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EVALUATION OF A FOTONOVELA TO REDUCE DEPRESSION AND STRESS IN
LATINO DEMENTIA FAMILY CAREGIVERS
Marian Tzuang, Irene Valverde, Paula Alvarez, Johanna Rengifo Nevarez, Ken Chen,
Tara Emrani, Ladson Hinton, Larry W. Thompson, Dolores Gallagher-Thompson
May 2, 2014
2014 ADI Conference, Puerto Rico
This study was funded by: National Office of the Alzheimer’s Association
Grant # IIRG-08-92099
Dementia in Latino Americans
Latino older adults are about 1.5 times as likely to have Alzheimer’s disease than whites1
A diagnosis of Alzheimer’s disease is more often missed among Latino elders1
In California, the number of Latinos living with Alzheimer’s disease will about triple (a 200% increase between 2008 and 2030) 2
1. (Alzheimer’s Disease Facts and Figures, 2014); 2. (CA AD Data Report)
Latinos at greater risk of developing AD
• an increase to age 87 by 2050 Average life expectancy is expected
to exceed all other ethnic groups
• more than half have 8 years or less of formal education
Have the lowest education levels of any group
• i eases the isk fo Alzhei e ’s disease and vascular dementia
Prevalence of Type 2 Diabetes and hypertension
• which can delay diagnosing Alzheimer’s disease
They do not utilize health care services as much
(CA AD Data Report, 2009)
Lati o Fa ily Caregivers’ Characteristics
Familismo
Women, 40 years of age or older, full-ti e e ployed, sa d i hed
More depressed, provide more hands-on-care for longer periods of time, and report poorer physical health when compared to Non-Hispanic Whites
(Family Caregiver Alliance, 2004; Pinquart & Sorensen, 2005)
The Fotonovela Project
• Popular cultural medium
• Combines education and entertainment
• Has i a ious odeli g pote tial • Specifically targets lower literacy (6th
grade & below)
• Content was determined based on 10 focus groups
Phase I: Development of the Fotonovela
Focus Groups
10 focus groups were conducted: Caregivers (4) & Professionals (6) in
English & Spanish
32 Caregivers, 34 Professionals
Topics covered: important difficult behaviors, coping strategies, how to
ask for help from family members and how the CG can take better care
of themselves, critical fotonovela content
Tape-recorded with detailed notes
Thematic analysis
Themes that Emerged
Lack of basic knowledge about AD and behavioral problems
Behavioral problems are a major issue
Specific behavioral problems commonly mentioned as more difficult:
Forgetfulness, aggression (verbal and physical), mood/depression,
hygiene, sexually inappropriate behaviors
Caregiver isolation/depression critical
Family context is critical
◦ Family often ignorant of behavioral problems
◦ Family conflict a major source of stress for caregivers
Final Product - Fotonovela
The Ji é ez fa ily…
The “to yli e…
Getti g a Alzhei e ’s diag osis
Caregiver in stress, including scenarios like: reacting to a confused grandmother; safety concerns - u i g pots a d pa s; a d deali g ith a ot
uite o oa d othe . Coping Strategies
The dist a tio te h i ue
Seeking support from family, friends, and community resources (i.e. support group, adult day care center
Family meeting mediated by a social worker
Other Information
What is dementia?
CG self screen for depression and a referral recommendation
Phase II: Multi-Site Randomized Controlled Study
Recruitment for RCT
Service providers were contacted:
In-home supportive services
Social workers in community-based agencies
Primary care medical clinics
Flyers in Spanish and English were distributed
Announcements were made in the Latino media (newspaper, radio and
television)
Inclusion Criteria Self identified as Latino, 21 years old or older, either male or female
Provide care to a family member with significant memory problems or diagnosed dementia for at least 12 hours a week for a minimum of 6 months
Report experiencing distress as a consequence of their caregiving role based on positive response to at least 2 of 6 items (e.g., felt overwhelmed, report moderate to high levels of stress, etc)
CGs in immediate need of assistance were referred
All CGs signed written informed consent; this project was approved by the Stanford University School of Medicine IRB
Participant Enrollment N=147 Latino family caregivers were enrolled from four sites in California:
◦ Salinas (n = 78)
◦ Santa Cruz (n = 27)
◦ Sacramento (n = 21)
◦ San Diego (n = 21)
Participants were randomly assigned to either the intervention group (FN: fotonovela) or to the control group (UC: Usual Care)
The UC group (N=55 completers) received traditional pamphlets currently offe ed y the Alzhei e ’s Asso iatio a d the i te e tio g oup ( =55 completers) received the 20-page fotonovela.
4 monthly follow-up phone calls after baseline interview to assess the value and impact of both educational methods
Total (n=110) FN (n=55) UC (n=55)
Mean (SD)
Range Mean (SD)
Range Mean (SD)
Range T test P value
Age 55 (11.00) 36-85 54 (10.76) 36-82 56 (11.18)
36-85 1.234 >.05
Years in USA 37 (16.83) 5-80 35 (18.35)
5-75 38 (15.24) 9-80 -0.678 >.05
CGs’ Years of Formal Education
9 (4.47)
0-17 9.15 (4.66) 0-16 9.75 (4.30) 0-17 -0.696 >.05
Age of CR 82 (8.7)
52-100 81 (9.19) 59-96 83 (8.15) 52-100 -1.197 >.05
CRs’ Years of Formal Education
4 (4.01) 0-15 4 (4.36)
0-15 4 (3.65) 0-14 0.451 >.05
Demographics (1)
Demographics (2) Percentage (%)
FN (n= 55)
UC (n=55)
Total (N = 110)
χ² p
Gender Male Female
15 86
22 78
18 82
0.978 >.05
Marital Status Never Married
Married
Widowed
Divorced
Separated
20 66 7 2 7
16 60 6 6 13
18 62 6 4 10
2.22 >.05
CG Country of Birth United States
Mexico
El Salvador
Guatemala
Other
22 73 2 0 4
24 69 2 2 4
23 71 2 1 4
5.091 >.05
Relation to Caregiver
Parents
Spouse
Parents-in-law
Other Relative
75 11 11 4
67 11 11 11
71 11 11 7
10.667 >.05
Self-Rated Health Excellent
Good
Fair
Poor
9 16 37 38
6 15 31 49
7 16 34 44
1.552 >.05
Decrease of Depressive Symptoms (CES-D)
CES-D Total Baseline Month 4 Month 6
FNC Mean 19.66 15.37 10.01
SD 11.85 11.30 9.82
UC Mean 16.81 14.47 12.51
SD 13.74 12.01 10.34
Total Mean 18.23 14.92 11.26
SD 13.09 11.74 10.24
Memory and Behavior Problems (RMBPC)
There was a significant main
effect of Time on the RMBPC
Reaction ratings.
The CGs reported feeling less
upset o e the a e e ipie ts’ memory problems over time
No significant effect of
condition was found
Comparison of Reported Usage and Helpfulness of Educational
Materials Over Time
Have you read the FN/brochure? Yes (%) χ² p
Month1
FNC n=55
65.5
UC n=55
47.3
3.696
.
042
Month3 41.8 25.5 3.299 .053
Month4 52.7 36.4 2.981 .062
Number times read in the past month (Mean(SD) Effect F df p
Month 2
FNC n=55
2.29(1.23)
UC n=55
1.95(1.65)
Group
4.631
1/108
.034
Month 3 2.20(2.98) 1.36(.87) Time 1.577 2/216 .209
Month 4 1.84(1.15) 1.75(1.21) Group X Time 1.541 2/216 .216
How helpful were the materials? (Mean(SD) Effect F df p
Month 2
FNC n=55
4.13(1.38)
UC n=55
3.31(1.44)
Group
15.362
1/108
.000
Month 3 3.82(1.40) 3.33(1.26) Time 1.439 2/216 .239
Month 4 4.22(.88) 3.44(1.39) Group X Time 0.710 2/216 .493
Conclusions
Relatively inexpensive intervention
Significantly larger decrease in level of depressive symptoms
Participants in both conditions reported decreased stress ea tio to CR’s memory and behavior problems
G eate ea h a d ated o e helpful
Implications for practice
THANK YOU!
Project PI: Dolores Gallagher-Thompson, PhD ABPP [email protected] Project Coordinator: Marian Tzuang, MSW [email protected] Download the fotonovela at: http://www.alz.org/espanol/downloads/novella_english_081213.pdf
Community Teaching Guide: http://sgec.stanford.edu/resources/dementia_and_caregiving.html
