A Social Marketing Approach to Recruitment:
The Resources for Enhancing Alzheimer’s Caregiver Health (REACH) Study
Running Head: Social Marketing and Recruitment
Linda Nichols, Ph.D.
Memphis VA Medical Center
and University of Tennessee
Barbara Tarlow, Ph.D., R.N.
Hebrew Rehabilitation Center for AgedResearch and Training Institute
Jennifer Martindale-Adams, Ed.D.
University of Tennessee
Lou Burgio, Ph.D.
University of Alabama, Tuscaloosa
Robert Burns, M.D.
University of Tennessee
Dolores Gallagher-Thompson, Ph.D.
Veterans Affairs Palo Alto Health Care System
and Stanford University
David Coon, Ph.D.
Stanford University
Delois Guy, Ph.D., R.N.
University of Alabama at Birmingham
Marcia Ory, Ph.D.
National Institute on Aging
Trinidad Arguelles, M.S.
University of Miami
Diane Mahoney, Ph.D., R.N., GPN
Hebrew Rehabilitation Center for AgedResearch and Training Institute
Laraine Winter, Ph.D.
Thomas Jefferson University
Correspondence and reprints requests:
Linda Nichols, Ph.D.
Memphis VA Medical Center
1030 Jefferson Aveneue
Memphis, TN 38104
Linda.nichols@med.va.gov
(901) 523-8990, ext 5082
(901) 577-7439 (fax)
Abstract
Text – 4577 words
References – 872 words
Tables - 3
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Recruiting research subjects is one of the most challenging aspects of clinical research.
While these difficulties are understood clinically, only recently have recruitment issues become a
researchable topic.1-7 However, many recruitment studies continue to lack a theoretical
framework for understanding factors affecting these processes.8
Social marketing principles provide a useful theoretical framework for organizing the
recruitment activities inherent to clinical research and can help researchers identify the elements
that can be manipulated to maximize the achievement of recruitment goals. The basis of social
marketing is the application of marketing techniques to influence the behavior of target
audiences in order to improve their welfare and that of society.9 While social marketing is more
typically used in public health initiatives designed to change behavior,10 the use of marketing
principles can enhance subject recruitment, which is critical to the success of any research
study.11 The four Ps of product, price, place, and promotion, in conjunction with the concept of
partners, are the basics of any marketing strategy - variables that marketers can alter to
successfully sell a product.10
This article describes the application of social marketing principles as a theoretical
framework to organize and understand recruitment activities in a multi-site intervention study.
In the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) project, investigators
from multiple sites began with the same premise for product (intervention) development.
General and site-specific recruitment strategies were developed to: define the target audience for
the product (research subjects); develop the product (intervention); manage the price to the target
audience (in time and trouble); improve accessibility (place); promote the study; and develop and
work with partners.
3
REACH is a multi-site, randomized, controlled experimental study to evaluate the
feasibility of different social, behavioral, technological, and environmental caregiving
interventions on the health and well being of caregivers (CGs) of persons with dementia. In
response to an National Institutes of Health (NIH) cooperative agreement for caregiver research
sponsored by the National Institute on Aging (NIA) and National Institute of Nursing Research
(NINR), the project targeted a diverse population of CGs of persons with dementia. The six
clinical sites were located in Birmingham, Boston, Memphis, Miami, Palo Alto, and
Philadelphia. The Coordinating Center was located in Pittsburgh. (See Table 1 for institutions).
REACH was not only successful in overall subject recruitment (majority of sites recruited
more than their target numbers), but also in recruiting the targeted ethnic/minority groups. The
REACH cohort of 1222 caregiver/care recipient (CG/CR) dyads constitutes the largest national
database of diverse CGs actively participating in intervention studies (see Table 1).. Recruitment
goals were based on power analyses for detecting significant intervention effects of the different
intervention strategies at the six different sites hence the different numbers across sites.
Insert Table 1 about here
Defining the Target Audience
The first, and perhaps most important, part of a recruitment strategy is to determine the
target audience. Once the target audience is identified, program components can be developed
that address their needs, perceptions, and values.10 REACH's target audience included ethnic
minorities, who have been underrepresented in prior dementia research.12-15 Each site focused
recruitment efforts on the particular ethnic minority group available in their specific geographic
area, taking into account the different factors that might motivate subjects to enroll in the study
4
and differences in subjects' feelings, attitudes, and beliefs about the proposed psychosocial
interventions.16-17
Inclusion and exclusion criteria were developed to create a definable population of both
CGs and CRs at the six sites. To maximize intervention benefits, CGs were family members
who lived with the CR, provided a significant amount of care, and had been providing care long
enough to understand the challenges of caring for someone with dementia and problem
behaviors. CRs had disease that would conceivably “burden” CGs, yet who would remain
manageable at home over the eighteen months of data collection. In addition to the inclusion and
exclusion criteria across sites (see Table 2), all sites except Memphis had additional site-specific
inclusion and exclusion criteria related either to intervention design or to site-specific research
questions. For example, at Boston, which had a phone based intervention, CGs had to have
touch tone service; and Palo Alto’s research questions addressed issues related only to White and
Hispanic women only and therefore limited its enrollment accordingly.
Insert Table 2 about here
Developing the Product
Defining the Product
In marketing, a product is defined as the behavior, goods, service or program exchanged
for a price.10 In clinical research, the product is the intervention, and the intervention must meet
the needs, wants, interests or desires of the target audience – the potential research participants.
The basic REACH product was defined by NIH and NINR as social and behavioral interventions
– the most promising technological and community based interventions to enhance family
caregiving for Alzheimer's Disease and related disorders, particularly among minority families.
From this broad product definition, each REACH site further defined a caregiving intervention or
5
product to meet the needs of its target audience, including the ethnic minority group at each
site.18 See Table 3 for interventions - the site specific products.
Insert Table 3 about here
Competition for the Product
A significant obstacle to recruiting potential research subjects for participating in
interventions is the amount of competition for their time and energy. At the Boston site, for
example, the number of research and clinical drug trials recruiting Alzheimer’s patients
markedly increased at the time of REACH recruitment, resulting in intensive competition for
subjects. During the course of Boston’s recruitment period there were, on average, 15 studies
per month recruiting older adults in a regional recruitment program19-20 as well as 45 studies
listed in the local Alzheimer's Chapter's directory of research opportunities.21 Participation in
another ongoing study may be a formal exclusion criterion or, if not an exclusion, may be so
time consuming that individuals cannot participate in other studies. In addition, the presence of
other resources in a community, such as case management services and on-going support groups
sponsored by Alzheimer's Association chapters, social service agencies and some health plans
may give potential participants the impression that sufficient resources negate the need for
participating in unproved or non pharmacological interventions.
Managing the Price
In marketing, price is defined as the cost to the target audience member in money, time,
effort, lifestyle, or psyche, of engaging in the behavior. In recruitment, there also is a cost to the
target audience member (potential or actual subject) for participating in a research study. These
costs are in addition to those that may be required to implement the behavior change (which is
the usual definition of price). For CGs, costs for participation in an intervention can be high,
6
particularly if respite or sitter service is not available. The research participant must perceive the
cost of participating in the intervention to be a fair exchange for the benefit associated with the
behavior change or for an altruistic benefit, such as helping other CGs in the future.
Types of Costs
While there was no actual monetary "charge” for any of the REACH interventions,
participants nevertheless experienced a cost for joining the research project. Part of this cost was
fixed across sites, while another part varied across sites and across intervention settings. One
common cost in research studies is data collection. The 393 item REACH core data collection
battery was a “fixed cost” across sites, taking CGs an average of 60-90 minutes to complete
every six months. Each site added other measures to the core battery to investigate site-specific
research questions. These site-specific batteries ranged in length from 29 questions requiring an
additional 10 minutes at Boston to 200 questions and 60 additional minutes at Palo Alto. The
number of data collection points also varied, with two sites including at least one additional data
collection point between baseline and 18 months; thereby increasing costs to target audiences.
Moreover, while five sites ended data collection at 18 months, Memphis extended data collection
to 24 months.
An associated cost in REACH was actual intervention time. At several sites,
interventions and data collection occurred at the same visit, extending the amount of time
required of CGs (and perhaps CRs) per visit, but decreasing the number of trips required. The
duration of each active face-to-face intervention (not control/comparison groups) ranged from 0
at Boston (due to the computer interface) to 180 minutes per workshop at Birmingham. The
frequency of intervention contact varied across sites ranging from weekly to monthly to every
three months. These time costs affect homemaker, retired, and employed CGs differentially, as
7
they compete not only with caregiving tasks, other familial obligations, and personal needs, but
also with wage earning hours.
The time necessary for data collection and the time required to conduct interventions are
not the only costs to research participants as is common in other studies.22-23 Across the sites, 74
participants cited intervention or data collection length as reasons for discontinuing. In
Memphis, where neither data collection nor intervention were conducted in the home and where
people might travel many miles from rural areas to see their primary care physicians, travel time
was a major cost for participants. For many CGs, especially those with frail CRs, travel often
subsumed other costs. For example, CGs might require additional time to prepare their CRs for
travel, might need special transportation and thereby incur the monetary costs of that
transportation, might experience the cost and difficulty of hiring a sitter or finding a family
member to sit with the care recipient, and fatigue and additional behavioral problems involved
with taking the CR outside the familiar environs of home. For some participants, travel and
transportation proved to be an overwhelming cost.
Other costs were unique to specific sites. For example, due to the focus on behavior
problems, Birmingham CGs were asked to maintain a daily Behavioral Log throughout the 18
month study period. Although the tracking system was designed to minimize CG effort, extra
work and time were required. Palo Alto's Coping with Caregiving class participants were asked
to complete weekly homework assignments as a means of practicing skills taught in class
sessions.
Minimizing Costs
In marketing, an important pricing principle is the marketer's ability to reduce or
minimize consumer cost. At the onset of the REACH project, the majority of sites decided to
8
provide minimum services, such as payment for interviews, basic educational material on
dementia and caregiving topics, and active listening to caregiver concerns to the
comparison/control groups to balance the cost of participating in data collection. In addition,
Birmingham, Boston, Memphis, and Palo Alto offered to enroll their control/comparison groups
in more intensive interventions after completion of data collection. All but two sites paid
participants for data collection or intervention participation. For these two sites, whether a
financial incentive might have motivated individuals who refused to participate remains unclear.
In a substudy of REACH refusers in Boston, investigators did offer a monetary incentive in
combination with a one time only study contact and found little difficulty in recruiting
participants.3 Some REACH sites did follow-up interviews by telephone to minimize
participants' travel costs. Palo Alto provided funding for respite for the CR and provided
transportation for the CG to support group and class sessions. Birmingham and Memphis
provided a sitter and transportation (on an as-needed basis) as well as parking for group training
sessions, and intervention and/or data collection sessions.
To reduce the cost of CG time, Birmingham relaxed its requirement of daily completion
of the Behavioral Log during the intervention period. Both Miami and Palo Alto minimized CG
costs by providing recruitment, intervention and data collection activities in the preferred
language of the CG, either English or Spanish. An additional way in which Birmingham and
Memphis decreased the psychic or emotional cost to the CG was to have the same researcher or
interventionist see the CG each time. The rapport built over time appeared to be a significant
factor in retaining participants in the study, as CGs often listed the interventionists in their
support network. At Miami and Palo Alto, CGs and interventionists shared similar cultural
backgrounds with interviewers, interventionists, and recruitment staff further reducing psychic
9
costs to CGs. Although CGs and interventionists did not always share the same gender and/or
cultural background at other sites, interventionists were trained in cultural competency in the
participants’ culture.24
Improving Accessibility (Place)
In a research milieu, place can be conceptualized as where the individual will engage in
the behavior or receive information about the behavior, either as part of the intervention or as
part of recruitment. Intervention sites included participants’ homes, physicians’ offices, memory
clinics and other health care institutions, dementia-focused organizations (such as adult day care)
and other community sites. In many cases, these places were also recruitment sites. The more
accessible the place is to the participant, for recruitment and for intervention, the more likely it is
that participants will enroll in and remain in the study.
Birmingham’s initial workshop and Palo Alto’s classes and support groups were
conducted in churches and community sites such as senior centers, adult day centers, or adult day
health care centers that were not only convenient, but also were neutral or appropriate sites for
the cultural group recruited. Memphis conducted intervention and data collection during the care
recipient's regularly scheduled physician's visit. Philadelphia, Miami, and Boston all conducted
their interventions in the home, as did Birmingham after the workshop.
Promoting the Study
Promotions are defined as a combination of advertising, media relations, promotional
events, personal selling, and entertainment to communicate information about the product to
target audience members. An important component of promotion is to identify acceptable
avenues that reach the target population. Given the emphasis on recruiting minorities into this
study, REACH investigators at each site tailored and ensured recruitment strategies and media
10
expenditures took into account the needs and preferences of ethnic populations. For example,
each REACH site used professionally designed brochures, with translations appropriate for the
sociocultural context of local Hispanic populations (i.e., “memory loss.” instead of “dementia.”
Strategies used by sites included: newspaper ads, articles, flyers, and advertisements in
newsletters, newspaper ads, web sites, television and radio, targeted and mass mailings of
brochures, magnets and other promotional items, community presentations, and community
service.
Newspaper ads are often not successful in generating referrals and this held true for
REACH. The failure of newspaper ads to produce research referrals may be attributed, in part,
to ads not targeting the individuals who need the service, eligibility of fewer persons, and callers
knowing little about their “fit” with the project, as the amount of information in the ad is small.
Newspaper advertising also is relatively expensive, typically costing $800-$1,600 for a series of
ads. Nevertheless, newspaper ads proved useful in attracting some targeted REACH groups. For
example, Birmingham newspaper ads were a viable recruitment tool for persons in the Black
community disconnected from formal health care or social service networks. Philadelphia
achieved good results with ads placed in neighborhood newspapers and in series, for 4-6
consecutive weeks. In contrast, ads and articles in newspapers targeting the Latino community
were not successful in recruiting Hispanic CGs for Palo Alto.
Although work-place newsletters were not successful, senior-focused newsletters from
local hospitals and newsletters from Alzheimer's organizations were quite successful in
generating participants at Boston, Miami, and Memphis. Targeted mailings were also successful,
especially those with a personalized letter, while untargeted ones to a broad sample were not.
Memphis, Boston, and Birmingham used the mailing lists of local Alzheimer’s agencies or sent
11
materials to Alzheimer's agencies for distribution to their subscribers/supporters. Birmingham
also sent mailings to churches, while Palo Alto targeted Hispanic/Latino families through
university clinics and home care groups. Philadelphia’s mailings targeted family CGs of people
with memory loss who were on the local Area Agency on Aging’s waiting lists for in-home care.
Boston employed the high-tech medium of its Web site, which also allowed for on-line
screening of potential subjects. In Birmingham, Miami and Palo Alto, the REACH project was
featured on several local television and radio public service announcements as well as news and
health talk shows. Birmingham also aired a television feature that included interviews with
REACH participants who personally endorsed the REACH program. Nationally broadcast news
stories featuring the REACH project appeared on CNN and Headline News. In Miami and Palo
Alto, Hispanic caregivers responded well to television health and talk shows, but Miami
caregivers also responded well to radio programs, while Palo Alto caregivers did not.
Community outreach also served as a vehicle for promoting the REACH study.
Community forums, talks and lectures at professional and ministerial associations, meetings of
local health and social service organizations, churches, adult day-care centers, support groups,
civic organizations, and neighborhood associations served as avenues for informing other
professionals and dementia CGs about research opportunities at several sites. During these
events, REACH recruiters disseminated information about the project by talking with people and
by distributing flyers, brochures, and magnets. Investigators at Miami learned that Cuban
Americans preferred to be introduced to the concept of REACH within the context of a health
education program.
A time-consuming but successful tactic combined community service and recruitment.
Memphis staff worked with the Alzheimer’s Association on a customer satisfaction survey that
12
included two questions on knowledge about REACH and interest in learning more about
research studies. Boston's recruitment coordinator chaired committees for local Alzheimer's
organizations.25 Palo Alto offered frequent free workshops on dementia to the public at various
community sites and at well-advertised VA Memory Clinic locations to assess cognitive status in
a familiar, non-threatening environment. These Palo Alto activities were offered in English,
Spanish or both depending upon the needs and expectations of co-sponsors and the target
audience.
Working with Partners
Although classic marketing theory does not include partners as one of its Four P's, the
synergy of partners with place and promotion provides a powerful marketing strategy,
particularly in the context of research. Partners are defined as other organizations involved with
a social change effort or serving as conduits to target audiences. Partners played a major role in
recruiting REACH participants. Recruiting efforts were particularly successful when the
partners were located in a convenient or credible location, such as a physician’s office, or when
promotion efforts were directly tied to the partner’s roles, such as providing information on
REACH in an Alzheimer's day care newsletter. However effective partnering requires continued
attention from the research staff.
Partner Education. REACH sites provided their partners with information about the
project, and also engaged in relationship building activities. For example, Birmingham
researchers held a reception to provide a progress report of the research and to acknowledge the
contributions of the Visiting Nursing Association (VNA) (a major recruitment resource). This
strategy provided lower level employees an opportunity to interact with the REACH team.
Recruiting through home health agencies allowed Birmingham researchers access to more Black
13
CRs and families who do not usually seek specialized dementia evaluations or treatments for
their relatives. Palo Alto provided VA staff with educational information about the stresses of
caregiving, so that appropriate family members were referred. In addition, Palo Alto and
Memphis regularly placed notices about the REACH project in the VA newsletter and on the VA
internal email system to remind staff about this unique service.
Effective relationships with members of both formal and informal networks are essential
in marketing a research study as both formal and informal service providers support participants.
Memphis, Boston and Palo Alto provided training sessions at local Alzheimer's affinity group
meetings, aging affinity groups, and local hospital systems. Members of these groups provide
services to individuals with Alzheimer's or their CGs and were a good source of referrals for
REACH. Palo Alto staff further strengthened their network partnerships by offering training to
their partners, thereby creating a bridge for providing CG assistance within the community after
REACH contact ended. This mechanism created a snowball referral system, particularly in
Hispanic communities, where study participants and informal network members provided
additional referrals based on their positive relationships with study staff.
Partner Referrals and Recruitment. Recruitment efforts were particularly successful
when the place was linked to one of the REACH partners. For example, in Miami, White nonHispanic subjects responded well to letters about the REACH project sent by their physician at
the respective Memory Clinics. They often perceived the REACH project as an extension of the
clinical services of the Memory Disorders Clinic.
In Memphis, participants were recruited from their physician's office and seen at that
office. To obtain referrals, the Memphis staff modified the successful pharmaceutical detailing
strategy. At each visit to the office, REACH staff delivered recruiting reminders and provided
14
educational materials for the offices. Effective devices included sticky notes, magnets,
brochures with accompanying holders to place in waiting rooms, and small seasonal treats for
staff and patients to share (e.g., candy for Halloween with a REACH sticker on it). Weekly faxback forms provided by REACH staff enabled office staff to send a referral without writing out
an additional fax form for each referral. Continued personal contact over the course of the study
permitted research staff to learn the cultures – the norms, attitudes, behaviors and values – of the
referring agencies and their staff and how best to work within those cultures.
Some of the REACH sites provided incentives to their partners for referrals, including
monetary rewards and movie tickets. However, this strategy must be investigated thoroughly in
the planning phase since many Universities categorize this type of transaction as "fee-splitting"
and prohibit the giving of money or gifts to referral sites.
Barriers. Changes in partners can prove disastrous to recruitment efforts. Near the end
of the study’s recruitment phase at Birmingham, changes in client eligibility criteria as well as in
the reimbursement system of home health care agencies drastically reduced the number of
persons eligible to receive services and resulted in personnel cuts at these agencies.
Consequently, REACH staff experienced a commensurate decrease in referrals from these
agencies. Although monetary incentives for successful referrals from the home health agencies
were instituted to compensate for the loss, this measure proved ineffective in increasing referrals.
A series of concomitant events stumped Boston researchers during recruitment. A major
realignment of health care systems and the resulting downsizing during REACH’s first field year
severely crippled recruitment efforts.26 Boston’s major academic health care facilities realigned
into partnerships that markedly undermined research endeavors from non-partner agencies. The
Boston site’s original academic medical partner merged with another hospital, triggering
15
downsizing and the closing of several clinics that had agreed to refer potential participants. A
second referral site for Boston, which umbrellaed regional VNA and social service agencies,
converted to for-profit facility status. The public relations administrator opposed partnering the
study citing fear of possible negative publicity from the need to withhold services from
participants randomized to the control group. The research staff at Palo Alto also encountered
barriers spawned by serendipitous events. State propositions 187 and 209, broadly viewed as
anti-immigrant and anti-affirmative action legislation, were enacted by California voters before
and during REACH. These pieces of legislation erected barriers of mistrust between Hispanic
community partners (and their clientele) and the REACH staff who were employed by large state
university and federal government systems and who were marketing a federally-sponsored
project.
Research Partners. By virtue of the study’s structure, each of the REACH sites was
partnered by the Coordinating Center, NIA and NINR. At the project’s inception, a recruitment
and retention workgroup was assembled, composed of project managers and investigators from
each clinical site, as well as members of the Coordinating Center and NIH. Work group
members conducted monthly conference calls until recruitment was completed and conducted
bimonthly calls thereafter. Once recruitment began, the Coordinating Center provided the
workgroup and each site with monthly recruitment and retention figures for each site and for all
sites combined. The workgroup shared tips and strategies, and worked individually with sites
experiencing difficulties. Through this workgroup, all sites benefited from the advice given
Boston by their social marketing consultant and Miami’s experiences using the Adoption Process
Model, which is often used to market health education programs and to recruit participants.27
16
Conclusion
Every research encounters obstacles that influence recruitment or retention.28-30 In fact,
research shows that the number of subjects who meet entry criteria and agree to enter a study
will be fewer, often by several fold, than original projections.31 Unpredictable health care or
community forces that were not factors in the planning and design phase of a research study can
influence its implementation. In extreme instances, these factors may determine the project’s
success or failure; at a minimum they can influence a study’s timetable or recruitment goals,
necessitate staffing changes, or require fiscal adjustments. The REACH project illustrates how
unforeseen events, such as changes in the organization or reimbursement of health care, the
simultaneous presence of other studies, a loss of referring partners, and political shifts unrelated
to the study but influencing the target audience, can greatly affect the ability to recruit and retain
participants, particularly in multi-site research. Applying a social marketing theoretical
framework in the design phase of the study, rather than as a post hoc organizing principle, can
alleviate many of the difficulties sites face in recruiting and retaining research participants.
The hallmark of social marketing is close attention to the congruence among the target
audience, the product, and the mechanisms for marketing the product (price, place, promotion,
and partnering). To maximize this fit, researchers must develop not only a thorough
understanding of the potential research subjects and their community, but must also expand the
concept of partnership to include the participants and their community, "…embracing the
experience and partnership of those we are normally content simply to measure”.32
Partnership or collaboration among researchers, participants, and their community is
increasingly recognized as critical to the success of a study.32-34 Partnering will not eliminate
unforeseen difficulties but can help alleviate the damage they caused. In the initial phase of a
17
study, collaboration ensures the development of research methodologies that are consistent with
community values, realities, and expectations. As a study progresses, researchers who have
designed and implemented a study congruent with the culture of the community and who
function as partners are more likely to recognize developing trends or events that have
implications for the study. Frequently, researchers find themselves “blind-sided” by health care
organization or financing changes that negatively impact some aspect of the study. Applying
social marketing techniques that foster collaboration enables researchers and the community to
quickly identify and implement alternative strategies.
A social marketing framework enhances the congruence between the aspirations of
researchers and the goals of the community. Decisions about the format and about conduct of
the intervention and about recruitment and retention practices are reached with a full
understanding of the culture of the community; and in the best case scenario, with the assistance
and collaboration of the community.34 Congruence between the needs, wants, and preferences of
the target audience and the researchers is pivotal in facilitating the research process.
The ultimate goal of research is to develop and test interventions that will be broadly
implemented. Research conducted using a social marketing perspective is more likely to be
acceptable to a wider target audience than those who participate in the initial study. By
following a social marketing framework, the researchers’ understanding of the needs, wants, and
preferences of the target audience can be easily expanded to the general audience.
18
Acknowledgement
This research was supported through the Resources for Enhancing Alzheimer’s Caregiver
Health (REACH) project, which is supported by the National Institute on Aging and the National
Institute of Nursing Research (Grants: U01-NR13269, U01-AG13313, U01-AG13297, U01AG13289, U01-AG13265, U01-AG13255, U01-13305).
19
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23
Table 1- Recruitment by site and ethnicity
Birmingham Boston Memphis Miami Palo Alto Philadelphia All sites
Randomized
140
100
245
225
257
255
1222
% White
57.1
79.0
58.6
49.8
57.2
48.2
56.0%
% Black
42.9
16.0
39.8
0.0
0.0
47.8
24.2%
% Hispanic (Mexican)
0.0
0.0
0.0
0.0
30.0
0.0
6.3 %
% Hispanic (Cuban
0.0
0.0
0.4
50.2
0.8
0.0
9.5 %
% Hispanic (Other)
0.0
2.0
0.4
0.0
12.1
0.0
3.2 %
% Other
0.0
3.0
0.8
0.0
0.0
2.0
0.8 %
24
Table 2. REACH Subject/Participant Criteria: Shared Criteria Across All Sites
Caregiver Inclusion Criteria
Caregiver Exclusion Criteria
> 21 years old
Life expectancy < 6 months
Family member
Active treatment for cancer
Telephone
> 3 acute hospitalizations/past year
Plan to remain in area for study duration
Planned placement of CR (within 6 months)
Caregiver > 6 months
Involved in another clinical trial for caregivers
Daily > 4 hours supervision/assistance
Other (e.g., transportation, commitment, hesitancy)
Live in the same house with CR
Care Recipient Inclusion Criteria
Care Recipient Exclusion Criteria
NINCDS-ADRDA (MD diagnosis) or
Blindness or deafness if prohibit from data collection
cognitive impairment (MMSE < 23)
or participation in interventions
Two IADL or one ADL impairment(s)
Active treatment for cancer
> 3 acute hospitalizations/past year
Schizophrenia
Dementia secondary to head trauma
MMSE = 0 and bedbound more than 22 hours/day
Life expectancy < 6 months
25
Table 3. Summary of REACH Intervention Conditions
From: Rubert and Czaja
Site
Intervention
Description
Birmingham
Skill Training
Behavior management skills training; caregiver
University of
problem solving
Alabama,
Minimal Support
Interviewer provides active listening and empathic
Birmingham,
Control
comments
Memphis
Information and
Written AD information, referrals to AA
University of
Referral
Tennessee,
Behavioral Care
Tuscaloosa
Memphis VA
Medical
Information plus behavior management skills
training
Enhanced Care
Center
Information care + behavioral management care +
stress management. Relaxation training, coping
strategies.
Miami
Family-based Structural
Family system therapy to enhance family support
University of
Multi-system In-home
and functioning.
Miami
Interventions
FSMII + Computer
Family therapy plus computer telephone system to
Telephone Integration
facilitate family communication, messaging,
System
conferencing, respite functions and social support
Minimal Support
Interviewer provides active listening and empathic
Control
comments
26
Palo Alto
Coping with Caregiving
Psychoeducational class to teach coping and mood
Stanford
Class
management skills
University,
Enhanced Support
Support groups patterned after local community
Veterans
Group
support groups, standardized meeting frequency,
Affairs Palo
duration, length of time in group and educational
Alto Health
materials.
Care System
Minimal Support
Interviewer provides active listening and empathic
Control
comments
Philadelphia
Environmental Skill
In-home caregiver problem solving and use of
Thomas
Building
environmental strategies to manage behavioral
Jefferson
problems and ADL limitations
University
Usual Care
Provision of education and referral materials.
Boston
REACH for TLC
Monitors caregiver stress levels, voice mail support
Hebrew
group, provides expert advice, care recipient
Rehabilitation
behavioral distraction to reduce disruptive behaviors.
Center for
Usual Care
Aged-
consultation available, support group referral
Research and
Training
Institute
Pittsburgh,
University of
Pittsburgh
Medical services and testing, social work
Coordinating Center
27