Geriatric Nursing 37 (2016) 426e433

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Geriatric Nursing
journal homepage: www.gnjournal.com

Feature Article

INFOSA intervention for caregivers of the elderly, an experimental

study
Adelaida Zabalegui, RN, PhD, FEANS a, Maria Galisteo, RN, Msc c, *,
Maria Montserrat Navarro, RN, PhD c, Esther Cabrera, RN, MSc, PhD b
a
Hospital Clinic of Barcelona. Villarroel, 170, Es 1, pl 8, 08036 Barcelona, Spain
b
Tecno Campus Matar-Maresme, Matar, Spain
c
Hospital Clinic of Barcelona. Villarroel, Barcelona, Spain

a r t i c l e i n f o a b s t r a c t

Article history: An experimental study was carried out in a geriatric hospital unit (pre-discharge at home) with repeated
Received 21 November 2015 observations taken at baseline, on study completion and six months post-intervention to analyze the
Received in revised form impact of a psychoeducational intervention INFOSA addressed to caregivers who support dependent
29 May 2016
elderly people, on burden, psychological distress and perceived support. Univariate regression models
Accepted 6 June 2016
Available online 29 July 2016
showed that the participants in the experimental group had less burden (OR 35, IC 95% 7.47e163.99) and
emotional distress (OR 149.5, IC 95% 15. 57e1435.52) than participants in the control group. Odds ratios
effect were statistically signicant at post-test and six-month follow-up. The INFOSA intervention
Keywords:
Caregivers
reduced burden and emotional distress and enhanced caregivers perceived social support in the short-
Older people term, suggesting that applying the intervention for an extended period could maintain the positive effect
Elderly in the long-term.
Psychoeducational intervention 2016 Elsevier Inc. All rights reserved.
Educational program

Introduction These care recipients increase their degree of dependence

Aging in developed countries is mainly due to drops in fertility
rates and increases in life expectancy.1 These factors lead to a rise in
the number of dependent individuals and, consequently, a growing
need for prolonged care provision. Declining health status is the
most important factor that contributes to dependence in elderly
people.2 It is forecast that the number of elderly people without
physical functionality and autonomy to carry out the activities of
daily living (ADL) will double by 2050.3
Aging may cause progressive loss of autonomy, leaving them
dependent on others when performing ADL. In Spain, most care of
dependent elderly people is carried out voluntarily and informally
by family members in the home environment.4 Occasionally, this
situation leads to a co-dependent relationship between the care-
giver and the person being looked after, leading to further negative
effects on caregivers such as deterioration of physical and mental
health, economic difculties and a breakdown of the caregivers
social relationships.5e7 Caregiver depression, stress or exhaustion
increases the risk of institutionalization of the care recipient.8
Conict of interest: None.
* Corresponding author. Tel.: 34 932275400.
E-mail address: galisteo@clinic.ub.es (M. Galisteo).
because of their worsening health status until full-time care is
required from their caregivers. As dependence grows, caregivers
may refuse to continue taking care of their dependent relatives at
home; mainly because they do not feel they have the training to
cope with their care needs.9 Thus, the development of resources to
support caregivers is essential10 for the maintenance of long-term
homecare and to lessen demand for institutional care.11 In fact, it
has been shown that caregivers express a need for further infor-
mation, training and support from health and other professionals to
continue with their homecare duties.12,13
In the last 20 years, several studies have been performed to
develop or demonstrate the efcacy of various support measures
addressed to the main caregivers of people with diverse chronic
dependent conditions such as dementia and cancer.14,15 In a sys-
tematic review Zabalegui et al. (2008),13 classied these different
types of measures into counselling, educational, psychoeduca-
tional, multicomponent or breather. Content and educational
methods vary from study to study with psychotherapeutic and
psychoeducational programs implemented most frequently.16 The
majority of these interventions are designed to ameliorate the
emotional and physical consequences of care provision such as
levels of burden, anxiety and depression, and have shown moder-
ate or signicant results.17

0197-4572/$ e see front matter 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2016.06.001
 A. Zabalegui et al. / Geriatric Nursing 37 (2016) 426e433
During intervention
n=20
Nursing home discharge: n=3 Care recipient death: n=6
Employee with no free-time: n=13 Discharged to home: n=11
Unwilling to participate: n=2 Caregiver mental disease: n=2
No reason: n=1 Familial problem with caregiver: n=1
Not want to leave patient alone: n=1
Fig. 1. Reasons for withdrawal.
Psychoeducational programs focused on caregiving have to be
adapted to Mediterranean countries where patients want to be
taken care of at home and institutionalization is considered to
be caregivers last resort.18 The INFOSA program was designed to
respond to the cultural values of these countries, providing specic
information and education on the care of the dependent elderly
person and the lack, as far as we know, of tailored programs for this
population. The Informal Caregivers (ICs) report showed that
caregivers do not have time to attend psychoeducational programs
while they are taking care of the elderly person at home.17 More-
over, there are difculties in implementing the program in the
community due to limited social resources. Therefore, INFOSA has
to be implemented before the patient is discharged from hospital.
The aim of this study was to assess the efcacy of a psycho-
educational program with respect to degree of psychological
burden, psychological distress (somatic symptoms, anxiety and
insomnia, social dysfunction, and depression) and perceived social
support in the main caregivers of elderly dependent individuals.
Methods
Design
An experimental, convenience-sampling study was used to
assess the efcacy of the INFOSA psychoeducational program,
comparing efcacy at baseline assessment with efcacy post-
intervention and at six-month follow-up. A total of 56 informal
caregivers of elderly dependent adults over 65, who needed help
for activities of daily living (ADLs), were consecutively selected at
the time of the patients admission to a hospital geriatric unit be-
tween 2008 and 2009 and randomly assigned to an experimental or
control group through simple randomization.
Participants
The main informal caregiver was dened as the person
responsible for providing homecare who received no nancial
compensation for this role. The setting was La Albada Socio-health
Unit, which is part of the Corporacin Sanitaria Parc Taul de
Sabadell (Barcelona). This centre admits medium- and long-stay
patients who need rehabilitation before being discharged to re-
turn home or enter another long-term care facility (LTCF) following
referral from the reference hospitals acute units. Personal in-
terviews were carried out to ensure that candidates met all the
inclusion and none of the exclusion criteria. We included caregivers
older than 18 years who took care of elderly patients (above 65
years) at home following discharge from an acute hospital. Care-
givers with any physical illness or mental disability, anyone who
had previously taken part in a similar study and those with literacy
problems were excluded from the study. Caregivers of individuals
who lived in an LTCF, individuals who had been discharged from La
Albada Socio-health Unit or those with a life expectancy of less than
six months were also excluded from the study.
427
Post I Post II
n=20 n=25
Care recipient death: n=23
Nursing Home discharge: n=2
No reason: n=1
A total of 223 interviews were carried out to identify the care-
givers that met the selection criteria. Following the interviews, 96
(43%) caregivers were identied as candidates to participate in the
INFOSA program, although only 76 (34.1%) agreed to participate.
Participants were assigned to the experimental group (39) and the
control group (37) by simple randomization. For diverse reasons
(Fig. 1), 20 participants did not complete the psychoeducational
sessions, leaving 56 caregivers in the study, 32 in the experimental
group and 24 in the control group. In addition, 2 participants from
the experimental group who completed the psychoeducational
sessions could not complete the questionnaires. During the
post-intervention assessment carried out 6-months later, 23 care-
givers, 10 from the experimental and 13 from the control group,
abandoned the study.
Sample size calculation was performed based on what is
considered to be, according to the literature,19 the most difcult
variable to modify which is the degree of burden among care-
givers,19 with an error of 5% and a power of 90%.
Following the recommendations of the World Medical Associ-
ation Declaration of Helsinki, 2008, the study was approved by the
Research and Ethics Committee at Corporacin Sanitaria Parc Taul.
All participants provided written informed consent.
Care recipients also provided signed informed consent in case
the caregiver agreed to participate at the INFOSA intervention. In
cases where those receiving care were unable to sign due to
cognitive impairment, it was signed by their surrogate decision
makers.
The INFOSA intervention
The psychoeducational intervention, called INFOSA, was
designed to provide: (i) information aimed at improving the care-
givers knowledge; (ii) training intended to develop practical skills
for the care of frail, elderly persons and, (iii) emotional support. The
program was developed, following a literature review, by expert
nurses with relevant expertise in the eld. Subsequently, the con-
tent and reliability of the intervention was validated by the
Dependent Elderly Persons Care Group (CGGD), consisting of
nurses, physicians, psychiatrists and psychologists recognized by
the Generalitat de Catalunya Agency for Management of University
Funding and Research (Agencia de Gesti de Ajuts Universitaris i de
Recerca de la Generalitat de Catalunya, AGAUR). The intervention
was specically designed for caregivers of individuals with or
without cognitive impairment and can be adapted to distinct
educational and training levels.
The INFOSA content was delivered in small groups of ICs in
workshops led by a nurse with expertise in educational in-
terventions and care of dependent elderly people. In these work-
shops various aspects were covered, including caregivers self-care,
medication in patients with dysphagia, nutrition for the elderly,
hygiene, mobility, toileting, development of effective communica-
tion techniques and how to deal with aggressive or irritable
behavior by care recipients. The program consisted of weekly 90-
min sessions that took place over 8 weeks (Fig. 2).
428 A. Zabalegui et al. / Geriatric Nursing 37 (2016) 426e433
Fig. 2. Psychoeducational program contents.
The experimental group met in the geriatric unit in sessions
attended by a maximum of 5 caregivers. All sessions were led by the
same nurse to control possible variability between groups. The
experimental group received the INFOSA intervention program in
addition to treatment as usual (TAU) from the units health
personnel while the control group received TAU only. TAU consisted
of traditional care activities; and information provided on patient
or IC demand.
Socio-demographic variables
Socio-demographic variables associated with care were
collected at the beginning of the study. Regarding caregivers, data
on the following variables were collected: age, gender, educational
level, civil status and employment situation. For care recipients, the
variables recorded were: age, gender, and information on the
reason for admission to the geriatric rehabilitation centre, degree of
physical dependence based on the Barthel Index, and mental status
measured using the Pfeiffer Test.
Measures
The efcacy of the INFOSA psychoeducational program was
assessed through reliable, validated instruments suited to the study
population. Measurements were taken prior to the intervention, on
completion of the INFOSA program and at 6-month follow-up in
both the experimental and the control groups.
Barthel index of ADL
To assess the degree of physical functionality and autonomy of
the care recipient to carry out ADL, the original version by Mahoney
and Barthel (1965)20 was used. The Barthel Index, completed by the
interviewer, consists of 10 ADL related to self-care and mobility
with scores ranging from 0 (total dependence) to a maximum score
of 5e15 depending on the item measured. A score of 100 indicates
that the individual is totally independent. The degree of depen-
dence was classied as minor (scores from 60 to 95), moderate
(scores from 40 to 55) and severe (scores from 20 to 35). The care
recipient was considered to be totally dependent when the BI score
was below 20.
Interrater reliability mean Kappa values range from 0.47 to 1.00
and intrarater values range from 0.84e0.97.21
Pfeiffer questionnaire
The cognitive level of care recipients was evaluated using the
Pfeiffer questionnaire.22 This consists of 10 questions covering orien-
tation in time and place, remote memory, and general knowledge. The
Pfeiffers score records the number of errors. The cut-off was set at 3
errors to differentiate cognitive impairment from no cognitive
impairment with a sensitivity of 55% and specicity of 96%.23
The Zarit Burden Interview
The degree of caregiver burden was evaluated through the
Zarit Burden Interview (ZBI) using the adapted Spanish version
 A. Zabalegui et al. / Geriatric Nursing 37 (2016) 426e433 429

developed by Martin et al. (1996).24 The ZBI is a self-report measure Table 1

consisting of 22 items with scores ranging from 1 to 5 (1: never; 5: Characteristics and impact of caregiving.

nearly always) which provides a global assessment of physical and Total n 56

psychic health, social activities and economic resources. A score Dedication (hours/day) 16.9  8.7
equal to or less than 46 represents an absence of burden, between Years of caring
47 and 55 is considered moderate burden and equal to or more than <1 year 20 (35.7)
1e3 years 7 (12.5)
56 is classied as severe.
>3 years 29 (51.8)
Voluntary care
General health questionnaire (GHQ-28) Yes 46 (82.1)
No 10 (16.9)
To assess the degree of psychological distress in caregivers, the Institutionalization attempt
Yes 9 (16.1)
Spanish version of the GHQ-28 adapted by Lobo et al. (1986)25 was No 43 (76.8)
used. The GHQ-28 is a self-administered questionnaire with 28 Do not know 4 (7.1)
items grouped into four subscales: (A) somatic symptoms, (B) Shared care
anxiety, (C) social dysfunction and (D) depression. Each question Formal aid 21 (37.5)
House cleaning 4 (19.1)
has four possible responses, with higher scores indicating higher
Patient care 15 (71.4)
psychological stress. To calculate the subscale scores and general House cleaning care 2 (9.5)
psychological distress scores, we used a method based on assigning Informal aid 23 (41.1)
values of 0, 0, 1, 1 for each item.26 The cut-off point indicating No 12 (21.4)
psychological morbidity was set at 5/6, with a sensitivity of 77% and Impact on health 5.6  2.1
Yes 49 (87.5)
specicity of 78%.25 No 7 (12.5)
Perception of health 5.61  2.11
Social support questionnaire (Duke-UNK) Medication
Yes 24 (42.9)
No 29 (51.8)
Perceived social support was assessed through the Duke-UNK
Do not know 3 (5.4)
questionnaire in the Spanish version adapted by De la Revilla Reducing working hours
et al. (1991).27 The Duke-UNK is self-administered and has 11 items Yes 15 (26.8)
with scores ranging from 1 to 5, where higher scores represent a No 41 (73.2)
greater degree of social support. The scale has two dimensions, the Social relationship changes
Yes 36 (64.3)
condential (condant support) and the affective (demonstrations No 16 (28.6)
of love, affection and empathy) (Table 1). A total score lower than Do not know 4 (7.1)
32 represents a low level of perceived social support. Zarit burden 62.61  17.01
Severe 36 (64.3)
Moderate 11 (19.6)
Data analysis
No burden 9 (16.1)
General psychological distress (GHQ-28)
Analysis of study variables was performed using the IBM SPSS Total 12.02  6.73
statistics software version 17.0. Group comparisons were con- Somatic symptoms 3.63  2.36
ducted through the covariance analysis statistical model (ANCOVA) Anxiety 4.5  2.23
Social dysfunction 3.02  2.24
with adjusted non-parametric approximations for all variables Depression 0.75  1.37
related to care (socio-demographic data, caregiver health, degree of Social support (Duke-UNK) 35.71  11.66
dependence).4 We analyzed, as the independent variable, the use of
Results expressed as mean  SD.
the INFOSA program in the experimental group and included, as the
dependent variables, those related to the outcome (burden,
emotional distress, and perceived social support). The care re- greater daily commitments in the experimental group. Moreover,
cipients baseline scores were also included as covariables. Analysis most of the caregivers received help from another family member.
was carried out at three time-points; the rst at baseline (pre-test), More than half of the care recipients were men with a mean age
the second immediately post-intervention (post-test I), and the of 81.5  7.8 years. As regards civil status, 46.9% in the experimental
third at 6-month follow-up (post-test II). group and 58.3% in the control group were widows or widowers.
The most frequent cause of admission to the health centre was a
Results new, acute episode of their disease. Assessment of the degree of
physical functionality and autonomy required to carry out ADL,
Overall characteristics of the informal caregivers and dependent measured using the Barthel Index, revealed total dependence in the
elderly by group experimental group (12.6  18) and severe in the control group
(26  26.3). Similarly, the Pfeiffer Test score in both groups was
The baseline characteristics of the informal caregivers and the higher than 7 points, indicating severe cognitive impairment. No
care recipients are shown in Table 2. All study participants received differences were found in dependence and cognitive scores when
help from family members. The mean age of included caregivers, comparing the experimental and control groups in the follow-up
78% of whom were women, was 60  14.3 years. With respect to assessment (post-test II).
educational level, the majority had primary education. Regarding
civil status, the vast majority was married (70%) and had completed
primary education (37.5%). Levels of burden
Interestingly, 60% of caregivers in the experimental group and
41.6% in the control group were retired or were housewives. With However, the post-intervention evaluations carried out showed
respect to care history, over half of the caregivers (52%) had spent differences with respect to baseline values and the level of burden
more than 3 years taking care of their elderly family member, with was similar in both groups before the implementation of the
430 A. Zabalegui et al. / Geriatric Nursing 37 (2016) 426e433

Table 2 control group (p < 0.001). However, although both scores improved
Baseline characteristics informal caregiver and dependent elderly by group. at the second assessment (post-test II), with a greater change in the
Variables Experimental Control experimental group, these differences were not statistically sig-
group n 32 group n 24 nicant (p 0.158 and p 0.148, respectively).
Informal caregiver Changes in scores in the social dysfunction subscale showed
Age 59.9  14.3 53.6  13.2 signicant differences between groups at both post-test I and post-
Gender
test II (p < 0.001 and p 0.028). At the rst time-point post-
Male 6 (18.8) 6 (25)
Female 26 (81.3) 18 (75) intervention, scores were lower in the experimental and higher in
Marital status the control group; at the second, both groups showed a score
Unmarried 6 (18.8) 2 (8.3) reduction but with a bigger change in the experimental group.
Married 24 (75) 17 (70.8) When the depression scale was evaluated, a decrease in the
Widowed 1 (3.1) 3 (12.5)
Other 1 (3.1) 2 (8.3)
experimental group and an increase in the control group were
Educational background observed, both of which were signicant (p 0.001). However,
No formal education 10 (31.3) 9 (37.5) these differences were not maintained at post-test II (p 0.973).
Primary education 12 (37.5) 9 (37.5)
Secondary education 6 (18.8) 3 (12.5)
Undergraduate 4 (12.5) 3 (12.5) Perceived social support
Occupational status
Business or similar 1 (3.1) 1 (4.2) Pre-intervention evaluation using the Duke-UNK questionnaire
Employee 4 (12.5) 11 (45.8)
showed signicant group differences, with a lower level of social
Academic 3 (9.4) 0 (0)
Housewife 10 (31.3) 8 (33.3) support in the experimental group. Although post-test I scores
Retired 9 (28.1) 2 (8.3) improved in the experimental and worsened in the control group,
Unemployed 5 (15.6) 2 (8.3) these differences, compared to baseline values, were not signicant
Time spent caregiving everyday 20.1  7.6 13  8.6
(p 0.054). This trend was maintained at the second time-point,
Care assistance
Yes 24 (75) 20 (83.3) improving in the experimental group and worsening slightly in
No 8 (25) 4 (16.7) the control group, although there were no signicant differences
Care duration observed when the groups were compared (p 0.876) (Table 4).
<1-year 11 (34.4) 9 (37.5)
1e3-year 4 (12.5) 3 (12.5)
>3-year 17 (53.1) 12 (50) Treatment delity
Dependent elderly
Age (mean  SD) 81.5  7.8 83.9  7.2 Treatment delity was assessed to determine whether the
Gender
Male 18 (56.2) 14 (58.3)
intervention was implemented as intended by evaluating delivery,
Female 14 (43.8) 10 (41.7) receipt and enactment.28
Marital status Delivery was based on evidence that all participants had the
Married 17 (53.1) 10 (41.7) same intervention intensity, ensuring that participants had the
Widowed 15 (46.9) 14 (58.3)
same number, frequency and length of sessions in the intervention
Reasons for patient admission
Overall health deterioration 7 (21.9%) 7 (29.2%) program. The same teaching protocol was applied accurately and
Exacerbation disease 10 (31.2%) 4 (16.7%) consistently in each session by the same expert nurse and for each
New disease emergency 15 (46.9%) 13 (54.1%) of participants.
Barthel index 12.6  18 26  26.3 The sessions were structured in theoretical sessions and work-
Pfeiffer test 7.6  3 7.1  2.9
shops. Receipt was measured based on evidence of knowledge and
Results expressed as mean  SD or n (%). skill acquisition after each session. At the end of each session the
participants were asked to demonstrate their theoretical under-
standing or asked to perform their new skills acquired while the
intervention (62.09 vs 63.29). When burden was analysed post-
expert nurse observed the techniques. The very last session of the
intervention, the degree of burden was signicantly lower in the
intervention was a workshop where all the caregivers demon-
experimental group (56.5 vs 68.29). Furthermore, the assessment
strated that they had understood and improved their caregiving
conducted at the second time-point, i.e., post-test II, showed a
skills by asking them to perform the new techniques and how
reduction in degree of burden in both groups. Although the
condent they were in applying them. Condence and satisfaction
experimental group showed greater score changes than the control
were measured through a questionnaire at the end of the
group, the difference was not signicant (p 0.102) (Table 2).
intervention.
Enactment of the intervention was assessed at post I and post II
Emotional health assessment at home. The expert nurse asked caregivers to make
some of the caregiving techniques learned during the intervention
Psychological distress (Global GHQ-28) results prior to the to demonstrate they used them correctly at home with care
intervention were similar in both groups (Table 3). There were recipient. Also a self-report questionnaire was completed by care-
signicant changes in scores at post-intervention (p < 0.001) and in givers to assess their caregiving skills.
the 6-month (p 0.01) evaluation. While the score improved in the
experimental group and worsened in the control group at the rst Discussion
post-intervention (post-test I) assessment, at the second evaluation
(post-test II) both scores worsened, with a larger change in the Study results conrmed our initial hypothesis that the INFOSA
experimental group than in controls. psychoeducational intervention, designed to inform, train and
Changes in score by subscale were similar for somatic symptoms provide emotional support to informal caregivers of elderly
and anxiety. Thus, post-test I scores showed opposing changes in dependent people, had a benecial physical and psychological ef-
the groups, diminishing in the experimental and increasing in the fect on informal family caregivers.
 A. Zabalegui et al. / Geriatric Nursing 37 (2016) 426e433 431

Table 3
Changes in general health questionnaire (GHQ-28).

Pre-test Post-test I Post-test II

E (n 32) C (n 24) E (n 30) C (n 24) p E (n 20) C (n 11) p

Total GHQ-28
Total score 11.81 (6.68) 12.29 (6.92) 7.23 (6.1) 14.5 (6.88) 0.012 6.7 (5.76) 10.09 (5.89) 0.001
D score e e 4.9 (4.11) 2.21 (2.7) <0.001 6 (6.65) 2.09 (3.88) 0.001
Somatic symptoms
Total score 3.44 (2.54) 3.88 (2.13) 1.9 (2.22) 4.42 (2.17) 0.034 2 (2.15) 3.27 (2.37) 0.014
D score e e 1.53 (2.05) 0.54 (0.93) <0.001 1.4 (1.98) 0.27 (1.62) 0.158
Anxiety
Total score 4.63 (2.31) 4.33 (2.16) 3.17 (2.35) 4.92 (1.93) 0.02 2.8 (2.48) 3.73 (2.2) 0.02
D score e e 1.53 (1.87) 0.58 (1.1) <0.001 2.2 (3.04) 0.55 (0.93) 0.148
Social dysfunction
Total score 2.84 (2.17) 3.25 (2.35) 1.87 (1.93) 4.13 (2.35) 0.004 1.4 (1.14) 2.91 (2.17) <0.001
D score e e 1.17 (1.68) 0.88 (1.45) <0.001 1.95 (2.39) 0.64 (2.94) 0.028
Depression
Total score 0.69 (1.15) 0.83 (1.63) 0.4 (0.97) 1 (1.82) 0.096 0.4 (1.1) 0.18 (0.4) <0.001
D score e e 0.33 (0.48) 0.17 (0.56) 0.001 0.5 (0.89) 0.64 (1.36) 0.973

E: Experimental group; C: Control group.

Pre-Test: Pre-intervention; Post-Test I: Immediately Post-Intervention Post-Test II: Post-Intervention at 6 months.
Results expressed as mean (SD).

The design of the INFOSA program was based on the needs of the
caregivers and on published recommendations.17 With the results
obtained in this study, the content and the methodology of the
intervention could be optimized. The number of sessions, ranging
between 6 and 10 per informal caregiver, made it a mediumehigh
intensity intervention with a special focus on skills training.29,30
Furthermore, nursing professionals conducting the sessions
received extensive training in coping strategies, control and
problem-solving skills.29,30 Through this approach, primary care-
givers worked with elements related to specic knowledge of care
provision, including personal hygiene or mobility, and received
training sessions on physical care skills and management of
disruptive and agitated behavior. There was also a focus on asser-
tive communication and the self-esteem of the main caregiver.
The characteristics observed among of the caregivers were
similar to those found in previous studies.32,33 As we have shown,
the prototypical caregiver was a middle-aged woman with a
considerable degree of objective burden related to the number of
hours devoted to care provision each day.
The Zarit scale showed severe burden, with average scores
higher than those reported in prior studies.34,35,38 Our data could be
explained by the added stress experienced by the caregiver due to
the hospital admission of their family member. Moreover, no clin-
ically relevant levels of depression were revealed, in contrast with
the prevalence of depressive symptomatology found in other
studies.35,37
Despite the high percentage of lost-to-study participants, most
were due to the death or institutionalization of the care recipient;
only one caregiver voluntarily withdrew, indicating the INFOSA was
very well accepted. Numerous studies indicate that those in-
terventions in which contact with the caregiver was scant,33,38,39
Table 4
Rating aids available.
Professional aid 7.06
Non-professional aid 6.74
Emotional support 6.16
Disease information 5.85
Care skills training 5.51
Economic aid 5.04
Encourage leisure activities 4.63
Help to work 2.21
Results expressed as mean  SD.
which were too long29,40 or had many assessment points,41,42 had
a greater number of withdrawals. Thus, bearing in mind that all
sessions were imparted in the socio-health centre, the INFOSA
program was well adapted to the study population.
Regarding the efcacy of the INFOSA psychoeducational pro-
gram for informal caregivers of dependent elderly people, our re-
sults suggest that the intervention was benecial. This was
especially true bearing in mind that the caregivers in the experi-
mental group were taking care of elderly individuals with higher
dependency levels than those in the control group. It was observed
that, through this INFOSA intervention, there was a signicant
reduction in levels of burden, social dysfunction and anxiety,
although these positive effects diminished over time.
These results were in accordance with those published by
Zabalegui et al. (2008)17 in a meta-analysis of 15 randomized
clinical trials published between 1996 and 2006 designed to assess
the efcacy of a variety of interventions in caregivers of dependent
people over 65 years old. According to this meta-analysis, the ef-
fects of the interventions were moderate but signicant in the
short-term. With respect to depression, although there were no
clinically relevant levels revealed prior to the intervention, it was
observed that the INFOSA program proved to be a useful tool for
reducing levels of depression. A meta-analysis by Srensen et al.
(2002)31 found similar results and showed that the effect lasted for
up to seven months.
As the efcacy of INFOSA was only maintained in the long-term
(6 months) for a decrease in social dysfunction, the question re-
mains as to whether an extension of the INFOSA intervention over a
longer period of time would have helped to maintain the efcacy in
more of the evaluated elds in the long-term. The need to extend
the intervention is underlined by the fact that caregivers continue
to suffer social dysfunction in the long-term while their perception
of social support worsens.
Strong community and family values exist in Spain and other
Mediterranean countries where people look after their signicant
 3.34 others at home to assist with activities of daily living when they are
 3.71 unable to care for themselves. The INFOSA intervention places
 3.8
special emphasis on maintaining and focusing on these important
 3.76
 3.84 cultural values. Looking after the person at home for as long as
 3.85 possible helps to reduce the institutionalization of dependent
 3.78 elderly people which, in turn, has an impact on health costs.1
 3.69 Our society currently lacks the social resources required,
including nancial and social support for ICs, to adequately care for
432 A. Zabalegui et al. / Geriatric Nursing 37 (2016) 426e433
dependent elderly people at home. In view of this dearth of re-
sources to facilitate care at home and improve the poor caregiving
skills reported by ICs, the INFOSA intervention helps to enhance
these capacities and encourages IC self-care to avoid illness brought
on by care provision.
Northouse et al. (2010)43 published a meta-analysis of ran-
domized clinical trials that evaluated the efcacy of interventions
for caregivers of people with oncological illnesses. These re-
searchers demonstrated that, although some interventions showed
small but signicant long-term effects on some variables, such as
acquiring coping strategies, improving social or physical func-
tioning, or reducing anxiety, only 24% of the studies evaluated the
efcacy of the intervention for a period longer than six months,
hampering the detection and interpretation of effects over the
long-term. In addition, there was only one study that evaluated the
degree of burden for a period of time longer than six months
without signicant benets being observed over the long-term.
It is well-known that main-caregiver burden is the most difcult
variable to modify and where interventions have least impact. This
is one of the reasons why the literature suggests that, even though
most studies use measures of burden to assess the efcacy of these
interventions, it may not be the most valid indicator. This is further
complicated by implementation of numerous interventions with
methodological deciencies with respect to aims, content, sample
selection or the type of intervention. There is also the problem of
using inappropriate assessment instruments, which is one of the
main limitations affecting evaluation of the programs.30 In our
study, the INFOSA intervention was designed according to the
characteristics and needs of the participants, with rigorous meth-
odology and suitable assessment instruments. Consequently, levels
of burden, along with those for anxiety and depression, show
similar trends and demonstrate short-term positive effects.
As regards the level of social support perceived by the care-
givers, results were inconclusive, despite evidence of a slight
improvement in the experimental group in the short-term. The
literature shows contradictory results, revealing a need for further
studies evaluating this variable.36,42
Our study had some limitations. Firstly, it was a clinical trial
using a convenience sample, which could lead to selection bias.
Nevertheless, this type of sample facilitated access to participants,
with caregivers being included at the time of admission of the
elderly dependent person to the socio-health centre. Secondly,
despite the initial availability of the required number of subjects
according to sampling calculations, the number of subjects lost-to-
study during follow-up was high. This may be due to the cultural
factor that older patients were not used to health professionals
interviewing them at home and may have felt a sense of vulnera-
bility which led them to decline to participate in the follow-up
interviews. Finally, the follow-up period did not allow us to
determine how long the benecial effects persisted.
Further research is required to assess whether implementing
the INFOSA program with follow-up activities could maintain ef-
cacy in the long run in more variables.
Given these results and bearing in mind the alarming aging
trend in our population, it is essential to increase these types of
interventions that, beyond the scope of this study, cover the needs
of principal caregivers. Governments are currently encouraging
families to keep their elderly relatives at home for as long as
possible and this would imply a need for greater support for
caregivers.44 Psychoeducational intervention programs have been
shown to be effective in reducing the negative repercussions that
care provision has on caregivers but, importantly, interventions are
required which are more methodologically rigorous and durable so
that long-term results can be optimized. As recommended by
Capezuty and Hamers (2013),45 nurses need to promote person-
family centred care, particularly when looking after older adults
and their family caregivers.
Acknowledgements
The authors would like to express their gratitude to the care-
givers for their dedication and effort, and to the professionals who
participated in this process. We are especially grateful for the work
carried out by the members of the Cures a la Gent Gran Depen-
dent research group and for their part in the creation and vali-
dation of the INFOSA program.
This study was funded by the project PI09/0111, integrated into
National Research and development and funded by the Carlos III
General Subdivision Evaluation and the European Regional Devel-
opment Fund (ERDF).
Agency for manegement of University funding and Research
(Agncia de Gesti dAjuts Universitaris i de Recerca de la Gen-
eralitat de Catalunya, AGAUR). Research group recognized as
consolidated in Catalonia as Grup de Cures a la Gent Gran
Dependent. No Exp: 2009 SGR 916.
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