An international systematic review of dementia caregiving interventions for Chinese families

Can Occupation-Based Interventions for People Living with Dementia and Their Spousal Caregivers Support Positive Aspects of Caregiving? A Scoping Review

This scoping review aimed to explore the characteristics and outcomes of occupation-based interventions for people living with dementia and their spousal caregivers relating to positive aspects of caregiving. A conceptualization of positive aspects of caregiving was developed based on the existing literature encompassing three domains - quality of the caregiver/care receiver relationship, meaning of the caregiver's role in daily life, and caregiver's feeling of accomplishment. Arksey and O'Malley's guidelines were used and four databases were searched to identify studies discussing occupation-based interventions involving spousal caregivers and persons living with dementia in the community that addressed at least one of three domains of positive aspects of caregiving identified in our conceptualization. After screening 1,560 articles, 18 articles were included for analysis. Three types of interventions were identified (i.e. music therapy, reminiscence therapy and a tailored activity program) involving three components contributing to positive aspects of caregiving: socializing outside the dyad, producing tangible end products, and education for the caregiver or dyad. Findings indicate that occupation-based interventions can support positive experiences for the dyad by improving the quality of the dyadic relationship and caregivers' feelings of accomplishment.

'It's a lonely journey': caregiving experiences and psychosocial distress among Chinese American dementia family caregivers

OBJECTIVES

Chinese American family caregivers of persons with Alzheimer's disease and related dementia (ADRD) are a vulnerable but understudied population. The goal of this qualitative study was to examine their caregiving experiences and psychosocial distress process and explore intervention strategies.

METHODS

In-depth individual interviews were conducted with 18 Chinese American dementia caregivers. All interviews were transcribed verbatim; thematic content analysis was conducted to construct a conceptual framework.

RESULTS

All participants reported high levels of caregiving stress associated with care-recipients' advanced symptoms and required assistance in activities in daily living. The relationship of caregiver and care-recipient was strained in their roles transition. The complex healthcare system, insurance policies, and a lack of linguistically appropriate services aggravated their psychosocial distress. Chinese cultural norms on 'family harmony' hindered their seeking of social support. Prolonged caregiving stress led to physical and mental impairment, including poor sleep, depression, and chronic conditions. Participants described their caregiving experience as 'a lonely journey' with a pervasive sense of hopelessness and withdrawal; their distress process was positively or negatively influenced by their coping strategies. All participants were eager for any kind of support; especially culturally appropriate programs that could improve their caregiving skills, self-care, and access to services.

CONCLUSION

Our data suggest that Chinese American dementia caregivers, especially those with limited English proficiency, experience elevated psychosocial distress, which was aggravated by the barriers to social support and health services due to their immigrant and minority status. Culturally appropriate targeted intervention is urgently needed for this underserved and vulnerable population.

Chinese-Australian carers' perceived needs and preferences in planning to embed an iSupport for Dementia program in aged care services

OBJECTIVE

To assess Chinese-Australian carers' needs and preferences through co-design strategies with stakeholders to embed an evidence-based iSupport for Dementia program into routine community aged care services in Chinese ethno-specific aged care organisations.

METHODS

A cross-sectional survey was conducted from July to August 2022 in three Chinese ethno-specific aged care organisations in Australia. We applied a univariate analysis to test variables associated with carers' needs and preferences when embedding the iSupport for Dementia program into routine practice among community aged care services.

RESULTS

A total of 101 carers completed the survey. Most carers in our study preferred the iSupport program to be provided in their first language, have a program facilitator to lead the program and would like to interact with peers in the program. Most carers indicated that they are willing to pay for the iSupport program using the budget allocated to their home care package. Younger carers (younger than 65 years), and adult children's carers are more likely to use the web-based iSupport manual and invite their family members to the program compared to those older than 65 years. Other demographic characteristics had no significant association with their needs and preferences.

CONCLUSIONS

Chinese-Australian carers' perceived needs and preferences in this study will inform the implementation of a culturally tailored iSupport program to be embedded in community aged care services provided by Chinese ethno-specific aged care organisations. Findings will also inform culturally and linguistically congruent iSupport programs for carers from other culturally and linguistically diverse communities in Australia.

A WeChat-based Intervention, Wellness Enhancement for Caregivers (WECARE), for Chinese American Dementia Caregivers: Pilot Assessment of Feasibility, Acceptability, and Preliminary Efficacy

BACKGROUND

Chinese American family caregivers of persons with dementia experience high rates of psychosocial distress and adverse health outcomes. Due to their immigrant and minority status, they face substantial obstacles to care and support, including stigma and misperception of dementia, limited knowledge and use of welfare and services, and poor social support. Few interventions have been developed or tested for this vulnerable population.

OBJECTIVE

This study aims to pilot-test the Wellness Enhancement for Caregivers (WECARE) intervention, a culturally tailored program delivered via WeChat, a social media app highly popular in the Chinese population. The 7-week WECARE was designed specifically for Chinese American dementia caregivers to improve their caregiving skills, reduce stress, and enhance psychosocial well-being. Feasibility, acceptability, and preliminary efficacy of the WECARE were assessed in this pilot.

METHODS

A total of 24 Chinese American family caregivers of persons with dementia were recruited for a pre-post 1-arm trial of the WECARE. By subscribing to the WECARE official account, participants received interactive multimedia programs on their WeChat account multiple times a week for 7 weeks. A backend database automatically delivered program components and tracked user activities. Three online group meetings were organized to facilitate social networking. Participants completed a baseline and a follow-up survey. Feasibility was assessed by the follow-up rate and curriculum completion rate; acceptability was assessed by user satisfaction and perceived usefulness of the program; and efficacy was assessed with pre-post differences in 2 primary outcomes of depressive symptoms and caregiving burden.

RESULTS

The intervention was completed by 23 participants with a retention rate of 96%. Most of them (n=20, 83%) were older than 50 years and the majority (n=17, 71%) were female. The backend database revealed that the mean curriculum completion rate was 67%. Participants also reported high rates of user satisfaction and perceived usefulness of the intervention and high ratings of weekly programs. The intervention led to significant improvement in participants' psychosocial health outcomes; their depressive symptoms reduced from 5.74 to 3.35 with an effect size of -0.89 and caregiving burden decreased from 25.78 to 21.96 with an effect size of -0.48.

CONCLUSIONS

This pilot study suggests that WeChat-based WECARE intervention was feasible and acceptable; it also demonstrated initial efficacy in improving psychosocial well-being in Chinese American dementia caregivers. Further research with a control group is needed to assess its efficacy and effectiveness. The study highlights the need for more culturally appropriate mobile health interventions for Chinese American family caregivers of persons with dementia.

Cultural differences in caring for people with dementia: a pilot study of concern about losing face and loneliness in Chinese American and European American caregivers

OBJECTIVES

Heavy demands upon dementia caregivers can lead to a number of poor health outcomes including declines in physical, mental, and brain health. Although dementia affects people from all backgrounds, research in the US has largely focused on European American caregivers. This has made providing culturally-competent care more difficult. This study begins to address this issue by empirically examining how culturally-shaped beliefs can influence loneliness in family caregivers of people with dementia.

METHODS

We conducted a preliminary questionnaire study with Chinese American and European American family caregivers of people with dementia (N = 72).

RESULTS

Chinese American caregivers were more concerned than European American caregivers about losing face, which in turn, was associated with greater loneliness. This pattern remained when accounting for caregiver gender, age, and relationship to the person with dementia.

CONCLUSIONS

These preliminary findings highlight the role that cultural beliefs can play in adverse caregiver outcomes, and suggest that addressing concerns about losing face may be an important way for healthcare providers to help reduce loneliness among Chinese American caregivers.

CLINICAL IMPLICATIONS

Understanding how cultural beliefs influence caregiver outcomes is critical as healthcare professionals work to provide culturally-competent care and design culturally-sensitive interventions.

Cultural adaptation of the savvy caregiver program for Korean Americans with limited English proficiency: a feasibility and acceptability study

Background

Limited English proficiency (LEP) of dementia caregivers poses a critical barrier to these caregivers’ access to evidence-based interventions. In an effort to make such interventions available and accessible to dementia caregivers with LEP, in the present study we use Barrera and colleagues’ (2011) three-step model of cultural adaptation: (1) information gathering, (2) preliminary adaptation, and (3) full adaptation. Selecting Korean Americans as a target group and the Savvy Caregiver Program (SCP) as a target intervention, we demonstrate the sequential process of cultural adaption and report the outcomes on feasibility and acceptability.

Methods

Preliminary adaptation with linguistic attunement was conducted by translating the SCP manual into Korean and certifying two lay individuals who were bilingual in English and Korean as Savvy trainers. The 6-week online SCP program was delivered by the two trainers in Korean with six to seven caregiver participants per trainer (N = 13). Feasibility and acceptability of the SCP for both caregiver participants and trainers were assessed using mixed methods, and their data then informed full adaptation.

Results

Findings not only showed the initial efficacy of the linguistically attuned SCP but also suggested areas for further modification. Data-driven assessment yielded a list of recommended changes for full adaptation, which was reviewed by the SCP developer to ensure fidelity and by community and research partners to confirm contextual and cultural relevance.

Conclusions

The adopted changes are broadly summarized as representing logistical, technical, and cultural issues. Given our refined set of educational materials and implementation guidelines, we discuss future directions for research and development.

A Social Media-Based Intervention for Chinese American Caregivers of Persons With Dementia: Protocol Development

BACKGROUND

Racial/ethnic minority and immigrant caregivers of persons with dementia experience high rates of psychosocial stress and adverse health outcomes. Few culturally tailored mobile health (mHealth) programs were designed for these vulnerable populations.

OBJECTIVE

This study reports the development of a culturally tailored mHealth program called Wellness Enhancement for Caregivers (WECARE) to improve caregiving skills, reduce distress, and improve the psychosocial well-being of Chinese American family caregivers of persons with dementia.

METHODS

Community-based user-centered design principles were applied in the program development. First, the structure and curriculum of the WECARE program were crafted based on existing evidence-based interventions for caregivers with input from 4 experts. Second, through working closely with 8 stakeholders, we culturally adapted evidence-based programs into multimedia program components. Lastly, 5 target users tested the initial WECARE program; their experience and feedback were used to further refine the program.

RESULTS

The resulting WECARE is a 7-week mHealth program delivered via WeChat, a social media app highly popular in Chinese Americans. By subscribing to the official WECARE account, users can receive 6 interactive multimedia articles pushed to their WeChat accounts each week for 7 weeks. The 7 major themes include (1) facts of dementia and caregiving; (2) the enhancement of caregiving skills; (3) effective communication with health care providers, care partners, and family members; (4) problem-solving skills for caregiving stress management; (5) stress reduction and depression prevention; (6) the practice of self-care and health behaviors; and (7) social support and available resources. Users also have the option of joining group chats for peer support. The WECARE program also includes a back-end database that manages intervention delivery and tracks user engagement.

CONCLUSIONS

The WECARE program represents one of the first culturally tailored social media-based interventions for Chinese American caregivers of persons with dementia. It demonstrates the use of community-based user-centered design principles in developing an mHealth intervention program in underserved communities. We call for more cultural adaptation and development of mHealth interventions for immigrant and racial/ethnic minority caregivers of persons with dementia.

Cultural adaptation of World Health Organization iSupport for Dementia program for Chinese-Australian caregivers

BACKGROUND

Home-based dementia care is common in the Chinese-Australian community. However, dementia education programs for Chinese-Australians in the language of their choice are scarce. The World Health Organization has developed iSupport for Dementia, an online education program for informal caregivers. Cultural adaptation of the program for Chinese-Australian caregivers is an opportunity to address this gap in caregiver support.

AIM

The aims of the study were (1) to understand stakeholders' perspectives on the cultural and linguistic appropriateness of the Chinese iSupport for Dementia content and design and (2) to explore factors affecting the future implementation of the Chinese iSupport program in Australia.

METHODS

A qualitative descriptive design was applied to address the aims of the study. Focus group discussions with Chinese-Australian caregivers and community aged care workers were conducted to collect data. Thematic analysis was used to analyse data.

RESULTS

In total, six focus groups were conducted with 18 Chinese-Australian caregivers and 17 care workers. Six themes were identified and described as follows: (1) appropriateness of the Chinese iSupport content; (2) acceptability of the online Chinese iSupport design; (3) motivations to engage in the iSupport program; (4) desire to interact with peers and professional facilitators; (5) concerns about program accessibility; and (6) the need to extend the iSupport program to care workers.

CONCLUSIONS

Engagement with Chinese-Australian caregivers and care workers will inform further revisions of the Chinese iSupport program contents to ensure the program is culturally congruent to Chinese-Australian caregivers. Factors affecting the implementation of the program identified in the study will be considered in the intervention phase of the program.

A nurse-led multicentre randomized controlled trial on effectiveness and cost-effectiveness of Chinese iSupport for dementia program: A study protocol

AIMS

To describe a nurse-led multicentre randomized controlled trial protocol developed to evaluate the effectiveness and cost-effectiveness of a Chinese iSupport for Dementia program in Australia and Greater China including mainland China, Taiwan, Hong Kong and Macau.

DESIGN

A multicentre randomized controlled trial following the SPIRIT checklist.

METHODS

Participants in the study will be recruited from Australia and Greater China and will be randomly assigned to the intervention group or the usual care group. Interventions will include self-learning of the iSupport program, virtual peer support and nurse program facilitator support for 6 months. Primary outcome measures will be the 12-Item Short-Form Health Survey. Secondary outcome measures will include: Revised Scale for Caregiving Self-efficacy; Quality of Social Support Scale; Revised Memory and Behaviour Problem Checklist; the Quality of Life in Alzheimer's Disease-Proxy; usages of care services; and cost-effectiveness of the intervention. Outcomes will be measured at baseline, 6 months and 9 months from the baseline. Caregivers' experiences of the peer support will be explored. This project was funded by the National Foundation for Australia-China Relations, Australian Government (Project ID: NFACR216). The total amount is $440,000 Australian dollars (or £ 236,231).

DISCUSSION

Approximately, 20% of people living with dementia in the world live in Australia and Greater China. Older Chinese are usually cared for by family caregivers at home due to the influence of Confucianism. However, free and online psychoeducation programs for this large cohort of caregivers are not available or accessible. The World Health Organization iSupport for Dementia is an evidence-based online psychoeducation program for caregivers. Implementing a culturally adapted Chinese iSupport program will address this gap in supporting caregivers.

IMPACT

This study will provide research evidence on effectiveness and cost-effectiveness of an online psychoeducation program for caregivers. Findings will inform policy and practice development.

The early stages of caregiving: A qualitative study into the caregiving experiences of Asian family caregivers of persons with newly-diagnosed dementia

In Asian societies, the responsibility of caring for persons with dementia often falls upon an immediate family member. However, little attention has been paid to the early stages of caregiving, as well as their transition into a more experienced caregiver. Thus, a qualitative descriptive study involving a purposive sample of 11 main family caregivers of a person with newly diagnosed dementia was recruited from a tertiary hospital in Singapore. Three themes emerged from the data analysis: (1) Suspicions to seeking confirmation of dementia, (2) Grappling with dementia diagnosis, and (3) Making adjustments for the future. Areas of needs and support identified during the early caregiving journey suggest the need for caregivers to be prepared for the practical and emotional challenges. Unique to the Asian culture, our findings put forth the advocacy of engaging persons with dementia in the discussions of their long-term care and options.

The Impact of Structural Inequities on Older Asian Americans During COVID-19

Structural racism manifests as an historical and continued invisibility of Asian Americans, whose experiences of disparities and diverse needs are omitted in research, data, and policy. During the pandemic, this invisibility intersects with rising anti-Asian violence and other persistent structural inequities that contribute to higher COVID-19 mortality in older Asian Americans compared to non-Hispanic whites. This perspective describes how structural inequities in social determinants of health-namely immigration, language and telehealth access, and economic conditions-lead to increased COVID-19 mortality and barriers to care among older Asian Americans. Specifically, we discuss how the historically racialized immigration system has patterned older Asian immigrant subpopulations into working in frontline essential occupations with high COVID-19 exposure. The threat of "public charge" rule has also prevented Asian immigrants from receiving eligible public assistance including COVID-19 testing and vaccination programs. We highlight the language diversity among older Asian Americans and how language access remains unaddressed in clinical and non-clinical services and creates barriers to routine and COVID-19 related care, particularly in geographic regions with small Asian American populations. We discuss the economic insecurity of older Asian immigrants and how co-residence in multigenerational homes has exposed them to greater risk of coronavirus transmission. Using an intersectionality-informed approach to address structural inequities, we recommend the disaggregation of racial/ethnic data, meaningful inclusion of older Asian Americans in research and policy, and equitable investment in community and multi-sectoral partnerships to improve health and wellbeing of older Asian Americans.

Finding a balance in family caregiving for people with dementia: A correlational longitudinal study

AIMS

The "Finding a Balance Point" framework was used to explore the caregiving process over time for family caregivers of people with dementia in Taiwan. This study aimed to: (a) identify Taiwanese caregivers' different balance trajectories; (b) explore predictors of trajectory group membership; and (c) examine associations of different balance trajectories with caregiving outcomes.

DESIGN

A correlational longitudinal design was used.

METHODS

Data were collected from 200 family caregivers' self-completed questionnaires and they were followed over 2 years (June 2015-May 2017). Discrete balance trajectories were identified by group-based trajectory modelling. Predictors of trajectory group membership were identified from potential predictors of caregiving characteristics and caregiving factors using multivariate logistic regression. Associations of trajectory groups with caregiving outcomes (depressive symptoms and health-related quality of life) were explored using the generalized estimating equation.

RESULTS

Balance trajectories best fit a two-group trajectory model (poor and good). Caregivers with a poor sense of balance between competing needs were more likely to have more depressive symptoms (b = 11.71, 95% CI [9.04, 14.38], p < .001), worse physical health (b = -6.22, 95% CI [-8.71, -3.74], p < .001), and worse mental health (b = -11.1, 95% CI [-13.58, -8.63], p < .001) than caregivers with a good sense of balance. Caregivers experiencing lower role strain (b = -1.45, SE = 0.48, p = .003) or higher predictability (b = 2.83, SE = 0.76, p < .001) were more likely to belong to the good-balance group.

CONCLUSIONS

Caregivers with poor balance between competing needs are more likely to have worse caregiving outcomes. Role strain and predictability significantly predicted balance trajectory groups. Family caregivers with lower caregiving task difficulty and/or better knowledge of the care receiver were more likely to be in the good balance trajectory group.

IMPACT

Our findings support the framework, "Finding a Balance Point," and clarify the family caregiving process for people with dementia. This framework could be used to tailor interventions for home care nurses to improve family caregivers' caregiving outcomes.