Titler, M.G., Visovatti, M.A., Shuman, C., Ellis, K.R., Banerjee, T., Dockham, B., . . . Northouse, L. (2017). Effectiveness of implementing a dyadic psychoeducational intervention for cancer patients and family caregivers. Supportive Care in Cancer, 25, 3395–3406.

To test FOCUS, which is an evidence-based psychoeducational intervention, in terms of its feasibility, cost, and program satisfaction and assess its impact on patients' and caregivers' emotional distress and QOL as primary outcomes and benefits of illness, self-efficacy, and dyadic communication as secondary outcomes in two community service centers.

FOCUS is a psychoeducational intervention that is delivered to dyads of patients and their caregivers and addresses the following components: family involvement, optimistic attitude, coping effectiveness, uncertainty reduction, and symptom management. The components cover 104 activities relevant to the components in five sessions. The FOCUS program was administered by a trained social worker in one site and a family therapist in the second site. FOCUS was administered in a group format (3 to 4 dyads) and involved five weekly face-to-face sessions; each was two hours. 11 five-session programs were given over 12 months. The program implementation was guided by the Translating Research into Practice model; a one-day training program was held for the site directors and facilitators and they were given training manuals that were developed based on their role. Pre-packaged material to implement the five-week sessions were provided, weekly calls between program facilitators took place, and monthly meetings occurred between investigators.

• N = 36 dyads, 36 caregivers
• AGE: 55.9 years (SD = 15.1)
• MALES: 44.4%  
• FEMALES: 55.6%
• KEY DISEASE CHARACTERISTICS: Any cancer type, including advanced cancer, currently on treatment, or completed treatment in the past 18 months
• OTHER KEY SAMPLE CHARACTERISTICS: English-speaking only; married/partnered, largely Caucasian, with college degrees, and employed with moderate incomes, mostly caring for patients with stage II or IV cancer in current treatment

• SITE: Multi-site   
• SETTING TYPE: Other; local cancer support community. The CSC is a large network of community agencies in the United States that provide professional psychosocial care in a group format at no cost to patients with cancer and their caregivers.
• LOCATION: Cincinnati, Ohio and Santa Monica, California

PHASE OF CARE: Multiple phases of care

Pre-/postintervention design. Outcomes were assessed prior to the first intervention session and after the last session at week 5 postintervention. Translating research into practice model was used to implement the intervention in the two sites.

Primary outcomes:

• Cancer Support Distress Scale (CSSD) to assess emotional distress
• Functional Assessment of Cancer Treatment-General (FACT-G) to assess QOL

Secondary outcomes:

• Benefits of illness Scale to assess caregivers’ perceived benefits
• Lewis’ Cancer Self-efficacy Scale (CASE) to assess confidence to manage cancer
• Lewis’ Mutuality and Interpersonal Sensitivity Scale (MIS) to assess communication about cancer between patient and caregiver

Feasibility, satisfaction with program, and cost were also assessed. Feasibility was assessed by enrollment, retention, and intervention fidelity rates. Satisfaction was assessed by the FOCUS satisfaction instrument. Cost was assessed by multiplying hourly time estimates and median hourly wages for healthcare social workers in California and Ohio based on the U.S. Bureau of Labor statistics.

• Primary outcomes: FOCUS had significant positive effects on dyad (both caregiver and patient) QOL (p = 0.014), emotional well-being (p = 0.12), functional well-being (p = 0.049), and emotional distress (p = 0.002), but not on physical and social well-being. 
• Secondary outcomes: FOCUS has significant effect on benefits of illness (p = 0.13) and self-efficacy (p = 0.001), but not on dyadic communication. 
• Feasibility: FOCUS intervention program was feasible (enrollment rate 71.4% and retention rate 90%, intervention fidelity 85%).
• Satisfaction: High satisfaction among caregivers about helpfulness of intervention, length of sessions, and number of sessions. 
• Cost: Average cost estimates for oversight and delivery of one five-session FOCUS program with four dyads was $669.45 ($722.17 in California and $577.42 in Ohio).

In CSC, FOCUS intervention five-session, social-worker driven program is effective in improving caregivers’ (and patients’) outcomes. FOCUS appears to be feasible and acceptable with reasonable costs.

• Small sample (< 100)
• Risk of bias (no control group). 
• Risk of bias (sample characteristics)
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: Administered by trained social worker/family therapist, not a nurse; nurses could be trained. Results reported as “a dyad,” not CG-specific. Authors justified no control group because three prior RCTs demonstrated efficacy of FOCUS and all showed significant positive impact.

FOCUS is an effective psychoeducational intervention that can be administered by someone trained on the intervention and can be administered successfully in CSC.