psychoeducational program called Powerful Tools for Caregiving (PTC)was developed to address the issue of self-care for informal caregivers(including family and friends) of individuals with chronic illnesses. PTC runsfor six consecutive weeks, with each session lasting 2½ hours. The structureof PTC is based on the Chronic Disease Self-Management Program (Lorig &Holman, 2003; Lorig et al., 1996), a patient education program that reliesheavily on developing and building the participants’ self-efficacy. PTC usesfour strategies to enhance self-efficacy: skills mastery, modeling, reinterpre-tation of feelings and attitudes about caregiving, and persuasion (Boise,Congleton, & Shannon, 2005). Using these strategies, PTC teaches caregiversto manage their emotions, engage in self-care behaviors (e.g., take time torelax), and communicate assertively (Schmall, Cleland, & Sturdevant, 2000).

150 M. Y. Savundranayagam and M. Brintnall-Peterson


Detailed descriptions of the psychoeducational program are provided byBoise and colleagues (2005) and Schmall and colleagues (2000).

PTC is widely used across the United States; however, the existingresearch on its impact has not directly tested the theoretical framework thatguides the intervention. Previous studies on PTC have been detailed descrip-tive accounts that are helpful for organizations that are interested in offeringPTC (Boise et al., 2005; Kuhn, Fulton, & Edelman, 2003). Studies by Boiseand colleagues (2005) and Kuhn and colleagues (2003) primarily includedcaregivers of individuals with AD and tested the intervention by comparingpre- and posttest outcomes, including self-care and health risk behaviors.Self-efficacy was discussed as an outcome but not as an explanatory variablethat potentially contributed the change in self-care and health risk behaviors.Another study on PTC also focused on health risk behaviors but specificallyconsidered sociodemographic characteristics of the caregiver and care recipi-ent as its predictors (Won, Fitts, Favaro, Olsen, & Phelan, 2008). The onlysignificant predictor of health risk behaviors was the number of comorbidmedical conditions held by the care recipient.

SELF-EFFICACY AND SELF-CARE

In intervention research, it is important to understand why the interventionresulted in predicted outcomes and to measure the possible active ingredientor explanatory variable. The self-management model on which PTC is basedstates that self-efficacy is a key factor that influences change in self-care andhealth risk behaviors. This model is similar to stress process models in thecaregiving literature, in that both highlight the role of self-efficacy in predict-ing self-care and health risk behaviors (Rabinowitz, Mausbac, Thompson, &Gallagher-Thompson, 2007; Yee & Schulz, 2000). Accordingly, the primaryobjective of the current study is to investigate how PTC affects health riskand self-care behaviors of caregivers. Specifically, the current study aims toexamine the role of self-efficacy in reducing the likelihood of health riskbehaviors and increasing the likelihood of self-care behaviors (exercise,stress management, relaxation) among family caregivers of persons withAD. The following hypotheses and research questions were tested:

Hypothesis 1: There will be significant differences in health risk and self-carebehaviors from pre- to post-PTC.

Follow-up Research Question 1: Are there differences between spouses andadult children in health risk and self-care behaviors at pre- and post-PTC?

Hypothesis 2: Controlling for contextual variables, change in self-efficacy isexpected to predict change in health risk and self-care behaviors.

Follow-up Research Question 2: Are there differences between spouses andadult children in the extent to which change in self-efficacy predictschange in health risk and self-care behaviors?

Self-Efficacy and Self-Care Among Family Caregivers 151


METHOD

Procedure

The study was reviewed and approved by the Institutional Review Board atthe University of Wisconsin–Extension. Participants were caregivers whosigned up voluntarily to participate in the class. The classes were offeredby a variety of social service organizations such as local chapters of theAlzheimer’s Association and Aging and Disability Resource Centers. Theresponse rate was approximately 85%. Class leaders=facilitators obtainedconsent from participants prior to the completion of the pre-PTC question-naire. Caregivers were asked to complete the pre-PTC questionnaire eitherbefore or during Session 1. Post-PTC questionnaires were completed eitheron or after the last PTC session. The post-PTC questionnaire included anopen-ended question that asked participants to write about the ways inwhich PTC helped them with specific concerns or problems related to care-giving. Some of the one-time qualitative responses that were part of theposttest are included in the discussion to augment the quantitative findings.

Participants

Participants included 325 family caregivers of persons with AD who com-pleted evaluations for PTC classes held in Wisconsin from 2001 to 2004.The average age of caregivers was 65 years, and a little over three-fourthswere female. There were almost equal number of wives (38.2%) anddaughters-in-law (39.7%) in the caregiving role (see Table 1). An overwhelm-ing majority of participants were White (97%). Approximately 5% of the datawas missing. Expectation maximization was used to impute the missingvalues (Dempster, Laird, & Rubin, 1977; Horton & Kleinman, 2007).

Measures: Independent Variables

SOCIODEMOGRAPHIC AND BACKGROUND VARIABLES

Demographic data was collected pre-PTC and included caregiver age, gen-der, education, household income, and kinship status (spouse or adult child).Number of sessions attended by each participant was also included in theanalyses to control for the effects of exposure to PTC content. Programattendance was strong in the sample; 63% of participants attended all sixPTC sessions, 25% attended five sessions, 10% attended four sessions, and2% attended three or fewer sessions.

CAREGIVING DEMANDS

The care recipient’s level of severity of memory problems was measuredusing a single-item variable with three levels of mild, moderate, and severe



(Boise et al., 2005; Kuhn et al., 2003). Time spent on personal care, house-hold tasks, and arranging for help were measured using single items thatasked participants how often they engaged in the above tasks. The responseoptions included not at all, some days but not every day, and daily or almostdaily.

INTERVENTION OUTCOMES

CAREGIVER SELF-EFFICACY

The Caregiver Self-Efficacy Scale is an 11-item measure that was specificallydeveloped for PTC and was based on the skills, behaviors, and attitudes thatPTC aimed to influence (Boise et al., 2005). Participants were asked to ratethe level of confidence, on a scale of 1 (no confidence) to 5 (extremelyconfident), they had in performing tasks such as getting help with daily tasks,keeping from feeling sad or down in the dumps, and discussing their con-cerns with family and friends. For example, one item asks, ‘‘how confidentare you that you can discuss openly with the doctor any concerns orproblems that you may have related to your caregiving responsibilities.’’Cronbach’s alpha for this measure at pre- and post-PTC was .86 and .87,respectively.

TABLE 1 Description of the Sample (N¼ 325)

Caregiver

Average age and range 65 (38–90 years)GenderMale 22.1%Female 77.9%

Relationship to person with ADWife 38.2%Husband 13.8%Daughter 39.7%Son 8.3%

EducationGrades 0–8 5.2%Grades 9–11 2.5%High school graduate 33.5%Some college 27.1%Graduate coursework 19.7%

Household income<$10,000 5.5%$10,000–14,999 10.8%$15,000–20,000 14.8%>$20,000 68.9%

Average number of PTC sessions and range 5.5 (2–6)

AD¼Alzheimer’s disease; PTC¼Powerful Tools for Caregiving.



HEALTH RISK BEHAVIORS

Health risk was measured by asking participants whether they neglected aparticular health-related activity in the past 3 months. Example items inclu-ded: put off going to the doctor, failed to stay in bed when ill, postponedgetting regular checkups or exams, eaten poorly, and put off recreationalactivities. A score for health risk behavior was calculated by summing the‘‘yes’’ responses to the nine items. Cronbach’s alpha for this measure atpre- and post-PTC was .74 and .68, respectively. This measure was usedpreviously in studies that evaluated PTC (Boise et al., 2005; Won et al., 2008).

SELF-CARE BEHAVIORS

The frequency of exercise and stress management techniques used in thepast week was measured using single-item questions that asked participantsto choose one of the following options: none, <30 minutes, 30–60 minutes,1–3 hours, and >3 hours (Lorig et al., 1996). Participants were also asked tostate the number of times in the past week that they engaged in relaxationactivities such as muscle relaxation, prayer, and reading.

Analyses

Hypothesis 1 (differences in health risk and self-care behaviors from pre- topost-PTC for spouses and adult children) was tested using repeated measuresANOVA and MANOVA. Hypothesis 2 (the role of changes in self-efficacy inpredicting changes in health risk and self-care behaviors) was tested usingmultiple hierarchical regression analysis. Specifically, the regression analysistested whether changes in self-efficacy predicted changes in health risk andself-care outcomes while controlling for variables related to sociodemo-graphics and caregiving demands. Changes in self-efficacy, health risk, andself-care outcomes were calculated by subtracting pre-PTC scores frompost-PTC scores. The first set of variables included sociodemographic factors(age, gender, education, and household income) that may influence accessto health promotion opportunities. The second set of variables was associa-ted with caregiving demands (severity of memory problems, and time spenton personal care, household tasks, and arranging for help). The remainingvariables were entered separately (e.g., number of sessions attended by eachparticipant, change in self-efficacy, kinship status, and the interactionbetween kinship status and change in self-efficacy). The following categ-orical variables were dummy coded prior to regression analyses: gender(0¼male, 1¼ female) and kinship status (0¼ adult child, 1¼ spouse).Finally, change in self-efficacy was mean centered before it was used inthe regression analyses to (1) diminish potential multicollinearity betweenthe main effect (of change in self-efficacy) and the interaction (between



TABLE2

DescriptiveStatistics

ofMajorStudyVariablesan

dTheirIntercorrelations

Variables

12

34

56

78

910

11

12

13

14

15

1.Age

1.00

2.Gender

�0.23�

1.00

3.Education

�0.34�

0.00

1.00

4.Household

inco

me

�0.13�

�0.05

0.29

1.00

5.Severity

ofmemory

problems

0.11

�0.11

�0.10

�0.14�

1.00

6.Tim

espent:Personal

care

0.14�

0.01

�0.13�

�0.20�

0.24�

1.00

7.Tim

espent:Household

tasks

0.24�

�0.03

�0.14�

�0.20�

0.11�

0.45�

1.00

8.Tim

espent:Arran

ging

help

0.03

0.08

�0.03

�0.14�

0.11

0.43�

0.46�

1.00

9.NumberofPTCsessions

0.16�

�0.14�

�0.15�

0.00

0.05

0.01

�0.05

�0.07

1.00

10.Din

Self–efficacy

�0.07

0.05

�0.12�

�0.01

�0.05

�0.03

�0.03

�0.04

0.05

1.00

11.Kinship

status

0.77�

�0.11�

�0.30�

�0.07

0.14�

0.16�

0.27�

0.09

0.09

0.00

1.00

12.Din

health

risk

behaviors

0.06

�0.05

0.00

0.08

0.09

0.07

�0.02

�0.01

0.00

�0.32�

0.02

1.00

13.Din

exercise

�0.03

0.02

0.05

0.01

0.04

0.03

0.00

0.07

�0.08

0.14�

�0.01

�0.19�

1.00

14.Din

stress

man

agement

�0.09

0.11

�0.02

�0.08

0.08

0.00

0.02

0.08

0.14�

0.24�

�0.07

�0.12�

0.13�

1.00

15.Din

#ofrelaxation

activities

�0.11

0.15�

0.00

�0.10

0.01

0.03

0.07

0.03

0.10

0.20�

�0.02

�0.02

0.02

0.14�

1.00

M64.96

3.90

3.47

2.06

1.80

2.50

2.16

5.48

0.55

�1.07

0.37

0.57

1.21

SD11.85

1.26

0.89

0.67

0.82

0.66

0.68

0.78

0.58

2.04

1.25

1.37

6.44

Note:PTC¼PowerfulToolsforCaregiving.

� Correlationissignifican

tat

p<.05level.

155


change in self-efficacy and kinship status) and (2) to make parameterestimates easier to interpret (Aiken & West, 1991). Table 2 includes descrip-tive statistics and correlations of variables used in the analyses.

RESULTS

Differences in Health Risk and Self-Care Behaviors FromPre- to Post-PTC

Changes in participants’ health risk and self-care behaviors by kinship statusover the course of PTC were examined using a two-factor repeated measuresANOVA for health risk behaviors and number of relaxation activities, andrepeated measures MANOVA for time spent exercising and time spent onstress management techniques. There were no significant interactionsbetween kinship status and time for any of the outcomes. The main effectsfor kinship status, F(1,323)¼ 13.70, p< .001, gp2¼ .04, and time,F(1,323)¼ 90.08, p< .001, gp2¼ .22, were significant for health risk beha-viors. There were significant reductions in health risk behaviors from pre-to post-PTC for spouses and adult children. Adult children also engaged ina greater number of health risk behaviors compared to spouses. There wasa significant time main effect for number of relaxation activities,F(1,323)¼ 11.51, p< .01, gp2¼ .03. Over the course of PTC, spouses andadult children engaged in more relaxation activities. Finally, there was a sig-nificant main effect for time on exercise and stress management techniques,k(2, 322)¼ 38.44, p< .001, gp2¼ .19. Follow-up univariate tests revealed thatboth groups spent more time on exercise, F(1,323)¼ 28.90, p< .001, gp2¼ .08,and stress management techniques, F(1,323)¼ 57.16 , p< .001, gp2¼ .15, frompre- to post-PTC. Repeated measures ANOVA was used to test whether therewas a kinship status by time interaction for self-efficacy. Results revealedmain effects for kinship status, F(1,323)¼ 9.66, p< .01, gp2¼ .03, and time,F(1,323)¼ 282.27, p< .001, gp2¼ .47, but no interactions. Although adult chil-dren scored higher on self-efficacy over the course of PTC, both groupsshowed a significant increase in self-efficacy from pre- to post-PTC.

Changes in Self-Efficacy as a Predictor of Changes in Health Riskand Self-Care Behaviors

The separate sets of regression analyses revealed that there were no significantgroup differences in the extent to which change in self-efficacy predicted allfour outcomes (health risk behaviors, exercise, stress management techni-ques, and relaxation activities). Moreover, the full model for change in exer-cise was not significant, F(12, 324)¼ 1.08, p¼ .38. As a result, follow-upanalyses were conducted with three sets of regression analyses that did notinclude the kinship status and interaction variables (see Table 3). The full



TABLE3

Hierarchical

RegressionAnalysesforVariablesPredictingChan

gein

Health

Riskan

dSelf-CareOutcomes

Chan

gein

health

risk

behaviorsa

Chan

gein

timespenton

stress

man

agementb

Chan

gein

thenumberof

relaxationactivitiesc

Predictorvariable

BSE

Bb

BSE

Bb

BSE

Bb

Step1

Age

0.00

0.01

0.02

�0.01

0.01

�0.09

�0.06

0.03

�0.11

Gender

�0.10

0.27

�0.02

0.33

0.18

0.10

2.10

0.87

0.14�

Education

�0.09

0.10

�0.06

0.04

0.07

0.04

0.25

0.31

0.05

Household

inco

me

0.00

0.01

0.02

�0.12

0.09

�0.08

�0.73

0.41

�0.10

Step2

Severity

ofmemory

problems

0.21

0.17

0.07

0.20

0.11

0.10

0.20

0.54

0.02

Tim

espent:Personal

care

0.25

0.16

0.10

�0.11

0.11

�0.06

�0.13

0.50

�0.02

Tim

espent:Household

tasks

�0.18

0.20

�0.06

0.05

0.13

0.02

1.09

0.63

0.11

Tim

espent:Arran

ginghelp

�0.09

0.19

�0.03

0.17

0.13

0.09

�0.17

0.60

�0.02

Step3

NumberofPTCsessions

�0.02

0.14

�0.01

0.28

0.10

0.16�

1.17

0.46

0.14�

Step4

Chan

gein

self-efficacy

�1.11

0.19

�0.32�

0.54

0.13

0.23�

2.07

0.60

0.19�

Note:PTC¼PowerfulToolsforCaregiving.

Coefficients

arefrom

theStep

4model.PTC¼.

aFortheregressiononch

angein

health

risk

behaviors,R2¼.01forStep1(p

¼.42);DR2¼.02forStep2(p

¼.23);DR2¼.00forStep

3(p

¼.86);DR2¼.10forStep4

(p<.001).

bFortheregressiononch

angein

timespentonstress-m

anagement,R2¼.02forStep1(p

¼.10);DR2¼.01forStep2(p


3(p

<.01);DR2¼.05

forStep

4(p

<.001).

cFortheregressiononch

angein

thenumber

ofrelaxationactivities,R2¼.04forStep

1(p

<.05);DR2¼.00forStep2(p


3(p

<.01);DR2¼.03

forStep

4(p

<.01).

� p<.05.

157


model for change in health risk behaviors was significant, F(10, 324)¼ 4.59,p< .001, and explained 13% of the variance. Results indicated change inself-efficacy was the only significant predictor, accounting for 10% of thevariance in changes in health risk behaviors. Specifically, the increase inself-efficacy predicted the decrease in health risk behaviors (b¼�.32,p< .001). The full model for change in the frequency of using stress manage-ment techniques was significant, F(10, 324)¼ 4.10, p< .001, and explained12% of the variance. Results indicated the number of PTC sessions attendedand change in self-efficacy uniquely accounted for 3% and 5%, respectively,of the variance in changes in frequency of stress management techniques.Specifically, the more PTC sessions attended (b¼ .16, p¼ .004) and increasesin self-efficacy (b¼ .23, p< .001) predicted the increase in use of stress man-agement techniques. Finally, the full model for change in the number ofrelaxation activities was significant, F(10, 324)¼ 3.54, p< .001, and explained10% of the variance. Results indicated that gender, number of PTC sessionsattended, and change in self-efficacy uniquely accounted for 2%, 2%, and3%, respectively, of the variance in changes in the use of relaxation activities.Specifically, females (b¼ .14, p¼ .017) were more likely to the increase theiruse of relaxation activities. The more PTC sessions attended (b¼ .14,p¼ .011) and increases in self-efficacy (b¼ .19, p¼ .001) predicted theincrease in use of relaxation activities.

DISCUSSION

Overall, the findings from the current study are similar to previous studieson PTC (Boise et al., 2005; Kuhn et al., 2003; Won et al., 2008) in that theyillustrate the positive effect of PTC on health risk and self-care behaviorssuch as relaxation, exercise, and stress management. Moreover, participantsshowed improvements in self-efficacy over the course of PTC (e.g., ‘‘Myconfidence level has improved each week’’). The following commentsreflect the newfound awareness of self-neglect among participants thatprompted self-care: ‘‘The emphasis on self-care was critical for me as thisneglect of my needs was moving me into early burnout.’’ ‘‘It helped meto see I have to take care of myself so I can be around to take care ofmy husband in the future.’’ Participation in PTC gave caregivers permissionto engage in self-care behaviors, as illustrated by the following comments:‘‘Validated my need to care for myself, go to work, meet friends for coffee,lunch, etc.’’; ‘‘Gave myself permission to thrive, not just survive, and to takebetter care of myself.’’ These findings clearly illustrate that, though familymembers have been actively providing for their relative with AD, theirown needs have been either neglected or not affirmed in the past. Partici-pating in PTC brought their unmet needs to the forefront and, more impor-tantly, acknowledged the value of resolving unmet needs.



What is distinct about the current study is that it also examined the extent towhich changes in self-efficacy explained the favorable changes in health risk andself-care outcomes. Spouses and adult children did not differ in terms of theextent to which change in self-efficacy explained changes in health risk andself-care outcomes. Although change in self-efficacy did not explain the improve-ments in time spent on exercise, it was most influential in explaining thereduction in health risk behaviors, followed by increases in time spent on stressmanagement and increases in relaxation activities. Statements such as PTC ‘‘gaveme confidence to take care of self’’ and ‘‘gave me confidence in myself so that Ican better handle situations that arise’’ illustrate how self-efficacy influencedself-care. Getting family members to engage in self-care is challenging becausethe individual with the chronic illness such as AD is the focus of social and healthcare systems. To foster family-centered care, it is all the more important that psy-choeducational programs likePTCactively focus onboosting self-efficacy amongfamily caregivers so that they can also advocate for their own care.

The findings revealed that the number of sessions attended uniquely con-tributed to the increases in time spent on stress management and increases inthe number of relaxation activities. Each PTC session included developingaction plans for the upcomingweek and reporting on action plans from the pre-vious week. Action plans involved creating opportunities for the caregiver toengage in self-care activities. Participants were also encouraged to developaction plans around ways they could take better care of themselves or reducestress. Therefore, the more sessions attended, the more practice participantshad creating and following through on action plans that involved stress man-agement or relaxation (e.g., ‘‘action plans helped me plan how to get some timeto myself’’). Moreover, participants received weekly feedback and encourage-ment on action plans. This is critical in the case of caregivers of persons with ADbecause the PTC group might be their only opportunity to receive positive andaffirming feedback from others. Moreover, by having caregivers report on theiraction plans each week, their self-efficacy increased their ability to developaction plans that could be accomplished successfully. This is evidenced bythe following comments: ‘‘Motivated for movement on previously plannedaction’’ and ‘‘I found I can do better planning and enjoy my role more withgoals and thinking before I act.’’ In addition to action plans, each PTC sessionfeatured a different relaxation technique such as guided imagery, muscle relax-ation, and deep breathing. Relaxation tapes were also available for participantsto borrow or buy. Some of the participants took advantage of this opportunityand used the relaxation methods daily; those who attended all of the classeswere taught a variety of relaxation techniques to help maintain self-care.

Limitations

Although the sample size was relatively large for an intervention study, thereare several limitations of the current study in terms of the sample. First, it



included a convenience sample of individuals who self-selected to take PTCand complete the pre- and post-PTC questionnaires. Second, the sample wasrelatively homogeneous: most participants were female and White. However,this ethnic composition in the current study reflects the less urban areas ofWisconsin where PTC sessions were offered. Nonetheless, outreach to care-givers of color is critical and an area that is worthy of more research. Finally,there was no control group, and as a result one cannot be certain that thepositive outcomes are due to the intervention or indicative of general changeand adaptation over time. Unlike previous work on PTC (Boise et al., 2005),the current study reports on the immediate impact of PTC on caregivers.Longer term follow-up will be helpful not only to evaluate maintenanceeffects but also to examine whether there are delayed intervention effectsfor participants who did not show immediate improvements in self-efficacy,or health risk and self-care behaviors.

Although increased levels of self-efficacy improved the likelihood thatcaregivers engaged in self-care behaviors, self-efficacy only explained partof the variance in the outcome measures. Future research should considerother mechanisms (or mediators) that explain improvements in self-careand health risk behaviors. Moreover, other participant characteristics (ormoderators) apart from kinship status might influence the degree of improve-ment in self-care outcomes.

CONCLUSION

Testing theoretical models that underlie interventions by investigating themechanisms that contribute to positive health outcomes for caregivers isincreasingly important. The self-management (Lorig & Holman, 2003; Loriget al., 1996) and stress process models (Yee & Schulz, 2000) hypothesize thatself-efficacy plays a pivotal role in maintaining caregiver health. Previousresearch findings indicated that lower levels of self-efficacy are linked withnegative health behaviors among caregivers of persons with AD (Rabinowitzet al., 2007). As such, the current study directly tested whether changes inself-efficacy over the course of PTC predicted changes in health risk andself-care behaviors. The findings have important implications for psychoedu-cational interventions in general and for future PTC classes. First, the findingsillustrate that participants who increased their level of self-efficacy were ableto reduce health risk behaviors and increase their involvement in self-carebehaviors. Therefore, it is important for class leaders to be attuned toself-efficacy levels of their participants as they progress through the program.Perhaps PTC should be targeted to caregivers who have low levels ofself-efficacy at the start of the program. Second, trained class leaders needto know that attending all six PTC sessions increases the likelihood that care-givers will engage in self-care behaviors. Potential PTC participants need to



be encouraged to stay the course to achieve the full self-care benefits of theprogram. This might be accomplished in a variety of ways, including offeringrespite when PTC sessions are held. Some organizations that offer PTC doprovide respite and they should be commended for integrating services sothat family caregivers can learn more about self-care.

Overall, the study’s findings highlight the importance of creating aware-ness about the prevalence of self-neglect among family caregivers as a neces-sary first step in promoting family-centered health care practice. We arefinally reaching a point where service providers and health professionalsare realizing that caregiver health is important. It is up to professionals touse psychoeducational programs to inform family caregivers about thedeleterious effects of their self-neglect and to empower them with tools toengage in self-care behaviors. Such acknowledgment and support might helpfamily members be better able to maintain their roles as caregivers withoutrisking their own health.

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