Culturally tailored therapeutic interventions for people affected by dementia: a systematic review and new conceptual model

Meaning-making of dementia caregiving: A systematic review of qualitative studies

BACKGROUND

Being the backbone of informal care for people living with dementia, caregivers suffer overwhelming physical and psychological challenges in their daily caregiving experience. Proactive coping strategies to alleviate the caregiving burden are of utmost importance. Meaning-making emerges as an effective coping approach to benefit caregivers and mitigate their care burden. However, the conceptualisation of meaning-making on its dimensions and process has been ambiguously identified.

OBJECTIVES

To synthesise the qualitative research evidence on meaning-making in a dementia context to identify: (1) the situational dimension in making sense of caregiving scenarios, and (2) how the meaning-making process evolves during dementia caregiving.

METHODS

This systematic review identified 62 qualitative studies published between 1969 and 2022 from the major databases. Eligible studies met the following inclusion criteria: (1) having informal caregivers of people living with dementia; (2) involving meaning-making of care experience; (3) adopting qualitative design; and (4) full-text of research articles. The risk of bias was evaluated using the Clinical Appraisal Skills Programme checklist. By using Qualitative Evidence Synthesis, themes relevant to critical dimensions and phases of meaning-making were generated from the extracted data.

RESULTS

Sixty-two studies involving 2487 subjects were synthesised investigating the critical dimensions and process of meaning-making of dementia care experience. Results indicated that the dementia care experience can be made sense of in several folds: (1) it involved complicated demands from people living with dementia and requires customised care; (2) the dynamics of dyadic interactions with dilemma and ambivalence; and (3) adaptive coping encapsulating perceptions of loss and growth, complied and integrated values, balanced expectations of care and self, and improvement in self-efficacy. The meaning-making process underwent phases of meaning creation (meaning created in initial encounter with dementia symptoms), meaning appraisal (assimilation and accommodation pathways for appraisal), and meaning adherence (integration of the appraised meanings).

CONCLUSION

Findings suggest meaning-making of dementia caregiving is a multi-faceted and multi-phased recursive process. Future implications give directions on the facilitation of meaning-oriented interventions to enhance the awareness of caregiving role and the knowledge of dementia care, learn techniques of reframing and restructuring, and seek meaningful perspectives; and to adopt strategies to overcome the barriers for meaning-making by empowering self-identity, roles and expectations, and the dyadic relationship. In addition, our findings inform future advancement in the conceptualisation and measurement of meaning-making in the context of family caregiving. Optimisation of the meaning-making process inspires professional assistance to enhance caregivers' coping for dementia care experience.

Frameworks for cultural adaptation of psychosocial interventions: A systematic review with narrative synthesis

INTRODUCTION

Psychosocial dementia interventions may be less effective when used with populations for whom they were not initially intended. Cultural adaptation of interventions aims to increase effectiveness of interventions by enhancing cultural relevance. Use of theoretical frameworks may promote more systematic cultural adaptation. The aim of this review was to provide a comprehensive synthesis of published cultural adaptation frameworks for psychosocial interventions to understand important elements of cultural adaptation and guide framework selection.

METHOD

Five scientific databases, grey literature and reference lists were searched to January 2023 to identify cultural adaptation frameworks for psychosocial interventions. Papers were included that presented cultural adaptation frameworks for psychosocial interventions. Data were mapped to the framework for reporting adaptations and modifications to evidence-based interventions, then analysed using thematic synthesis.

RESULTS

Twelve cultural adaptation frameworks met inclusion criteria. They were mostly developed in the United States and for adaptation of psychological interventions. The main elements of cultural adaptation for psychosocial interventions were modifying intervention content, changing context (where, by whom an intervention is delivered) and consideration of fidelity to the original intervention. Most frameworks suggested that key intervention components must be retained to ensure fidelity, however guidance was not provided on how to identify or retain these key components. Engagement (ways to reach and involve recipients) and cultural competence of therapists were found to be important elements for cultural adaptation.

CONCLUSIONS

Comprehensive frameworks are available to guide cultural adaptation of psychosocial dementia interventions. More work is required to articulate how to ensure fidelity during adaptation, including how to identify and retain key intervention components.

Diverse demands and resources among racially/ethnically diverse caregivers

OBJECTIVES

The family caregiver population in the US is growing in conjunction with greater numbers of older adults with serious illness and complex care needs, and is becoming increasingly diverse. This study described and compared resources, demands, and health outcomes among diverse family caregivers by race/ethnicity.

DESIGN

This study was a cross-sectional secondary analysis of nationally representative data collected for Black/African-American, Asian American & Pacific Islander, Latino/Hispanic and non-Latino/Hispanic white caregivers (n = 2,010) in the Home Alone Revisited Study. We described available resources (e.g. income, paid help, social support) and demands (e.g. medical/nursing task performance) by racial/ethnic group. Using survey-weighted logistic regression, we examined relationships of resources and demands with caregiver outcomes (i.e. heath status; strain; depressive symptoms) by race-ethnicity controlling for socio-demographic variables.

RESULTS

Distribution of resources and demands was similar by race/ethnicity, except for higher income for non-Latino/Hispanic white caregivers. Nearly half assisted with personal care (47.5%) or medical/nursing tasks (49.7%). Higher social support and satisfaction with social relationships was associated with positive health outcomes regardless of race/ethnicity, while income was consistently associated with positive health outcomes only for non-Latino/Hispanic white caregivers. Medical/nursing task performance was significantly associated with negative health outcomes for Asian American & Pacific Islanders in multivariable models.

DISCUSSION

Many caregiving demands and tasks are similar by race/ethnicity and represent considerable investment of time, energy and care. Differences in the effects of resources and demands by race/ethnicity should be explored in future research as they may have implications for assessment and planning of culturally and linguistically appropriate interventions.

Culturally Adapting Evidence on Dementia Prevention for Ethnically Diverse Communities: Lessons Learnt from co-design

OBJECTIVES

40% of dementia cases can be prevented by addressing 12 lifestyle factors. These risk factors have increased presence in ethnic minorities, yet dementia prevention messages have not reached these communities. This article investigates the experience of co-designing a dementia prevention animated film with 9 ethnic groups in Australia.

METHODS

Evidence-based recommendations were adapted through an iterative process involving workshops with a stakeholder advisory committee and nine focus groups with 104 participants from the Arabic-, Hindi-, Tamil-, Cantonese-, Mandarin-, Greek-, Italian-, Spanish-, and Vietnamese-speaking communities. Data were analyzed using the Normalization Process Theory.

RESULTS

Cultural adaptation involves consideration of the mode of delivery, imagery and tone of the resource being developed; ensuring cultural adequacy; anticipating the need of the end-users; and managing linguistic challenges associated with working across multiple languages.

CONCLUSIONS

Learnings from this co-design process offer valuable insights for researchers and program developers who work with ethnic minority groups.

CLINICAL IMPLICATIONS

• Adaptation across cultures and languages is a negotiation not a consensus building exercise• Linguistic adaptation requires consideration of the education levels, and linguistic and intergenerational preferences of community members• Co-designing across multiple languages and cultures risks "flattening out" key aspects of cultural specificity.

The role of demographic change in explaining the growth of Australia's older migrant population living with dementia, 2016-2051

OBJECTIVE

To examine the demographic drivers contributing to the future growth in the population of older migrants in Australia living with dementia.

METHODS

Using birthplace-specific cohort-component projection models, we projected the number of older migrants living with dementia. ABS data on births, deaths, migration and birthplace were used, alongside Australian Institute of Health and Welfare (AIHW) estimates of dementia prevalence with birthplace dementia weights calculated from administrative data.

RESULTS

The number of older migrants living with dementia is projected to increase from about 134,423 in 2016 to 378,724 by 2051. Increases in populations with dementia varied considerably, from a slight decrease for those born in Southern & Eastern Europe to over 600% increases amongst the South-East Asia, Southern & Central Asia, and Sub-Saharan Africa-born populations.

CONCLUSIONS

Cohort flow is the primary driver increasing the number of older migrants living with dementia. This growth is largely inevitable because the cohorts are already living in Australia as part of the migrant population, but currently at ages below 60 years.

IMPLICATIONS FOR PUBLIC HEALTH

High relative growth and shifting birthplace composition in the number of migrants living with dementia poses implications for culturally appropriate care, health care access and workforce needs to support migrant families, carers and their communities.

Knowledge, attitudes, and practice of general practitioners toward community detection and management of mild cognitive impairment: a cross-sectional study in Shanghai, China

BACKGROUND

General practitioners (GPs) are in a unique position for community detection and management of mild cognitive impairment (MCI). However, adequate knowledge, attitudes, and practice (KAP) are prerequisites for fulfilling such a role. This study aims to assess the MCI-related KAP of GPs in Shanghai, China.

METHODS

An online survey was conducted on 1253 GPs who were recruited from 56 community health centres (CHCs) in Shanghai between April and May 2021. Knowledge (8 items), attitudes (13 items), and practice (11 items) were assessed using a scale endorsed by a panel of multidisciplinary experts. An average summed score was calculated and transformed into a score ranging from 0 to 100 for knowledge, attitudes, and practice, respectively. Adjusted odds ratios (AORs) were calculated for potential predictors of higher levels of KAP scores (with mean value as a cutoff point) through logistic modelling. The mediating role of attitudes on the association between knowledge and practice was tested using the PROCESS model 4 macro with 5000 bootstrap samples through linear regression modelling.

RESULTS

A total of 1253 GPs completed the questionnaire, with an average score of 54.51 ± 18.18, 57.31 ± 7.43, and 50.05 ± 19.80 for knowledge, attitudes, and practice, respectively. More than 12% of respondents scored zero in knowledge, 28.4% tended not to consider MCI as a disease, and 19.1% completely rejected MCI screening. Higher levels of knowledge were associated with more favourable attitudes toward community management of MCI (AOR = 1.974, p < 0.001). Higher compliance with practice guidelines was associated with both higher levels of knowledge (AOR = 1.426, p < 0.01) and more favourable attitudes (AOR = 2.095, p < 0.001). The association between knowledge and practice was partially mediated by attitudes (p < 0.001). Training was associated with higher levels of knowledge (AOR = 1.553, p < 0.01), while past experience in MCI management was associated with more favourable attitudes (AOR = 1.582, p < 0.05) and higher compliance with practice guidelines (AOR = 3.034, p < 0.001). MCI screening qualification was associated with higher compliance with practice guidelines (AOR = 2.162, p < 0.05), but less favourable attitudes (AOR = 0.452, p < 0.05).

CONCLUSION

The MCI knowledge of GPs in Shanghai is low, and is associated with less favourable attitudes toward MCI management and low compliance with practice guidelines. Attitudes mediate the association between knowledge and practice. Training is a significant predictor of knowledge. Further studies are needed to better understand how the attitudes of GPs in Shanghai are shaped by the environments in which they live and work.

The Impact of Demographic, Socio-Economic and Geographic Factors on Mortality Risk among People Living with Dementia in England (2002-2016)

Increasing numbers of people living with dementia (PLWD), and a pressured health and social care system, will exacerbate inequalities in mortality for PLWD. There is a dearth of research examining multiple factors in mortality risk among PLWD, including application of large administrative datasets to investigate these issues. This study explored variation mortality risk variation among people diagnosed with dementia between 2002-2016, based on: age, sex, ethnicity, deprivation, geography and general practice (GP) contacts. Data were derived from electronic health records from a cohort of Clinical Practice Research Datalink GP patients in England (n = 142,340). Cox proportional hazards regression modelled mortality risk separately for people with early- and later- onset dementia. Few social inequalities were observed in early-onset dementia; men had greater risk of mortality. For early- and later-onset, higher rates of GP observations-and for later-onset only dementia medications-are associated with increased mortality risk. Social inequalities were evident in later-onset dementia. Accounting for other explanatory factors, Black and Mixed/Other ethnicity groups had lower mortality risk, more deprived areas had greater mortality risk, and higher mortality was observed in North East, South Central and South West GP regions. This study provides novel evidence of the extent of mortality risk inequalities among PLWD. Variance in mortality risk was observed by social, demographic and geographic factors, and frequency of GP contact. Findings illustrate need for greater person-centred care discussions, prioritising tackling inequalities among PLWD. Future research should explore more outcomes for PLWD, and more explanatory factors of health outcomes.

Building a Research Roadmap for Caregiver Innovation: Findings from a Multi-Stakeholder Consultation and Evaluation

Across the world, informal (unpaid) caregiving has become the predominant model for community care: in the UK alone, there are an estimated 6.5 million caregivers supporting family members and friends on a regular basis, saving health and social care services approximately £132 billion per year. Despite our collective reliance on this group (particularly during the COVID-19 pandemic), quality of life for caregivers is often poor and there is an urgent need for disruptive innovations. The aim of this study was to explore what a future roadmap for innovation could look like through a multi-stakeholder consultation and evaluation. An online survey was developed and distributed through convenience sampling, targeting both the informal caregiver and professionals/innovators interested in the caregiver demographic. Data were analysed using both quantitative (summary statistics) and qualitative (inductive thematic analysis) methods in order to develop recommendations for future multi-stakeholder collaboration and meaningful innovation. The survey collected 174 responses from 112 informal caregivers and 62 professionals/innovators. Responses across these stakeholder groups identified that there is currently a missed opportunity to harness the value of the voice of the caregiver demographic. Although time and accessibility issues are considerable barriers to engagement with this stakeholder group, respondents were clear that regular contributions, ideally no more than 20 to 30 min a month could provide a realistic route for input, particularly through online approaches supported by community-based events. In conclusion, the landscape of digital health and wellness is becoming ever more sophisticated, where both industrial and academic innovators could establish new routes to identify, reach, inform, signpost, intervene and support vital and vulnerable groups such as the caregiver demographic. Here, the findings from a consultation with caregivers and professionals interested in informal caring are presented to help design the first stages of a roadmap through identifying priorities and actions that could help accelerate future research and policy that will lead to meaningful and innovative solutions.