Increasing self‐efficacy and knowledge in carer training: Hispanic versus Caucasian

Abstract Aim Nurses are teachers to their patients and need to know best practices for diverse families living with dementia. Little is known about Hispanic beliefs around dementia knowledge and self‐efficacy that may have an impact on the learning situation. Design A pre‐/postresearch design was used in this intervention study with a baseline assessment of dementia knowledge and caregiver self‐efficacy and a reassessment at training completion. Methods Investigation of education training with two caregiver groups caring for persons with dementia: Caucasian and Hispanic. Convenience sample consisted of 567 Caucasians and 104 Hispanic dementia caregivers. Groups received training in their primary language accompanied by a training book (Dealing with Dementia Guide) also in the primary language. Results Dementia knowledge and caregiver self‐efficacy increased in both groups with the Hispanic group demonstrating significantly greater increase in self‐efficacy. The Caucasian group had a significantly greater increase in the dementia knowledge compared with the Hispanic group.


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EASOM Et Al. (U.S. Census Bureau, 2015). The older Hispanic community continues to age with the number of Hispanics over the age of 65 doubling by year 2030 (Vega et al., 2017). Older Hispanics are one and onehalf times as likely to have Alzheimer's disease or other dementias as older Caucasians (Alzheimer's Association, 2019). Complicating this issue is the language barrier, with only 40% of Hispanics 69 years or older being fluent in English. Central to any communication is the ability to understand what is being taught and shared. This language barrier limits access to resources and understanding of training and education that is available.
Contributing to the stress of a language barrier is also the lack of knowledge about dementia and the belief that one can be confident of one's ability to provide good care of an individual with dementia.
Increasing one's knowledge is affirming, but the confidence to manage a situation is critical. Self-efficacy is the belief of one capabilities to assess and carry out the proper courses of action to manage a situation. One's self-efficacy beliefs affect one's coping resources, degree of effort and persistence to keep on trying even when the outcome appears bleak. Individuals with lower self-efficacy lack the confidence to persist and may give up without much effort. Those individuals with higher self-efficacy have a "can do" attitude and a strong belief in their capabilities. Both knowledge and self-efficacy are integral components to success in caring for another, especially in dementia care (Depp et al., 2005).
Additionally, cultural backgrounds can be linked with behaviour and can predict behaviour and choices. In the United States, the traditional notion of the melting pot symbolization of cultural integration has been replaced by the salad bowl metaphor, indicating that the various groups retain the cultural values and habits from the country of origin (Beniflah & Chatterjee, 2015). In regard to caregiving, there is little known about Hispanic beliefs around dementia caregiving and practices that may have an impact on the carer learning situation.
Overall, little is known about the impact on carer groups from different cultural in their self-efficacy and dementia knowledge through exposure to a structured dementia training workshop using printed materials in the primary language of the participant. The present intervention study was to assess and evaluate dementia knowledge and self-efficacy in two cultural groups (Hispanic and Caucasian) prior to training participation and at training end.

| Design, setting and sample
This intervention study used a pre-and postresearch design with baseline assessment of carers occurring prior to the workshop and reassessment at workshop end. The final convenience sample of workshop attendees were 567 Caucasian, non-Hispanic family carers and 104 Hispanic family carers. The Caucasian carers were recruited from their communities through service providers and community marketing by the trainers. Hispanic carers were recruited through the Hispanic Ministries in the United Methodist Churches in their respective towns. Inclusion criterion was that the carer must currently be caring for someone living with dementia. Most Hispanic carers (79.1%) were female and less than 60 years of age while the Caucasian carers (71.3%) were female and more than 60 years of age. Most of the carers from both groups were from urban areas and had been caregiving for <5 years. Spanish, written at a fifth-grade reading level, and uses large font and bold headings to guide the reader's eye to the information they seek.
There are six sections of the guide: • Introduction: illustrates a deep understanding of the carer experience and mindset in a supportive and encouraging tone; • Understanding Dementia: basic information on how dementia affects the brain, the four most prevalent types of dementia and the basic stages of dementia; • General Caregiving Tips: chapters on safety, medication management, building care teams, creating a dementia-friendly environment, etc.; • Dealing with Behavioral Issues: demonstrates a nine-step problem-solving model with applications to dementia behaviours and chapters on specific behaviours such as agitation, bathing, wandering and incontinence; • Taking

| Ethical approval
This study was approved (IRB#15-009) by the Institutional Review Board of the Georgia Southwestern State University. Each participant also signed a consent form available in their primary language.

| Intervention
The primary objective of the study, which was based on Knowles Adult Learning Theory (Knowles, 1984), was to measure and observe two different cultural groups (Hispanic and Caucasian) responses (similarities and/or differences) in regard to changes in self-efficacy and dementia knowledge when participating in a 4-hr dementia training workshop. According to the theory, adults are most interested in learning about a topic which relates directly to their lives (Knowles, Swanson, & Holton, 2005). Each of the carers in the study was active carers of persons with dementia and was eager to participate and learn.
Over a period of 1 year, a total of 10 four-hour workshops were held with Hispanic carers and 25 four-hour workshops were held with Caucasian carers. Data were collected at the beginning of the workshop (before training started) and at training end with reliable and valid tools (Revised Scale for Caregiving Self-Efficacy and the Alzheimer's Disease Knowledge Scale) and through observation by the workshop leaders.

| Measures
In addition to obtaining demographic information on each training

| Analysis
Statistical analysis was performed using SPSS for Windows version 24. Paired-sample t tests examined differences within the mean from baseline to programme completion for the variables of self-efficacy and Alzheimer's disease knowledge. Frequency distributions were performed to analyse descriptive data. Statistical significance was considered at p < .05.

| RE SULTS
Both groups had statistically significant increases in self-efficacy (SE) and Alzheimer's knowledge (ADKS) from baseline to programme end assessment (all p <.001,

| D ISCUSS I ON
The purpose of this intervention study conducted a comparison of the results of training with two carer groups caring for persons with dementia: Caucasian (primary English speaking) and Hispanic (primary Spanish speaking). Healthcare providers working with these populations can use the lessons learned from this comparison as they incorporate healthcare training for individuals caring for someone with dementia. Conflicts may occur between nurses' cultural values and care practices in dementia care settings; thus, there is a need for ongoing education to decrease the possibility of such conflicts (Kang, Moyle, & Venturato, 2011 This is an interesting result as the education levels of the Hispanic group were lower than the Caucasian non-Hispanic group. Earlier research (Gallagher-Thompson, Arean, Rivera, & Thompson, 2001) identified that barriers among Hispanic carers to access to care services included the carers' language proficiency and limited education. Perhaps having the training materials translated into Spanish and at a fifth-grade reading level encouraged learning and knowledge uptake.
The positive effect on ADKS occurred similarly between the two groups. In other words, the increases (pre-post) in ADKS score were quite close between the groups. However, the ADKS scores (both baseline and after follow-up) of the Caucasian carers were significantly higher than those of the Hispanic carers. This may be explained by the lower educational level. Researchers have found that Hispanics providing care to a family member with Alzheimer's disease and related dementias face numerous language, literacy and cultural barriers to accessing and housing health services (Weitzman, Neal, Chen, & Levkoff, 2008). Healthcare providers working with the Hispanic population need to have printed materials in Spanish and at a lower reading level for easy understandability. Other researchers (Hirata & Harvath, 2017) found that residents with dementia experienced stress which transferred to carer worker stress and staff turnover. Perhaps increasing carer knowledge of dementia may translate into lower stress for residents and carer worker retention as well.
Researchers have also found that training and intervention programmes with Hispanic carers were slow, labour intensive and required twice the amount of time allotted initially (Gallagher- Thompson et al., 2001;Llanque & Enriquez, 2012). In the current study, we found that the Hispanic carer group did require more trainer attention and responded positively to more interaction. The Hispanic carer group voiced that they would like to do a craft and take it home to the care recipient as a way to include the recipient in the training. The cultural influence of collectivism may explain these findings. Collectivism relates to altruistic motivations and the desire to strengthen social ties according to Finkelstein (2010). Hispanic culture embraces collectivism with beliefs that the group is more important than the individual, whereas the Caucasian culture values individualism. The healthcare provider must be aware that cultural values and family variables may play a statistically significant role in adherence to the healthcare regime and plan for more time and family inclusion when planning health training.
Some limitations of the current study should be noted. The different backgrounds of the trainers and the difficulty assuring consistent delivery of training in the field are limitations in this study.
The limited geographical area may influence the generalizability of the results. Future studies should include a more diverse groups of cultural backgrounds to participate in the training.

| CON CLUS IONS
With the prediction that Hispanics will occupy one-third of the population of the United States in future years, strategies to reach and teach carers of this group are important. The current study findings indicated that best practices for healthcare instruction include that printed materials translated into the primary language are important for the teaching message to be understood. Allowing more time and incorporating more group interaction within the teaching time were anecdotal findings that can have a positive impact on the learning experience. These practices contributed to increased selfefficacy (confidence) and increased dementia knowledge levels for the Hispanic carers in this study.

ACK N OWLED G EM ENTS
Funding was provided by a cooperative agreement (No. 90AEO339) from the Administration on Aging, Administration for Community Living and U.S. Department of Health and Human Services.

CO N FLI C T O F I NTE R E S T
No Conflict of Interest.