An online psychoeducational pilot program with home care workers of dependent older adults: Lessons learned and initial findings

1 ONLINE PROGRAM FOR HOME CARE WORKERS This is an Accepted Manuscript of an article published by HOGREFE in GeroPsych The Journal of Gerontopsychology and Geriatric Psychiatry, 38(1), 23-36, Published February 19 2025, available at https://doi.org/10.1024/1662-9647/a000344. This version of the article may not completely replicate the final authoritative version published. It is not the version of record and is therefore not suitable for citation. 2 ONLINE PROGRAM FOR HOME CARE WORKERS An online psychoeducational pilot program with home care workers of dependent older adults: Lessons learned and initial findings Igone Etxeberria1, Fátima María García-Pena1, Arantxa Gorostiaga1, Chloe RezolaPardo2, Maialen Aiestaran2, and Karl, A. Pillemer3,4 1Department of Clinical and Health Psychology and Research Methods, Faculty of Psychology, University of the Basque Country UPV/EHU. Donostia, Spain. 2Department of Physiology, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU. Leioa, Spain. 3College of Human Ecology, Cornell University, Ithaca, New York, USA. 4Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, USA. ORCID Igone Etxeberria: 0000-0003-2276-8355 Fátima Maria García-Pena: 0000-0002-2304-0617 Arantxa Gorostiaga: 0000-0002-3477-3488 Chloe Rezola-Pardo: 0000-0001-9715-4564 Maialen Aiestaran: 0000-0002-3289-9001 Karl A. Pillemer: 0000-0002-7700-3563 Funding: This research was funded by the initiative Etorkizuna Eraikiz, promoted by Diputación Foral de Gipuzkoa, grant number DGE20/02. Conflict of interest: The authors declare no conflict of interest. Correspondence concerning this article should be addressed to Igone Etxeberria, Department of Clinical and Health Psychology and Research Methods, Faculty of Psychology, University of the Basque Country UPV/EHU. Avda Tolosa, 70, 20018 San Sebastián, Gipuzkoa, Spain. Email: [email protected]us 3 ONLINE PROGRAM FOR HOME CARE WORKERS Abstract Although home care workers play an important role in caring for dependent older adults, no resources are targeted specifically at this population. This study describes the implementation of an online psychoeducational pilot program among home care workers of older adults receiving dependent care and presents preliminary results in research settings. The research design was quasi-experimental and consisted of a single group of 20 home care workers completing baseline and post-intervention assessments. The intervention consisted of an online 6-week psychoeducational program conducted by a psychologist via videoconferencing. Attendance and dropout rates were recorded, along with completion of homework assignments, participation in intervention sessions, and the collection of qualitative information about the intervention’s acceptability indexes. Lessons learned from the implementation of the pilot study are discussed, followed by the preliminary results regarding its effects on the well-being of care workers (trend towards improvements in burnout, anxiety, and depression). Finally, clinical implications and future directions for online program development are proposed. Keywords: home care worker, psychoeducational pilot program, online, dependent older adults 4 ONLINE PROGRAM FOR HOME CARE WORKERS An online psychoeducational pilot program with home care workers of dependent older adults: Lessons learned and initial findings Introduction In many countries around the world, families often choose to employ home care workers to care for older adults (Galloti, 2016). This trend arises from the increasing incorporation of women into the labor market and other socioeconomic changes including the increasing need for multiple incomes per household, which results in a lack of informal caregivers to care for the elderly (Rogero-García, 2009). Home care workers offer personalized and dedicated care, ensuring the wellbeing of older adults within the comfort of their own homes. As society continues to age the cost of long-term care continues to rise and the demand for home care workers is likely to increase. Therefore, the continuous improvement of support systems for families and care workers is essential. Similar to other countries, paid care workers play a vital role in looking after dependent adults in Spain and elsewhere in the Mediterranean (Di Rosa et al., 2008). They are usually migrants who often lack the necessary training and have no prior experience in the field before starting their career (Di Rosa et al., 2008; Martínez-Buján, 2014; Schneider, 2017). Some authors refer to this phenomenon as the “modified family social structure,” in which care is outsourced but is still provided within the family environment, mainly by women, replicating a traditional family care model (Díaz & Martínez-Buján, 2018). Among these care workers, live-in and live-out care workers are distinguished. Live-ins (mostly migrants), are those who live in the household of the person they care for while live-outs live elsewhere. The negative health consequences of caring for loved ones by family caregivers have been widely studied in the scientific literature, such as chronic stress, anxiety, 5 ONLINE PROGRAM FOR HOME CARE WORKERS depression, and a weakened immune system (Bom et al., 2019; Instituto de Mayores y Servicios Sociales, IMSERSO, 2005; Pinquart & Sörensen, 2003). However, little is known about the stress experienced by home care workers, the impact of this stress on their overall health, or even if such stress influences their ability to deliver care. Some authors have drawn attention to the precarious working conditions to which these workers are exposed to (long hours, of which few are officially recognized, low pay, situations of abuse, and little personal and leisure time) and have highlighted the fact that being the principal source of care for a dependent older adult has negative consequences for workers’ psychological and physical health (Hewko et al., 2015). Fleming and Taylor (2007) observed that home care workers express significant concerns regarding their working hours, support and supervision, and workload pressures. These factors were perceived as unsocial, unreliable, and disruptive to their own family life, potentially exerting negative effects on their mental health. In particular, long working hours, precarious working conditions, and the presence of pain, influence their psychological and emotional health (Andersen & Westgaard, 2014). Another challenge to be considered for home care workers is how the interactions with care recipients and their families are managed. Difficulties in handling clients’ attitudes and demands were associated with diminished overall health among this population (Denton et al., 2002). Furthermore, discrepancies and disagreements that arise with care recipients or their family members may have adverse health consequences for the home care workers themselves (Muramatsu et al., 2019). In conclusion, it appears that caregiving has negative consequences for home care workers, who provide home care to older dependent adults. However, to date, few intervention programs have been designed to improve the health and well-being of this population. Specifically, our review of the scientific literature revealed only four such 6 ONLINE PROGRAM FOR HOME CARE WORKERS intervention programs: one by Barbero and Etxeberria (2011), one by Saavedra et al. (2020), one by Gum et al. (2022), and one by Vahabi et al. (2022). Saavedra et al. (2020) conducted a psychoeducational course carried out with 29 care workers (mostly Spanish, only one migrant) providing home care to older dependent adults. The results revealed a reduction in dysfunctional thoughts about caregiving by participating care workers, with a medium-large effect size. Similarly, Barbero and Etxeberria (2011) implemented a psychoeducational program with 13 migrant care workers providing home care to older dependent adults, observing improvements in participants’ depression and subjective well-being levels after the intervention. Finally, Gum et al. (2022) ran a pilot study in Israel with 6 migrant care workers. They trained participants in behavioral activation (a cognitive behavioral therapy (CBT) skill used to treat depression), and results revealed that participants increased their engagement in valued and meaningful activities, benefiting both themselves and the older adults. This helped participants be more satisfied with their work following the intervention, have a higher quality of life, and a higher sense of achievement. Interestingly, participants in this study suggested adapting the intervention to an online format for greater access. Although these programs followed a face-to-face format, over recent years, information and communication technologies (ICT) have enabled interventions with family caregivers to be carried out over the Internet, and the advantages of this format have been outlined in several different studies (Etxeberria et al., 2021; Parra-Vidales et al., 2017). Despite the advantages of internet-based interventions, however, only one online intervention program focused on migrant live-in care workers has been found. The study was conducted in Canada and it assessed the efficacy of a 6-week online psychological intervention based on acceptance and commitment therapy (ACT) among 7 ONLINE PROGRAM FOR HOME CARE WORKERS 17 migrant live-in care workers. Results showed improvements in reducing psychological distress and promoting mindfulness and resilience for participants in the experimental group, although differences were not significant, probably due to the small sample size (Vahabi et al., 2022). Same authors reported a preference for online health resources among this population since it allows for greater reach and flexibility (Vahabi & Wong, 2017; Vahabi et al., 2018). However, there are added difficulties involving such a format with this particular population, including an immense digital divide, difficulties surfing the Internet, and limited Internet access. With the aim of producing highly potent and implementable behavioral interventions that improve well-being among this workforce, we followed the NIH Stage Model for Behavioral Intervention Development (Onken et al., 2014). Precisely, stages 0 basic research, I intervention generation and refinement, and II testing in research setting were conducted. In stage 0, we explored how our intervention could positively impact the well-being of home care workers. In stage I we developed an innovative online psychoeducational program utilizing a combination of cognitivebehavioral and person-centered approaches. Due to the limited existing information on programs tailored to this specific population, we relied on available evidence concerning online interventions (Etxeberria et al., 2021; Sherifali et al., 2018). By combining these evidence-based approaches in an online format, we aimed to address the gap of accessible support for home care workers and promote positive mental health outcomes in this vital workforce. Finally, in stage II, we tested the behavioral intervention in a research setting with the aim of examining intervention components mechanisms of behavioral change and feasibility. The aim of this paper is to describe stage II, namely the implementation of an online psychoeducational pilot program for 8 ONLINE PROGRAM FOR HOME CARE WORKERS home care workers of dependent older adults and to share preliminary results in research settings. 9 ONLINE PROGRAM FOR HOME CARE WORKERS Materials and Methods Participants Participants were recruited using an incidental sampling method due to the absence of previously identified potential participants. Therefore, a randomization of the sample was not feasible. A total of 63 potential participants were contacted, but only 35 home care workers were recruited, all of whom provided home care to dependent older adults and met the inclusion criteria for participating in the study. These criteria were as follows: being over 18 years of age, having at least one year’s experience caring for dependent older adults, and caring for a dependent older adult for at least 5 hours a week at the time of recruitment. Exclusion criteria included being on sick leave for an extended period of time at the time of recruitment. The establishment of inclusion and exclusion criteria helped to ensure uniformity among participants, all adults with some experience caring for dependent older adults. Furthermore, these criteria enabled all participants to integrate and apply the acquired techniques and skills into their daily professional activities since they were working during the psychoeducational pilot program. Thirty-five participants were evaluated in the baseline assessment. After this evaluation, however, 15 people withdrew due to: timetable clashes (n = 8), lack of interest (n = 5) and lack of response (n = 2). In the end, 20 home care workers started the online psychoeducational program (see Figure 1). (Figure 1 about here) The majority of participants were women (90%), from Latin America (78.5%), with a mean age of 41 years (SD = 11.11) (Table 1). Most were single (70%) and their mean number of children was 2.18. As regards their education level, 35% completed secondary education, 25% had a university degree, 25% a professional certificate and 16 ONLINE PROGRAM FOR HOME CARE WORKERS low level of digital literacy observed among participants, we decided to change the evaluation strategy to a pencil and paper format. Experienced psychologists were present while the questionnaires were self-administered by participants. In light of their difficulties with new technologies, and given the fact that the psychoeducational pilot program was to be carried out online, we decided to run a brief 2-hour training course focusing on information and communication technologies (ICT) and to compile a user’s guide to enable care workers to participate in the program over the Black Board Collaborate (BBC) platform. A “test session” was also held to ensure that all participants were able to correctly manage the platform prior to the start of the program. With the goal of ensuring attendance, participants were sent a telephone message every week reminding them of the date and time of the intervention session. The message also contained the link for accessing the BBC videoconferencing platform. Finally, the post-intervention evaluation was also a self-applied format and was completed by participants at home, with help and support provided by the psychologist who had run the intervention over the BBC platform. Data analysis To analyze the impact of the program on home care workers well-being, the scores obtained before and after the intervention were compared. To this end, and due to the small size of the sample and the fact that it did not meet the assumption of normality, we used non-parametric statistical group comparison tests for related samples (Wilcoxon signed-rank test), and calculated effect size using r. When interpreting this index, r = .30 was considered indicative of a medium effect size and r = .50 indicative of a large effect size (Rosenthal, 1991). Participants who did not complete the postintervention evaluation were eliminated from the analyses. All analyses were carried out using version 25 of the SPSS software package (IBM Corp., 2017). 17 ONLINE PROGRAM FOR HOME CARE WORKERS We used open coding to analyze the qualitative data inductively, starting with descriptive coding to summarize the main topics. Two researchers independently assigned codes and then worked together to consolidate similar codes into categories and, ultimately, themes. Any discrepancies were resolved through team discussions. Given the small data set, qualitative analyses were carried out by hand, without using any software package. 18 ONLINE PROGRAM FOR HOME CARE WORKERS Results Descriptive analyses of health-related variables In relation to burnout levels, 30% of participants reported high emotional exhaustion, 20% high levels of depersonalization and 5% low personal accomplishment. Moreover, 55% and 35% of participants scored low in the physical and mental dimensions of HRQOL (respectively). In terms of mental health, 25% and 5% of scores corresponded to probable clinical cases of anxiety and depression (respectively), and 20% and 10% of scores corresponded to clinical cases of anxiety and depression (respectively). Table 3 presents a more detailed overview of the scores obtained by participants in all health-related variables prior to the intervention. (Table 3 about here) Implementation of the program Attendance and dropout rates Although 20 people started the intervention, only 35% (7/20) of the sample completed it. Of these, over half (57.1%; 4/7) attended all six sessions that made up the program, 28.6% (2/7) attended five sessions and 14.3% (1/7) attended four sessions. The reasons given for not attending were care worker illness or personal issues. On the sample, 40% (8/20) did not even start the intervention, and the dropout rate among those who did was 25% (5/20). The reasons for dropping out of the intervention were: changes in working hours (61.5%; 8/13), care worker illness (15.4%; 2/13), change of job (7.7%; 1/13), unknown (7.7%; 1/13) and personal issues (7.7%; 1/13). Due to the high dropout rate among participants, we analyzed the differences in sociodemographic and care-related variables between those who completed the intervention program and those who did not. To this end, we used chi-squared test for 19 ONLINE PROGRAM FOR HOME CARE WORKERS categorical variables and Mann-Whitney U test for continuous variables. The results indicated that there were no statistically differences, except for sex variable (chi-square = 4.127. p = .042). Specifically, there were more men in the group that completed it than in the dropouts group. Completion of homework assignments and participation during online sessions Of those who completed the intervention, 42.9% (3/7) participated in all sessions and completed all homework assignments. A further 42.9% (3/7) participated in five sessions and completed 80-90% (8-9/10) of homework assignments. Lack of participation and/or failure to complete homework assignments were due to failure to attend some of the intervention sessions. Qualitative information In general, participants reported a high level of satisfaction with both the intervention itself and the techniques learned [“this is my first experience and it’s been great” (participant 7), “the content is very important, and it is very useful” (participant 6), “there’s always something more to learn about this topic” (participant 5)]. In relation to the techniques covered throughout the course of the program, participants particularly appreciated thought-stopping techniques and diaphragmatic breathing [“I have learned to relax in order to be able to do certain things” (participant 2), “learning to relax has been very helpful, because it’s something you can do in the moment when you realize what’s happening” (participant 1), “I loved the techniques and they’ve really helped me” (participant 4)]. Some participants reported behavioral changes, both in themselves and in their care recipient [“when I signed up I didn’t have much hope, but it really helped me improve the care I provide” (participant 1), “there was a very positive change in their attitude” (participant 4), “I’ve learned to help them in the way I’m supposed to; now, 20 ONLINE PROGRAM FOR HOME CARE WORKERS when they can’t do something, they call me” (participant 2), “they didn’t want to look after their plants and I didn’t know why; now I understand it’s because of (physical) space limitations” (participant 2)]. The fact that the online psychoeducational pilot program followed a group format was also viewed by participants as a positive feature that enabled them to learn not just from their own experiences, but from other people’s experiences as well [“being in group helped us learn more; we learned from each other” (participant 3), “other people’s experiences and stories help too” (participant 1), “it helped me let off steam, and sharing my experiences with others has enabled me to learn” (participant 7)]. Some participants also claimed to feel comfortable in the space generated for the intervention “as immigrants, we rarely feel we can talk about these things; I really appreciated the confidential nature of the sessions” (participant 1)], and stated that they now felt able to help others who were unable to participate “it’s enabled us to help other colleagues who are in a similar situation” (participant 2)]. Comments about the less useful aspects of the course focused on time issues [“I felt it was too short” (participant 5)] and new content that should be included. This content include grief management [“when someone we are caring for passes away, we suffer too” (participant 1), “the first lady I cared for died in my arms; that is a hard thing to get over” (participant 7)] and conflicts that may arise with relatives of the care recipient [“the issue of the family is very important” (participant 6)]. Impact of the intervention on home care workers well-being Table 4 presents the baseline and post-intervention score comparisons for all the variables studied. Although none of the differences reached statistical significance, the large effect size revealed that scores were lower after the intervention in a subdimension of burnout (emotional exhaustion), as well as in anxiety and depression. In 21 ONLINE PROGRAM FOR HOME CARE WORKERS the depersonalization sub-dimension of burnout, the scores were lower after the intervention with a medium effect size. In the rest of variables studied (personal accomplishment and the physical and mental dimensions of HRQOL), the effect size was small. In relation to satisfaction with treatment, 100% of the sample rated the service received as “excellent”. All participants stated that the intervention program had satisfied their needs, that they would recommend it and they would participate in it once again, remarking that the services received had enabled them to cope with problems more effectively (very much: 85.7% and quite a lot: 14.3%). (Table 4 about here) 22 ONLINE PROGRAM FOR HOME CARE WORKERS Discussion The aims of this study were to describe the implementation of an online psychoeducational pilot program for home care workers of older adults receiving dependent care and to share preliminary results in research settings. Despite certain barriers and challenges, the program’s implementation was found to be feasible, and the acceptance level was good among those who completed the intervention. Promising outcomes were also observed regarding participants’ psychological health. Lessons learned The first challenge when implementing this intervention was the high digital divide among home care workers. However, with proper training, care workers were able to carry out the intervention online. Despite the fact that other studies (Gum et al., 2022) have suggested the need for online interventions for greater access, the digital divide must be taken into account before carrying out interventions in this format. Despite a certain degree of initial reticence among participants about having to use a mobile device (tablet or smartphone) to attend sessions, the intervention was in fact carried out online. This leads us to conclude that, with adequate training, this population group is capable of using mobile devices for therapeutic purposes. Indeed, one of the aspects of the program that was rated highest by participants was its online format. Care workers stated that, once they had learned how to use the application, having online sessions was helpful in ensuring regular attendance despite the constraints imposed by working hours, since some attended sessions from their workplace. Nevertheless, another lesson learned from this study is that the involvement of these care workers in this type of intervention is made challenging by the intense and changing work schedules they have. Of the 35 people who expressed an initial interest, 23 ONLINE PROGRAM FOR HOME CARE WORKERS only 20 started the intervention and only 7 completed the entire program. The most common reason given for not participating was scheduling clashes, with some potential participants being employed to care for more than one dependent adult or providing live-in care, which left them little or no time to participate in the online psychoeducational pilot program. Nogueira and Zalakain (2015) argue that migrant care workers are often exposed to (among other things) a high degree of job instability and intense working hours, a circumstance which often leads to exhaustion, social isolation, and few opportunities to engage in training or education. This pattern is also reflected in the reasons given by participants for dropping out of the intervention (e.g., a change of job or changes in working hours). Another finding worth highlighting is that some care workers said they did not want to participate due to fear of possible reprisals linked to their lack of legal immigrant status in the country, and others said they had to “ask their employer family for permission”, which they claimed may prove an obstacle to their participation. This is consistent with the fact that caring for dependent older adults is the principal labor market niche for migrants in Spain (Díaz & Martínez-Buján, 2018). Positively valued aspects of the psychoeducational pilot program So far we have focused on the negative aspects of the lessons learned; however, the program also had several positive aspects that will be discussed below. Our study shows that an online psychoeducational pilot program based on Cognitive-Behavioral Therapy (CBT) and the Person-Centered Care approach is accepted by those care workers who completed the intervention. The answers in the Client Satisfaction Questionnaire (CSQ) and participant satisfaction survey revealed that most aspects of the intervention program, both those linked to its format and its content, were rated as satisfactory and useful in practice, and were deemed to meet participants’ needs. 24 ONLINE PROGRAM FOR HOME CARE WORKERS The fact that the program featured a group intervention enabled participants to learn from their colleagues and to feel that their professional experience was recognized and valued by others. This is fundamental since, as Schneider (2017) pointed out in her review, the social status of these workers is low, which may result in diminished selfesteem; however, there is evidence to suggest that coming together may help home care workers overcome these negative connotations. This is evident in the fact that participants in our program viewed the intervention as a “mutual support group”, a place where they could let off steam and talk about the difficulties they encountered during their work, both with their fellow care workers participating in the sessions and with other colleagues who were not. The use of the Person-Centered Care approach is particularly worth mentioning, along with the functional behavior analysis that was designed to encourage participants to use elements such as non-verbal language, context, and their own behavior to reduce any problem behaviors they may encounter during their caregiving activities. Participants viewed these techniques in a positive light, which is consistent with that reported by Muramatsu et al. (2019), who found that home care workers were highly motivated to make an effort to promote the health of the dependent older adults in their care, although they often lacked the training necessary to do so. In this sense, the home care workers who participated in our program stated that the techniques they learned had helped them cope better with problems. In relation to the content of the intervention sessions, participants were very appreciative of the strategies learned, highlighting in particular the usefulness of thought-stopping techniques and diaphragmatic breathing, but also proposing new contents to improve the program (grief management and problem-solving strategies with families). Participants stated that they used these techniques not only to reduce the 25 ONLINE PROGRAM FOR HOME CARE WORKERS anxiety-related symptoms associated with care situations, but also to cope with different daily life situations. This is important since, as Muramatsu et al. (2019) point out, stress processes among home care workers are not only influenced by their work providing home care, but also by their personal life. The fact that the strategies learned during the intervention were then applied in other areas of their lives outside the workplace is a positive result that reflects the possibility of reducing anxiety-related symptoms. Impact of the intervention on home care workers well-being Finally, and related to the preliminary data about the impact of the intervention on home care workers well-being, none of the results reached statistical significance in any of the variables analyzed, but the effect sizes were medium or even large in certain variables. The absence of statistical significance in these variables may potentially be attributed to the small sample size (n = 7) and its limited statistical power, especially considering the very high attrition rate. For example, a decrease was observed in the scores obtained for different variables, such as emotional exhaustion and depersonalization, which is consistent with the results reported by Saavedra et al. (2020). Although in that study, the effect sizes were very limited, whereas in our one, they were high and medium, respectively. A decrease was also observed in the scores obtained for depression, with a large effect size. This is consistent with that reported by Barbero and Etxeberria (2011). Scores for anxiety were also observed to drop, with a large effect size. It is possible that the change may be due to the importance attached throughout the program to relaxation techniques (diaphragmatic breathing and visualization). Vahabi et al. (2022) found similar results in anxiety although the differences were not significant. Other results worth highlighting are: the decrease in personal accomplishment and physical HRQOL scores, and the increase in mental HRQOL scores (albeit with a 32 ONLINE PROGRAM FOR HOME CARE WORKERS Hewko, S. J., Cooper, S. L., Huynh, H., Spiwek, T. L., Carleton, H. L., Reid, S., & Cummings, G. (2015). 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Acta Psychiatrica Scandinavica, (67)6, 361-370. https://doi.org/10.1111/j.16000447.1983.tb09716.x 36 ONLINE PROGRAM FOR HOME CARE WORKERS Table 1 Sociodemographic and Care-related Characteristics of the Participants Sociodemographic variables Full sample (N = 20) Dropouts (N = 13) Completers (N = 7) M SD n % M SD n % M SD n % Sex 20 13 7 Women 18 90.0 13 100.0 5 71.4 Men 2 10.0 2 28.6 Age 41.00 11.11 19 41.08 11.28 12 40.86 11.69 7 Education level 20 13 7 University degree 5 25.0 5 38.5 Professional Certificate 5 25.0 1 7.7 4 57.1 Secondary qualifications 7 35.0 5 38.5 2 28.6 Primary qualifications 3 15.0 2 15.4 1 14.3 Marital status 20 13 7 Married 2 10.0 1 7.7 1 14.3 Single 14 70.0 10 76.9 4 57.1 Divorced 4 20.0 2 15.4 2 28.6 Children 20 13 7 Yes 17 85.0 11 84.6 6 85.7 No 3 15.0 2 15.4 1 14.3 Number of children 2.18 1.07 17 1.91 1.13 11 2.67 0.81 6 Age of youngest child 15.59 8.98 17 15.55 8.85 11 15.67 10.07 6 Age of eldest child 20.29 9.47 17 20.09 10.48 11 20.67 8.18 6 Non-Spanish national 19 13 6 Yes 16 84.2 11 84.6 5 83.3 No 3 15.8 2 15.4 1 16.7 Country of birth 14 9 5 Nicaragua 9 64.4 6 66.7 3 60.0 El Salvador 1 7.1 1 20.0 Honduras 1 7.1 1 11.1 Spain 3 21.4 2 22.2 1 20.0 Care-related variables M SD n % M SD n % M SD n % Live-in care worker 20 13 7 Yes 4 20.0 4 30.8 No 16 80.0 9 69.2 7 100.0 Weekly working hours among live-in care workers 141.50 21.51 4 141.50 21.51 4 Weekly working hours among live-out care workers 29.69 21.54 16 29.78 17.92 9 29.57 27.05 7 Time (years) in current job 1.99 1.39 20 2.23 1.54 13 1.55 1.02 7 Time (years) in current profession 7.44 4.73 19 7.08 4.62 13 8.22 5.33 6 37 ONLINE PROGRAM FOR HOME CARE WORKERS Care for dependent adults outside work 20 13 7 Yes 4 20.0 3 23.1 1 14.3 No 16 80.0 10 76.9 6 85.7 Weekly hours spent providing care outside work 10.50 14.45 4 12.00 17.32 3 1 Diagnosis of the care recipient 15 9 6 Mobility problems 3 20.0 2 22.3 1 16.7 Dementia 4 26.7 3 33.3 1 16.7 Stroke 3 20.0 3 33.3 Unknown 5 33.3 1 11.1 4 66.6 Type of disability of the care recipient 14 8 6 Physical disability 4 28.6 2 25.0 2 33.3 Physical and mental disability 10 71.4 6 75.0 4 66.7 Note: The response of all participants is not available for some variables (non-Spanish national, country of birth, time (years) in current profession, diagnosis and type of disability of the care recipient). 38 ONLINE PROGRAM FOR HOME CARE WORKERS Table 2 Aims and Contents of the Online Program Session Intervention aims Content and techniques used 1: Welcome and why are we doing this? 1.- Presentation of the intervention program, the psychologist, and the in-home care workers. 2.- Conceptualization of burnout and its consequences. 3.- Identification of the possible physical consequences of long-term care (stress and anxiety). 4.- Coping with stress / anxiety through diaphragmatic breathing. During the session:  Burnout, stress and anxiety.  Diaphragmatic breathing. Homework:  Diaphragmatic breathing and recording. 2: What causes BPSDs and other behavioral problems? 1.- Focus on the importance of self-care to reduce the consequences of burnout. 2.- Conceptualization of the Behavioral and Psychological Symptoms of Dementia (BPSD) associated with dependency and other behavioral problems that carers may encounter when looking after older adults. 3.- Analysis of the emergence of BPSD and other behavioral problems using Functional Behavioral Analysis (FBA). 4.- Information about positive reinforcement and putting it into practice. 5.- Coping with stress / anxiety by practicing visualization. During the session:  Self-care, BPSD and other behavioral problems.  FBA and positive reinforcement.  Visualization. Homework:  Relaxation and recording.  FBA, positive reinforcement and recording. 3: How does caring for a dependent older adult affect my emotions? 1.- Identification of how care tasks influence in-home care workers at an emotional level (unpleasant emotions). 2.- Fostering understanding of how unpleasant emotions arise, using Ellis’ ABC model. 3.- Identification of thoughts using the thoughtstopping technique. 4.- Coping with unpleasant emotions through self-instructions. 5.- Engaging in pleasant activities that improve psychological well-being. During the session:  ABC model, thoughtstopping and selfinstructions.  Pleasant activities.  Visualization. Homework:  Relaxation and recording.  ABC model, thoughtstopping, self-instructions and recording. 39 ONLINE PROGRAM FOR HOME CARE WORKERS 6.- Coping with stress / anxiety by practicing visualization.  Pleasant activities and recording. 4: How can I manage BPSDs and other difficulties associated with care? 1.- Conceptualization of the Person-Centered Care (PCC) approach. 2.- Planning and implementation of care tasks, bearing in mind the different domains of the Person-Centered Care approach: getting to know the person, personal treatment, and respect and acknowledgment. 3.- Coping with stress / anxiety by practicing visualization. During the session:  PCC domains: getting to know the person, personal treatment, and respect and acknowledgment.  Visualization. Homework:  Relaxation and recording.  Practicing the PCC approach and recording. 5: How can I manage BPSDs and other difficulties associated with care? II 1.- Planning and implementation of care tasks, bearing in mind the different domains of the Person-Centered Care approach: promoting independence and autonomy, space and meaningful environment. 2.- Identification of alternative behaviors in response to PBSs and other behavioral problems, in accordance with the PCC approach. 3.- Coping with stress / anxiety by practicing visualization. During the session:  PCC domains: promoting independence and autonomy, space and meaningful environment.  Alternative response behaviors.  Visualization. Homework:  Relaxation and recording.  Practicing the PCC approach and recording. 6: Leave taking 1.- Review of the techniques and skills learned. 2.- Identification of the long-term benefits that come with continued practice. 3.- Prevention of relapse. During the session:  Coping with anxiety (relaxation), unpleasant emotions (thought-stopping, self-instructions and pleasant activities), BPSDs and other behavioral problems (PCC, positive reinforcement, etc.).  Feedback to paid caregivers.  Evaluation of the program. Homework: 40 ONLINE PROGRAM FOR HOME CARE WORKERS  Continue to practice the skills and techniques learned. 41 ONLINE PROGRAM FOR HOME CARE WORKERS Table 3 Characteristics Linked to the Health of the Participants at Baseline (N = 20) Variables M SD Cutoff points n (%) Burnout High Average Low Emotional exhaustion 20.39 12.51 6 (30%) 5 (25%) 9 (45%) Depersonalization 5.35 6.40 4 (20%) 4 (20%) 23 (60%) Personal accomplishment 41.68 5.70 15 (75%) 4 (20%) 1 (5%) Self-rated health Over 50 Under 50 Physical dimension 46.61 8.57 9 (45%) 11 (55%) Mental dimension 49.03 11.46 13 (65%) 7 (35%) Anxiety and depression No case Probable case Case Anxiety 6.95 4.33 11 (55%) 5 (25%) 4 (20%) Depression 4.35 3.94 17 (85%) 1 (5%) 2 (10%)