Namkoong, K., DuBenske, L.L., Shaw, B.R., Gustafson, D.H., Hawkins, R.P., Shah, D.V., . . . Cleary, J.F. (2012). Creating a bond between caregivers online: Effect on caregivers' coping strategies. Journal of Health Communication, 17, 125–140.

To evaluate the effects of bonding experience among caregivers of patients with advanced lung cancer while participating in a structured, Internet-based education, communication, and coping skill-building program on caregiver coping strategies. (The main study results on caregiver quality of life and mood associated with this program were presented in 2010 by DuBenske et al. at the International Psyco-Oncology Society in Quebec.)

Patient and caregiver pairs were randomized to participate in the Comprehensive Health Enhancement Support System (CHESS), an Internet-based program incorporating an asynchronous support group, education, communication, and coping skill instruction (“Coping With Lung Cancer: A Network of Support” module), or a control group able to access the Internet freely and provided with several reputable websites on lung cancer.

• The sample was comprised of 285 patient–caregiver dyads (104 completed).    
• Caregiver mean age was 55.56 years, with a range of 18–84 years.
• The sample was 31.7% male and 68.3% female.  
• Patients were diagnosed with stage IIIA/B or IV lung cancer, with clinician-estimated prognosis of four+ months to live.
• Patients were recruited between January 2005 and April 2007.

• Multisite
• Home setting
• Four cancer centers located in the northeastern, midwestern, and southwestern United States

Mutliple phases of care

A randomized controlled trial design was used, with attentional control of provision of Internet sites for the control group.

• Bonding  was measured using a five-item Likert-type scale developed and validated previously by the investigators.
• Three domains were selected from Carver’s (1997) Brief COPE tool: (a) active coping, (b) positive reframing, and (c) instrumental support.

This paper focused on the effect of bonding among the caregiver participants in the CHESS group on coping. A mediating effect was noted using structural equation modeling, with the caregiver-perceived bonding with other group members positively associated with the three coping domains (active coping: β = 0.26, p < 0.05; positive reframing: β = 0.20, p < 0.05; instrumental support: β = 0.32, p < 0.01). Other variables such as age, gender, education level, caregiver comfort with the Internet at study entry, and baseline bonding and coping scores were not significant in the model. The report does not provide data on differences in outcomes between groups; it only cites a prior presentation of these findings that are apparently not yet published.

Caregivers of patients with lung cancer that participated in the CHESS program perceived increased levels of human bonding within their group, and this effect was related to coping.

• The study had a risk of bias (sample characteristics).*
• Selective outcomes reporting occurred.*
• Subject withdrawal was ≥ 10%.
• * Study eligibility relied on subjective clinician prognostication of survival; whether bias might have been introduced during the selection period is unknown. This paper did not report the full study intervention description and overall findings, potentially limiting interpretation of the overall context. Of 325 dyads enrolled, 40 withdrew prior to pretest and 39 withdrew prior to intervention start (4 due to patient deaths). Only 104 caregivers completed the six-month instruments from which the main study and this paper’s conclusions were based.

This study illustrated that caregiver and patient participation in an Internet-based, self-paced support, educational, and coping program with a consistent group of peers facilitated human bonding with those in a similar situation, which apparently enhanced quality of life (per a reference to the results of the main study) and positive coping. It is valuable for nurses to encourage caregivers to engage in such a program where they can seek support, receive and share information, and be coached through communication skill-building from home at a time of their choosing. Because of the high attrition rate noted, it appears that more work to understand how to keep participants engaged over time for maximum benefit is needed.