The study findings suggest that the Living with Hope Program shows promise in increasing hope in rural women caregivers of persons with advanced cancer after one week compared to baseline scores.
Several hope focused interventions have been found to be effective in fostering hope in other populations such as persons with advanced cancer , recurrent cancer  and newly diagnosed cancer patients . A recent review of intervention studies for caregivers of persons with cancer, however, did not identify any psychosocial hope focused interventions . Thus the Living with Hope Program is unique and may address this gap in knowledge. Changes in the hope score occurred at day 7 and 12 months. Although the sample size was small, there is the possibility that the Living with Hope Program has a short effect and does not have an impact over time. In Herth’s  evaluation of a hope intervention for persons with recurrent cancer, there were significant positive changes in hope and quality of life over time (3, 6 and 12 months). Herth’s intervention consisted of eight two hour hope focused interventions with a skilled health care professional over an eight week time period. This type of intervention would not be feasible for rural caregivers actively caring for persons with advanced cancer at home. Herth’s results, however, suggested that a hope intervention may have longitudinal effects. More research is needed with larger sample sizes and possibly viewing the film more than once and extending the journaling exercise of the Living with Hope Program over time.
The testing of the model suggests that the possible mechanism by which the Living with Hope Program increases hope was through increasing feelings of self –efficacy (confidence in the ability to deal with difficult situations) and decreased feelings of loss and grief. The model also suggested that hope predicted mental health summary scores. This hypothesis was supported in the data. Loss and grief were also predictors of mental health summary scores. The qualitative data from the journals supported this finding, with participants, suggesting that the Living with Hope Program helped them to address their fears and find the positive in their situation. The model representing the mechanisms through which the Living with Hope Program was effective was revised based on these findings.
The model did not include demographic variables and physical health as there were no statistically significant associations found among the demographic variables with the main variables and no significant changes over time in participants’ physical health summary scores. Of concern in this study is the negative relationship of general self-efficacy and hope with physical health summary scores and the positive loss and grief relationship. Two other studies have reported unexplainable relationships with the SF-12 physical health summary scores and other psychological measures [39, 40]. These authors suggest that SF-12 physical health summary scores does not correlate with psychological measures. As a result, these results were not added to the revised model. Future studies should use more valid and reliable quality of life measures.
The physical and mental health summary scores clearly indicate the poor physical and mental health of the participants. Although research studies have established the impact of family caregiving on caregivers and rural Canadians have reported poorer health status than their urban counterparts , this is the first study to compare their health to population norms. Physical and mental health scores using the SF-12v2 compared to normative population scores in the United States, suggest that the participants’ physical and mental health were well below population norms (at the 25 percentile or less). These findings underscore the need to monitor the effects of caregiving on rural caregivers’ physical and mental health and for practical support of rural women caregivers of persons with advanced cancer. Fostering their inner resource of hope is only one mechanism to achieve that goal.
There are several limitations to this study that include study design and sample characteristics. A quasi-experimental time series design compares changes, not to a control group, but rather to the participants themselves. As well, it does not involve randomization. The design was chosen based on its suitability to the study purpose and the nature of the population. Harding and Higginson , in a systematic review of interventions in palliative care suggested that interventions should be evaluated using repeated measures from baseline and that ideal randomized controlled trials may be inappropriate. These design recommendations were supported by Grande and Todd  following their review of randomized control trials in palliative care research. Grande and Todd also recommended using mixed method designs (quantitative and qualitative) to improve interpretation of the results.
The small sample size reflected the difficulties in accessing and recruiting potential participants. The findings specific to the low physical and mental health scores of the participants, provide insight as to why recruitment was difficult. In a qualitative study of rural caregivers of family members with advanced disease, the participants described the multiple significant transitions they experienced in caring for their family member . These included significant changes in their own physical and mental health. It is difficult then for rural women caregivers, who were dealing with their own health issues as well as trying to provide the care to their family member with advanced cancer, to take on the burden of participating in a research study. The small sample size does limit the generalizability of the findings. However, in spite of the small sample size, there were significant study results, suggesting that the Living with Hope Program shows promise in increasing feelings of self-efficacy, decreasing loss and grief and increasing hope in this high-risk population.