Carolyn L. Bird, Ph.D., AFC, RFG®
North Carolina State University
Ann A. Berry, Ph.D., RFG®
Associate Professor and Extension Specialist
The University of Tennessee Extension
Many caregivers focus solely on the person needing care, neglecting their own needs. While this servant attitude is admirable, if caregiver needs are neglected too long, severe consequences can emerge.
The current economic downturn exacerbates the monetary costs and future financial impacts stemming from the costs of family caregiving. The Making Ends Meet for Caregiving program draws from theory and real-life experiences to encourage positive action among family caregivers.
Uniquely, this article synthesizes an education model that employs two theories to promote caregiver self-care in the realm of preparation for later-life financial security. Educational programming for small or large group audiences is illustrated.
caregiving, theory of planned behavior, transtheoretical model of change, retirement planning, financial management
Family caregivers make important and substantive contributions to the well-being of individuals and to the nation’s domestic gross product (Feinberg, Reinhard, Houser, and Choula 2011). However, family caregivers face many challenges in balancing their work and family life and the care of a loved one, leaving little time or energy to attend to their personal well-being; that is, their own physical and financial health (Bird and Berry 2012). More baby boomers in their fifties and peak earning years will become working caregivers and have a need to make sufficient provisions for their own retirement while caring for an aging parent. Women in particular need to be better informed about potential impacts of caregiving and strategies to mitigate negative consequences. Specifically, it is important to fully consider the impact of leaving a job, dropping back to part-time, or taking a lower-paying job to accomplish greater flexibility for caregiving (MetLife Mature Institute 2011). The MetLife Mature Institute study (2011) advances the position that “if … caregivers understand the financial implications of caregiving described in this study, they may be better able to plan for their own retirement as well as fulfilling their caregiving role.”
While caregiving is a well-investigated topic (Bird and Berry 2012) the authors found no programming that integrated theory and research with providing a tool to assist caregivers in their quest for balance between caring for others and caring for self. The authors developed a model, grounded in a blend of two behavior change theories, to respond to the needs of caregivers for improved later-life financial security. They subsequently developed a program, Making Ends Meet for Caregiving (MEMC), based on their model.
The MEMC program, focused on baby boomers, should be beneficial in helping them to accomplish better financial security in later life than their predecessors. The authors’ experience of conducting the MEMC educational program at two professional meetings, serving diverse audiences, validated the need for this programming. The first presentation was given at the Caring for the Caregiver 2008 conference, for which 189 participants registered. Of these, 57 returned conference evaluations in which 25 indicated they attended the Making Ends Meet for Caregiving session. When asked “What would you consider to be the strengths of the conference?” at least one respondent specifically identified “Making Ends Meet for Caregiving.” The second presentation was to Extension professionals at a regional conference. There was great enthusiasm from the participants; many indicated the program heightened their awareness of their own financial vulnerability and of caregiving needs and resources. Even though a formal evaluation was not conducted, several participants commented that they were appreciative of the retirement planning resources that were identified.
Making Ends Meet for Caregiving should be of great utility for caregivers given the context of demographic changes, actual caregiver comments on the value of the programming, and educators’ enthusiasm for the educational model when presented. Our model, as used within the MEMC program, is an adaptation and combination of the Transtheoretical Model (TTM) shown in Figure 1, and the Theory of Planned Behavior (TPB), as shown later in Figure 2. Our model expands on these precepts in the areas of family resource management and caregiving.
Theoretical foundation for the conceptual framework
The Transtheoretical Model (Prochaska, DiClimente, and Norcross 1992) incorporates concepts related to an individual’s predisposition to modify a behavior (stages of change) and defines the process (processes of change), or the activities involved to achieve the targeted behavior change. The “stages of change” —(1)precontemplation, (2)contemplation, (3)preparation, (4)action, and (5)maintenance—are detailed in the literature (Prochaska, DiCliemente, and Norcross 1992). The TTM posits that individuals move through stages of change from precontemplation to maintenance. The stages are not linear in that a person can start at any stage of change, revert back to an earlier stage, or skip forward based on internal or external factors and move through the stages multiple times in what is known as “recycling” before accomplishing lasting change (Norcorss, Krebs, and Prochaska 2011). Thus educators should not expect linear movement through the stages of change. Processes of change are the “covert and overt activities that individuals engage in” (Cancer Prevention Research Center n.d.) to progress through the stages. The processes are broad categories and encompass multiple techniques, methods, and relationship stances traditionally associated with disparate theoretical orientations (Norcross, Krebs, and Prochaska 2011). This adaptation of TTM focuses on the processes of change.
Figure 1: Transtheoretical Model.
[Alt tag content for Figure 1: Transtheoretical model diagram from consciousness raising to self liberation. ]
[D link content for Figure 1: A diagram of the transtheoretical model illustrating each of the nine phases of the process of change beginning with consciousness raising and ending with self liberation. ]
The Theory of Planned Behavior (TPB) advances that behavior is affected by intention to do the behavior (behavioral intention), which in turn is predicted by attitudes, perceived behavioral control, and subjective norms (Ajzen 1991). The TPB has been shown to be effective in programming for caregivers through expanding participant perceptions concerning the issue and stimulating plans for self-care (Bird and McClelland 2010). Similarly, Making Ends Meet for Caregiving seeks to motivate participants to implement processes of change and stimulate plans for self-care in relation to later-life financial stability.
Figure 2: The Theory of Planned Behavior.
[Alt tag content for Figure 2: A diagram of five circles with interconnecting arrows indicating relationships.]
[D content for Figure 2: A diagram with three circles in the first column with arrows connecting them vertically to each other and arrows from each of the three circles pointing to the right to connect it to the circle in the second column, one circle in the second column with an arrow pointing to the circle in the third and last column, and one circle in the third and last column. The circles in the first column also have arrows on curved lines indicating reciprocal relationships between the concepts. The concepts in the first column are, top to bottom, attitude toward the behavior, subjective norm, and perceived behavioral control. The concept in the second column is intention, and the concept in the rightmost circle is behavior.]
In many educational settings, as opposed to clinical settings, it is difficult for the educator to ascertain each participant’s stage of change in relation to the topic. Thus, the blend of the TTM and the TPB theories provides a framework well-suited to guide programming designed to be used with diverse audiences. Making Ends Meet for Caregiving programming is designed to promote planning for the caregiver’s financial success by moving participants through consciousness raising, expanding their perceptions and changing their attitudes, and finally empowering them to act. MEMC provokes thought and provides activities to assist caregivers in moving toward more financially secure later-life situations.
The processes of change in Making Ends Meet for Caregiving, and its delivery at the two conference sessions, are as follows:
Consciousness raising increases awareness about the causes, consequences, and cures for a particular problem behavior. The intervention employed to increase awareness is education. At present there are too few educational resources that move caregivers through consciousness raising to resource identification and action. The Making Ends Meet for Caregiving program was designed to help caregivers recognize and self-identify as a caregiver and connect to a shared experience with other attendees through case study discussions and spontaneous sharing of personal experiences. Having established the caregiving role and identified the issues sets the stage to discuss strategies and resources for the caregiver’s improved later-life financial stability.
In the conference sessions the participants moved through affirmation of their caregiving experiences to the realization of the need to concretely quantify direct and indirect costs of caregiving. Consciousness raising helps clients move from precontemplation (no plans of changing) to contemplation (awareness of a problem and consideration of change) and helps participants increase their awareness of the benefits of making a change (Norcorss, Krebs, and Prochaska 2011). MEMC identifies four objectives designed to facilitate consciousness raising. The objectives for the participants are to (1) understand the relationship between caregiving and personal retirement security, (2) recognize how the retirement system compounds caregiving costs, (3) obtain an appreciation for the dollar magnitude (of the loss of wealth), and (4) recognize the limitations of retirement resources.
Some caregivers may have a vague idea about how reducing their engagement in the labor market impacts retirement benefits, and others may not have thought specifically about future implications of reducing work or leaving the labor market altogether. MEMC first creates a relationship with the caregivers by identifying caregiving costs that are cited in the literature as frequently being covered, at least in part, by caregivers. Participants are given an opportunity to share their personal experiences. MEMC then proceeds to convey dollar values of current and future economic losses resulting from curtailed or discontinued employment. People are frequently fuzzy about the value of Social Security benefits, which are an important part of retirement income. MEMC insures that participants understand that Social Security is intended to replace only approximately 30 percent of retirement income needs. Thus it would be unwise to be overly reliant on this source of later life income.
Dramatic relief initially produces emotional experiences followed by reduced negative effect if appropriate action can be taken. The interventions employed included role-playing and personal testimonies. Emotional arousal promotes anticipatory grieving and facing the fear, guilt, or regret that would come from not changing. Self-evaluation sets the stage for thinking about positive images to improve and enact change (Norcross, Krebs, and Prochaska). Making Ends Meet for Caregiving participants had an opportunity to share their personal caregiving experiences. These personal testimonies served to help participants recognize and self-identify as caregivers. They also served to establish social and subjective norms (TPB) through hearing the experiences of others who are in roles similar to their own, thus dispelling any self-devised myths about social expectations for a caregiver’s sentiment about her or his experience.
In a more structured manner, MEMC induces anticipatory grieving through communicating statistics reflecting experiences of women caregivers, such as the fact that they are 2.5 times more likely to live in poverty than non-caregivers (Hounsell 2007). Case study analysis is conducted in small groups with subsequent reporting out to the larger group. Participants discuss a Family Caregiving Decisions Scenario developed by one of the authors based on a real life family experience. The case study presents thought-provoking questions leading to the exploration of several facets of caregiving, including caregiving requirements, options available at the time the caregiving need is identified, future options to meet caregiving needs, an analysis of how the choices will affect each family member, and other prompts. Participant analysis includes the identification of resources for the family. As noted earlier, the small groups report out their strategies and resource ideas. Participants’ sharing of resources can serve to instigate a reevaluation of their perceived behavioral control, which in the TPB is an important element for promoting and accomplishing behavior change. Awareness of resources and exposure to strategies is key to behavior change since behavioral intention can find expression in behavior only if the person can decide whether or not to perform the behavior (Ajzen 1991).
Environmental reevaluation combines both affective and cognitive assessments of how the presence or absence of a personal habit affects one’s social environment. It also can include the awareness that one can serve as a positive or negative role model for others. Nearly all Making Ends Meet for Caregiving participants expressed surprise upon learning about hidden costs in the form of reduced Social Security Income, low or non-existent 401(k) accounts, and lost opportunities for employer contribution match and interest earnings. Of interest to caregivers was the global nature of the prevalence of family caregiving and that an examination of 22 countries found three themes common to most nations, no matter how evolved their policies around caregiving: (1) caregivers feel isolated and fail to self-identify; (2) caregivers need to become more active politically; and (3) there is a need to better understand the role of young caregivers under the age of 18 (Third International Conference on Family Care 2002). Different from most programs targeted to caregivers, MEMC speaks to the social costs of family caregiving to provoke an evaluation of implications broader than individual and family level impacts. Aggregate costs of family caregiving to American society include: one-fifth of workers exiting the workforce, a reduced tax base for Social Security, employers’ cost of replacing workers who quit, employees with high rates of absenteeism, and interruptions to the workday, all of which increase employers’ cost of operation. While caregivers may not be able to dramatically change some of these behaviors, understanding the impact beyond themselves should improve their understanding of an employer’s position and hopefully inform their approach to caregiving responsibilities.
Social liberation requires an increase for social opportunities or alternatives especially for people who are relatively deprived or oppressed. Appropriate policies can produce increased opportunities. An important part of Making Ends Meet for Caregiving programming is an increased understanding of the various sources of retirement income, the factors affecting the amount of retirement income available, and easy-to-use tools to help individuals put together disparate resources for a more comprehensive view of their entire set of retirement resources. The MEMC programming advances these goals through sharing financial planning resources as part of a discussion of Social Security Income, the characteristics of defined contribution and defined benefit retirement plans, and the use of the Ballpark E$timate (American Savings Education Council). The Ballpark E$timate is a worksheet that provides an estimate of future retirement resources needed and annual savings required to accomplish an individual’s retirement goal, say a retirement income at 80 percent of current income. The Ballpark E$timate incorporates current retirement account balances, regular contributions, and projected Social Security Income benefits to arrive at an estimated value of needed additional annual savings.
Self-reevaluation combines both cognitive and affective assessments of one’s self-image with and without a particular unhealthy habit, such as one’s image as a couch potato or an active person. Value clarification, healthy role models, and imagery are techniques that can move people through evaluation. Making Ends Meet for Caregiving promotes reflection and identification of new strategies and resources useful for improving financial outcomes for the caregiver. Participants report on new ideas or tips gleaned from their small group and what MEMC information or strategies they employed to solve the Family Caregiving Decsions Scenario. More importantly, participants are asked specifically about their plans for implementation. Questions posed include “What information from this presentation will you use or share with someone you know who is a caregiver?” “How will you use information from this presentation,” and “What policy changes would you suggest (to better support family caregivers)?”
Helping relationships combine caring, trust, openness, and acceptance as well as support for the healthy behavior change. Rapport building, a therapeutic alliance, counselor calls, and buddy systems can be sources of social support. While it is not possible to establish long-term supportive relationships with program attendees, Making Ends Meet for Caregiving recognizes caregivers’ current need for helping relationships. To meet this need, MEMC recommends that the caregiver assess her/his own and the care recipient’s situation as a precursor to establishing relationships with support service organizations. Caregivers are advised to attend to their own financial security and to consider seeking the advice of a financial planner.
Counter conditioning requires the learning of healthier behaviors that can substitute for problem behaviors. Caregivers, possibly due to stress and time constraints, tend to access their personal resources to provide supplemental financial assistance for meeting the needs of the care recipient (Hounsell 2007). Using personal financial resources first is a problem behavior contributing to later-life financial insecurity for the caregiver. A counter behavior is for caregivers to be intentional about protecting their personal financial resources while seeking to supplement the financial resources of the care recipient. Struggling family caregivers need to tap into all the available resources to help with caring for their family member before they deplete their own savings and potentially harm their retirement incomes.
Making Ends Meet for Caregiving promotes healthier behaviors such as creating a budget for the caregiver’s family, as well as for the family member for whom they are providing care. This includes identifying assets and resources the individual and the family have to use for caregiving and identifying the community resources available to provide assistance with transportation, meals, assistance with daily living, and so on. For example, assistance may be available from food pantries, churches, and other non-profits. Physicians and social service agencies can provide recommendations for some services. MEMC encourages participants to access any government assistance for which the family member qualifies. The focus of the counter conditioning behavior is to prompt the caregiver to take precautions to protect his or her own physical, mental, and financial health.
Reinforcement management provides consequences for taking steps in a particular direction. While reinforcement management can include the use of punishments, self-changers can rely on rewards much more than punishments.
Reinforcement management is expected to occur over time as Making Ends Meet for Caregiving participants experience positive outcomes. With a heightened awareness of the consequences of employing or not employing certain practices, MEMC participants are anticipated to recognize the current and future economic value of implementing strategies that facilitate caregiving while protecting their personal financial resources. They will feel more positively about accessing resources and feel a greater sense of control of their financial future as they strategize for their own later-life financial security.
Self-liberation is both the belief that one can change and the commitment and recommitment to act on that belief. New Year’s resolutions, public testimonies, and multiple, rather than single, choices can enhance self-liberation, or what the public calls “willpower.” The sharing of personal caregiving experiences sets the stage for self-liberation as participants disabuse themselves of misconceptions about social norms and gain an appreciation for the fact that many others are facing and managing similar challenges. The public testimonies and sharing of strategies expands each participant’s choice set as they learn of “tried and true” strategies from others who are similarly situated. In addition, Making Ends Meet for Caregiving delineates actions that participants can take to improve their future, such as regularly contributing to an employer-sponsored 401(k) and maximizing employer matches. Other important choices include taking care of their own health, planning for their own long-term care needs, and critically thinking issues through before reducing hours or leaving the workforce to provide care. Tapping all available community, family, and government resources before sacrificing personal income needed for daily living expenses and other needs/obligations, as well as for retirement savings, is also important (Hounsell 2007).
While programming on the costs of caregiving and retirement preparation cannot change the history for the baby boomers or the characteristics of women’s labor force participation, it can promote better planning within a known context for their improved later-life security outcomes. This model has shown, at two conferences, that it can lead participants through consciousness raising, expand their perceptions, change their attitudes, and finally empower them to act. This model is the first of its kind to help caregivers strategize to better their financial management of their current caregiving responsibilities and protect their own financial futures. Making Ends Meet for Caregiving provides an important tool to assist caregivers in their quest for balance between caring for others and caring for self. MEMC blends two powerful behavior change theories, TTM and TPB, to effectively reach caregivers at whatever their current stage of change might be. Making Ends Meet for Caregiving coaches caregivers through the processes of change while leveraging the power of behavioral intention and imparting accessible strategies for action. This education model assists caregivers in strategizing for their own later-life financial success.
Ajzen, Icek.1991. “The theory of planned behavior.” Organizational Behavior and Human Decision Processes 50(17):9-21.
American Savings Education Council. n.d. The Ballpark E$timate. Retrieve at http://www.choosetosave.org/ballpark
Bird, Carolyn L., and Ann A. Berry. 2012. “The effects of the economics on caregivers.” The Forum for Family and Consumer Issues, Vol(16). Available at http://www.ncsu.edu/ffci
Bird, Carolyn L., and Jacquelyn McClelland. 2010. “Practical application of theory-driven intervention to extension programming.” Journal of Extension 48:6. http://www.joe.org/joe/2010december/a4.php
Cancer Prevention Research Center, University of Rhode Island. n.d. Transtheoretical Processes of Change. http://www.uri.edu/research/cprc/TTM/ProcessesOfChange.htm
Feinberg, Lynn, Susan Reinhard, Ari Houser, and Rita Choula. 2011. “Valuing the invaluable: 2011 update the growing contributions and costs of family caregiving.” AARP Public Policy Institute. http://assets.aarp.org/rgcenter/ppi/ltc/i51-caregiving.pdf
Hounsell, Cindy. 2007. “Key economic trends: Baby boomer caregivers and retirement security.” In Family Caregiving: State of the Art, Future Trends. Family Caregiver Alliance Conference Proceedings, 20-23. Chicago: Women’s Institute for a Secure Retirement.
MetLife Mature Market Institute (2011, June). Caregiving costs to working caregivers: Double jeopardy for Baby Boomers Caring for their parents. Available at http: http://www.MatureMarketInstitute.com.
Norcross, John, Paul Krebs, and James Prochaska. 2011. “Stages of change.” Journal of Clinical Psychology 67(2):143-154.
Prochaska, James, Carlo DiClimente, and John Norcross. 1992. “In search of how people change.” American Psychologist 47:1102-1114.
Third International Conference on Family Care. 2002. Conference Report. Washington, DC. http://www.caregiving.org/data/conferencereport.pdf