Extension has an important role to play in improving the quality of care for the frail, rural elderly. While care of these elderly in America requires the cooperation of many individuals and groups, family and friends are most often the primary caregivers or helpers. Research shows that families provide 80%-90% of medically oriented personal care and related services for their frail elderly members.1 This article is about Extension's role in teaching informal caregiving skills for frail elderly in a rural setting.

To determine what services were uniquely needed for the elderly in Arizona's rural communities, the University of Arizona Gerontology Center and the Cooperative Extension faculty in Yavapai County conducted a joint study in 1981.2 The survey showed a need for family members or friends of the frail elderly to learn home care skills that would strengthen and enhance their capabilities as informal caregivers. A series of training modules was developed by the Gerontology Center, pilot tested, and modified.3 The Extension home economist in Yavapai County used an expanded version of the curriculum, with support from some of the Extension state specialists. The findings reported here on the 25-hour course are based on experiences in five rural communities teaching 43 women and five men aged 55 to 86.

The course objectives are to enhance the caregiver's knowledge of normal and abnormal aging, improve their basic home nursing skills, and reduce caregiver stress and burnout.

The course has three major modules. The first begins with some of the major research on theories about aging to give a perspective on the aging process. It then depicts the major organ or system changes that normally occur with aging and their effects on the body. Considerable time is spent on the emotional responses triggered by these changes, not only in the aging individual, but in those who care for that person.

One of the experiential activities used at this time sensitizes class participants to the visual and auditory impairments that often accompany the aging process. Participants' eyeglasses are covered with several layers of cellophane to blur their vision. Then they're given a series of tasks to perform, such as threading a needle with a small eye and finding a name in a telephone book.4

In another simulation, participants listen to a tape5 and write down the words they hear in a series of readings. The words are carefully chosen to sound like other words, but the high frequency tones are filtered out. The words are then repeated with the high frequency tones emphasized as it is in hearing aids. Finally, the words are read with full frequency tones - only more softly. Since high frequency and volume are common hearing losses among the elderly, the tape mimics the ways people experience hearing loss as they age.

The lively discussion that follows these activities usually elicits feelings of frustration, anger, and helplessness. Typically, participant reactions are: "I had no idea how distorted the senses can get." "Now that I know how it feels, I'll be more understanding and patient."

The second module in the course focuses on home nursing skills and the advantages and problems of home care. Research on the positive economic impact of home care versus institutional or formal care by health professionals is shared.6 Primary home care skills are demonstrated by the trainers or other resource people and practiced by the participants in a hands-on situation. As a supplement, parts of a videotape series on home nursing skills and adapting the home to facilitate home care are shown.7

Two sections are especially important additions to skill building. One stresses the importance of social support, respite, and ways to cope with personal loss and grief. The main thesis of the other section is "you are what you do" - that even with limitations, home-bound patients can maintain some of their independence by learning to use helping tools and by participating in meaningful activities and exercises.

The last module of the course includes information on nutrition, finding community resources and support networks, communicating effectively, assertiveness training, identifying personal stress, and practicing techniques for stress reduction.

Pre- and post-tests for each module showed an average knowledge gain of 10.5%. Some of the participants were retired health professionals who said the course was an excellent review and update. With rare exceptions, the curriculum evaluations rated the course as beneficial. The most valued topics were those devoted to giving physical care to a bed-bound patient. Also cited were the frank discussions on the normal changes of aging which most, but not all, viewed as a positive experience. Suggestions were made that the course also be given to younger people, and that more training was needed on care for the depressed or mentally disabled older person.

To measure the impact of the course, a 14-item questionnaire was sent to each of the 48 participants six months after the course was completed. Twenty-four of them were returned for a response rate of 50%. Most questions were open-ended to assess recall, changed attitudes, and ways the information was used. Not all respondents answered every question and up to half responded that they hadn't yet had the need to use some of their new skills. There was ample evidence from many responses that the new knowledge and skills were used in participants' personal lives as well as with the person for whom they were the caregiver.

Some representative answers on how the information about common chronic illness was used included:

• "I keep my husband on his diabetic diet."
• "I didn't panic in an asthma attack."
• "I took care of an 89-year-old man with new patience, compassion, and understanding."

In describing ways they helped cope with the emotional aspects of chronic illness, many of the responses included listening with greater patience, more sharing of feelings, encouraging discussion of problems, and lowered expectations. One poignant comment was, "Previously, I couldn't face or communicate with my neighbor who lost a spouse. Now I feel assured of what I should say."

In responding to how information on planning for home care and nursing was used, most replied that their awareness of what to do and how to do it was greatly enhanced. Many examples cited the helpfulness of the techniques learned in moving, lifting, and transferring patients. Of those with experience, one wrote, "I was surprised to learn it was so easy." Others said: "I learned to use my legs instead of my back." "I didn't realize how using a belt (around the patient's waist) made the job (of lifting) so much easier."

Improvisations listed were making back rests, "potty" chairs, and raising the bed on blocks. One woman wrote: "My neighbor told me her bed-bound mother couldn't go to the beauty shop. I suggested a bed hair wash and showed her how to do it. She was thrilled." Almost all respondents noted ways they applied the information about using medicine. Frequently mentioned behaviors were: "looked at expiration dates," "asked about side-effects," "no longer save old prescriptions," "got physician's advice," "kept better records," and "stuck to the directions." One wisely cautioned that "you have to watch and make sure the medicine is swallowed." Another wrote she now could prove to her mother that "more is not necessarily better."

Many of the comments about use of the communication skill training were stated as what not to do: don't threaten, judge, lecture, advise, argue, or ridicule. Other comments were: "I let 'em talk." "I look at the person more." "Saying nothing beats putting your foot in your mouth." Several noted that the training also helped them deal with their husbands, mothers, siblings, and church friends. One wrote: "I practice them every day." Examples cited of ways stress was managed included respite care, support, more exercise, and time for myself - without feeling guilty.

In the "comments" section of the evaluation and in an occasional attached letter, the most commonly noted benefits of the course were increased self-confidence and tolerance for the needs of disabled people.

Extension is being challenged to direct its energies to help people solve problems of national importance. One such problem families face is how to meet the health care needs of aging family members. National demographic data show that the older population isn't only growing in size, but in how long they live.8 High costs for professional health care services and geographical isolation from medical services and providers add impetus for family members to learn informal home-based caregiving competencies. Historically, skill building has been an integral part of Extension's mandate. With new curricula, Extension home economics can bring its teaching expertise to address this new need.

1. Elaine M. Brody, "Parent Care as a Normative Family Stress," The Gerontologist, XXV (February 1985), 19-29 and U.S., House of Representatives, Select Committee on Aging, Exploding the Myths: Caregiving in America, Publication No. 100-665 (Washington, D.C.: U.S. Government Printing Office, 1988), p. 34.

2. Christine Bursac, "A Profile of Rural Retirement Community Residents: Implications for Planning and Service Delivery" (Tucson: Arizona Long Term Care Gerontology Center, 1984).

3. A Series of Training Modules for Informal Caregivers (Tucson: Arizona Long Term Care Gerontology Center, 1987).

4. Share D. Bane and Burton P. Halpert, Instructors Manual: Information for Care Givers of the Elderly (Kansas City: University of Missouri-Kansas City, Center on Aging Studies, 1986), p. 12.

5. "An Unfair Hearing Test: Getting Through" (Chicago, Illinois: Zenith Radio Corporation,1975).

6. Gail L. Cafferata, "Marital Status, Living Arrangements and the Use of Health Services by Elderly Persons," Journal of Gerontology, XLII (No. 6, 1987), 613-18.

7. "At Home with Home Care," videotapes (Wycoff, New Jersey: Billy Budd Films, Inc., 1986).

8. A Profile of Older Americans: 1988 (Washington, D.C.: U.S., Department of Health and Human Services, 1988).

This article is online at http://www.joe.org/joe/1990fall/a1.html.

Copyright © by Extension Journal, Inc. ISSN 1077-5315. Articles appearing in the Journal become the property of the Journal. Single copies of articles may be reproduced in electronic or print form for use in educational or training activities. Inclusion of articles in other publications, electronic sources, or systematic large-scale distribution may be done only with prior electronic or written permission of the Journal Editorial Office, joe-ed@joe.org.