The role of attitudes and culture in family caregiving for older adults

Psychological distress in Asian American informal caregivers: an analysis by disaggregated ethnic groups

BACKGROUND

Despite Asians being the fastest-growing ethnic group in the US, most studies have focused on Asian Americans as an aggregate racial/ethnic group. The burden of mental health problems is increasing among caregivers due to population aging, yet little is known about the distress experienced by Asian caregivers when examined by disaggregated ethnic groups.

METHODS

Using 2019-2020 California Health Interview Survey data, we examined disparities in psychological well-beings between non-Hispanic White and Asian American adult caregivers, with an emphasis on understudied Asian ethnic groups. Psychological distress was measured using the Kessler 6 scale, with scores ≥6 indicating mental distress and ≥13 indicating serious mental illness. Multivariable logistic regression adjusted for socio-demographics, physical health, caregiving relationship, intensity of care, and care recipients' characteristics.

RESULTS

The study included 8,722 caregivers (mean age, 58.7 years; 61.3% women; 14.1% Asian [379 Chinese, 260 Filipino, 167 Japanese, 138 South Asian, 105 Korean, 101 Vietnamese, 78 other Asian], 85.9% White). Overall, 26.8% had mental distress, and 8.5% had serious mental illness. Compared to White caregivers, Korean American caregivers had higher odds of mental distress (Odds Ratio [OR], 2.37; 95% CI, 1.47-3.82) and serious mental illness (OR, 2.15; 95% CI, 1.17-3.92), while Chinese (OR, 0.72; 95% CI, 0.55-0.95) and Japanese (OR, 0.67; 95% CI, 0.45-0.99) American caregivers had lower odds of mental distress. Korean American caregivers had the highest prevalence of mental distress (43.1%) and serious mental illness (15.3%), compared with White and other Asian American caregivers.

CONCLUSION

Disaggregating data reveals significant mental health disparities among ethnic subgroups of Asian American caregivers. Tailored resources should address the distinct needs of ethnic subgroups of Asian American caregivers, considering language barriers, acculturation, and cultural norms that may exacerbate psychological distress.

Resilience in family caregivers of Asian older people with dementia: An integrative review

AIM

To identify factors associated with resilience in family caregivers of Asian older people with dementia based on Luthar and Cicchetti's definition of resilience.

DESIGN

Integrative review of resilience in family caregivers of Asian older people with dementia reported by studies with quantitative and qualitative research designs.

DATA SOURCES

Databases used for the literature search included CINAHL, PubMed, EMBASE, PsycINFO and Google Scholar.

REVIEW METHODS

A total of 565 potentially relevant studies published between January 1985 and March 2024 were screened, and 27 articles met the inclusion criteria.

RESULTS

Family caregivers were most commonly adult children of care recipients, female and providing care in their home. Two themes emerged from the review: factors associated with adversity (dementia severity, caregiver role strain, stigma, family stress, female gender, low income and low education) and factors associated with positive adaptational outcomes (positive aspect of caregiving, social support and religiosity/spirituality).

CONCLUSION

In our review of Asian research, four new factors-caregiver role strain, stigma, family stress and positive aspects of caregiving-emerged alongside those previously identified in Western studies. A paradigm shift was observed from a focus on factors associated with adversity to factors associated with positive adaptational outcomes, particularly after the issuance of the WHO's 2017 global action plan for dementia. However, a gap remains between WHO policy recommendations and actual research, with studies often neglecting to address gender and socioeconomic factors.

IMPACT

The review findings will broaden healthcare providers' understanding of resilience in dementia caregivers and use them to develop comprehensive programmes aimed at reducing factors associated with adversity and enhancing those associated with positive adaptational outcomes. This approach can be customized to incorporate Asian cultural values, empowering caregivers to navigate challenges more effectively.

NO PATIENT OR PUBLIC CONTRIBUTION

This paper is an integrative review and does not include patient or public contributions.

Strategies and sacrifices of family caregiving in the Somali-American community: a qualitative study

BACKGROUND

Among the many pressing concerns of the Somali-American community, and other similar immigrant and refugee communities as they grow in the United States, is the provision of care for older adults and adults with disabilities. The implications of effective caregiving range from the facilitation of community building and place-making to the delivery and management of healthcare on a systemic level. However, little is currently known about Somali-American family caregivers, including their duties and responsibilities, primary concerns, and the impacts of surrounding influences on their ability to fulfill their role.

METHODS

Semi-structured interviews were conducted with 10 Somali-American family caregivers in Somali language. The resulting transcripts were translated into English by a professional interpreter and analyzed using an inductive thematic analysis approach. A key informant from the community was additionally consulted for insights regarding cultural nuances and interpretations of idiomatic expressions and concepts.

RESULTS

Thematic analysis of the reports revealed the principal themes of visitation, patient accompaniment, and self-sacrifice through acceptance and God-consciousness as pervasive and salient concerns across participants. Furthermore, the heightened stresses of the COVID-19 pandemic revealed just how severe the consequences can be when access to culturally habituated navigational tools and coping mechanisms are restricted.

CONCLUSIONS

In light of our findings, the growing concern for discrimination and sociocultural discord in the Somali-American community presents a particularly prescient threat to the well-being and sustainability of family caregivers. Their experiences must be understood and used to promote education and partnership between the healthcare system and the community in order to build trust and ensure a healthy future for this indispensable population.

Societal Costs of Dementia: 204 Countries, 2000-2019

Background

Dementia prevalence is expected to increase as populations grow and age. Therefore, additional resources will be needed to meet the global demand for care for Alzheimer's disease and related dementias (ADRD).

Objective

Estimate global and country-level health care spending attributable to ADRD and the cost of informal care for people living with ADRD.

Methods

We gathered data from three systematic literature reviews and the Global Burden of Disease 2019 study. We used spatiotemporal Gaussian process regression to impute estimates for the many countries without underlying data. We projected future costs to 2050 based on past trends in costs, diagnosis rates, and institutionalization rate.

Results

We estimated that in 2019, the direct health care spending attributable to ADRD across 204 countries reached $260.6 billion (95% uncertainty interval [UI] 131.6-420.4) and the cost of informal ADRD care was $354.1 billion (95% UI 190.0-544.1). On average, informal care represents 57% (95% UI 38-75%) of the total cost of care. We estimated that direct health care spending attributable to ADRD will reach $1.6 trillion (95% UI 0.6-3.3) in 2050, or 9.4% (95% UI 3.9-19.6%) of projected health spending worldwide. We estimated the cost of informal care will reach $0.9 trillion (95% UI 0.3-1.7) in 2050.

Conclusions

These cost estimates underscore the magnitude of resources needed to ensure sufficient resources for people living with ADRD and highlight the role that informal care plays in provision of their care. Incorporating informal care cost estimates is critical to capture the social cost of ADRD.

Access and Use of Services by Caregivers of Older Adults: A Scoping Review of Cultural and Linguistic Diversity

Westernized countries are home to an increasingly culturally and linguistically diverse (CLD) older adult population. Informal caregivers of CLD older adults face unique challenges accessing and using home- and community-based services (HCBS). This scoping review sought to identify facilitators and barriers to access and use of HCBS for informal caregivers of CLD older adults. Arksey and O'Malley's framework guided a systematic search of five electronic databases. The search strategy retrieved 5979 unique articles. Forty-two studies met the inclusion criteria and informed this review. Facilitators and barriers were identified at three stages of using services: knowledge, access, and use of services. Findings concerning access to HCBS were subdivided into willingness and ability to access HCBS. Results emphasize the need for changes in healthcare systems, organizations, and providers to provide culturally appropriate care and improve the accessibility and acceptability of HCBS for informal caregivers of CLD older adults.

Parenting style in childhood and attitudes toward caregiving in adulthood: a qualitative study

This study aims to explore how relationships with parents during childhood can influence an individual's attitude toward caregiving later in life. The qualitative data came from 47 respondents who care for adult loved ones, with a caregiver mean age of 46.7. The respondents reflected on their recent experience of providing care for their loved ones and how experiences with their caregivers growing up may have influenced their caregiving attitudes. Using a codebook thematic analysis, themes were generated linking childhood experiences to current attitudes toward caregiving. Themes included reciprocating good care, performing obligatory care, and stopping the generational transference of negative care. For most participants, providing quality care for adult loved ones happened regardless of whether the one's childhood experiences with caregivers were positive or negative. Knowledge about the impact of childhood experiences can help health professionals develop interventions to support family caregivers that consider childhood experiences with parents.

Applying the Dual Filial Piety Model in the United States: A Comparison of Filial Piety Between Asian Americans and Caucasian Americans

The definition and measurement of filial piety in existing research primarily focuses on the narrow conceptualizations of Asian filial piety, which would inflate cultural differences and undermine cultural universals in how people approach caring for their elderly parents. Employing the Dual Filial Piety Model (DFPM), this study aimed to examine the relationship between filial piety and attitude toward caring for elderly parents beyond the Asian context. In our study (N = 276), we found that reciprocal filial piety (RFP) does not differ across cultures while authoritarian filial piety (AFP) does. We also found that collectivism, rather than ethnicity, predicted RFP and AFP, which in turn predicted positive attitude toward caring for elderly parents. Our work demonstrates the cross-cultural applicability of the DFPM and highlights the universal and culture-specific aspects of filial piety.

A lifespan approach to understanding family caregiver experiences of a blood cancer diagnosis

OBJECTIVES

The study examined the diagnosis experience of midlife family caregivers of a patient with a blood cancer, exploring similarities and differences between parent caregivers and adult-child caregivers.

METHODS

Participants were between 30 and 65 years old and were family caregivers of a living patient with acute myeloid leukemia, acute lymphoblastic leukemia, or lymphoma. We conducted semi-structured interviews with parent caregivers (n = 20) and adult-child caregivers (n = 19) and a thematic analysis of the interview data.

RESULTS

Both types of caregivers report the patient experiencing (1) mis- and missed diagnosis (facing delayed diagnosis or treatment and having symptoms dismissed or overlooked) and (2) emotional distress (being in shock and survival mode, struggling with uncertainty, and confronting mortality). Adult-child caregivers also experienced relational shifts in assuming control of their parent's care, sometimes despite geographic distance, and struggled to distribute the care burden among family members.

SIGNIFICANCE OF RESULTS

Differences between the caregivers' experiences emerged based on the relational role and the patient's place in the lifespan. Findings can be used to inform the development of support resources to address the needs of each group.

Perceptions of staff and family responsibility to provide hospitalized older adults with basic activities care and emotional support

Many older adults need help with Activities of Daily Living (ADL) and emotional support during hospitalization. Hospital staff is officially responsible for care, but most older adults are accompanied by family members who provide at least some of the support. In this study, we asked physicians, nurses, nursing assistants, and relatives about hospital staff versus family responsibility for providing ADL care and emotional support, and about actual levels of help provision by the hospital staff in Israel.  Staff members (except physicians) tended to see staff as more responsible for ADL care than family, while emotional support was a shared responsibility. Nursing assistants were the most likely to report that staff provided high levels of support, and all participants reported that staff provided more ADL care than emotional support. It is important for family members and hospital staff to have open discussions of their expectations and responsibilities when older adults are hospitalized.

Factors Associated with Burden in Caregivers of Patients with End-Stage Kidney Disease (A Systematic Review)

BACKGROUND

Caring for a patient with end-stage kidney disease (ESKD) is highly stressful and can impact negatively on the physical and psychological well-being of caregivers. To accurately assess caregiver burden (CB), health care providers (HCPs) need to identify characteristics associated with an increase in CB.

AIM

The aim of this review is to explore CB in caregivers of adult patients with ESKD and to identify characteristics associated with any increase in CB.

METHOD

A comprehensive literature search was completed using five electronic databases. Medline, Embase, CINHAL, PsycINFO, and Scopus. The Joanna Briggs Institute checklist (JBI) was used to quality appraise full text papers included in the review. No time limit for the date of publication of studies was employed, to enable the inclusion of more extensive literature.

RESULTS

A total of 38 relevant studies from 18 countries were identified and included in the review. A variety of patient and caregiver factors can impact positively or negatively on CB, including socio-demographic factors of patients and caregivers, disease-related factors, situational and relational factors, environmental factors, and psychological factors.

CONCLUSION

This review provides awareness to HCPs of the important factors associated with CB, when assessing or targeting interventions for caregivers experiencing burden.

Association between filial responsibility when caring for parents and the caregivers overload

Objective:

To analyze the association between filial responsibility and the overload of the children when caring for their older parents.

Method:

Cross-sectional study with 100 caregiver children of older adults. Filial liability was assessed by the attitudes of the responsible child (scale of expectation and filial duty) and by care behaviors (assistance in activities of daily living, emotional and financial support, and keeping company). The overload was assessed by the Caregiver Burden Inventory. To assess the associations, the correlation coefficients of Pearson and Spearman, Kruskal-Wallis Test, and Mann-Whitney were employed. Variables that presented p-value<0.20 in the bivariate analysis were inserted in a multivariate linear regression model.

Results:

The factors associated with overload were: formal employment (p=0.002), feelings regarding family life (p<0.001), financial support (p=0.027), and assistance with Activities of Daily Living (ADLs) (p<0.001).

Conclusion:

Children who were more involved with the ADLs and provided financial support showed higher levels of overload.

Objetivo:

Analisar a associação entre a responsabilidade filial e a sobrecarga dos filhos cuidadores de pessoas idosas.

Método:

Estudo transversal com 100 filhos cuidadores de pessoas idosas. A responsabilidade filial foi avaliada pelas atitudes de responsabilidade filial (escala de expectativa e dever filial) e pelos comportamentos de cuidar (auxílio nas atividades de vida diária, apoio emocional, financeiro e companhia). A sobrecarga foi avaliada pelo Inventário de Sobrecarga do Cuidador. Para avaliar as associações utilizaram-se os coeficientes de correlação de Pearson e Spearman, Teste de Kruskal-Wallis e Mann-whitney. Variáveis que apresentaram valor de p<0,20 na análise bivariada foram inseridas em um modelo multivariado de regressão linear.

Resultados:

Os fatores associados com a sobrecarga foram: emprego formal (p=0,002), sentimentos na vida familiar (p<0,001), apoio financeiro (p=0,027) e ajuda nas Atividades da Vida Diária (AVDs) (p<0,001).

Conclusão:

Os filhos que mais auxiliavam nas AVDs e prestavam apoio financeiro apresentaram maiores níveis de sobrecarga.

A systematic review of Indigenous caregiver functioning and interventions

PURPOSE

There is a global increase in chronic, degenerative illnesses that require long-term intervention and support as a result of the aging population. The majority of support needs are met by informal family caregivers. While there have been three decades of research focusing on caregivers in general, the extent to which research has focused on Indigenous caregivers is unclear. Worldwide, Indigenous peoples face severe economic and health disadvantages that may make them even more vulnerable to the negative aspects of informal caregiving. The current systematic review aimed to synthesize the extant literature on Indigenous caregiver functioning and the interventions that are efficacious in alleviating Indigenous caregiver distress.

METHODS

Systematic review Inclusion criteria were peer-reviewed quantitative studies examining Indigenous caregiver functioning or evaluating Indigenous caregiver interventions.

RESULTS

1172 unique records were located in the final search undertaken; only 7 articles, representing 6 unique studies, met the full inclusion criteria. Most studies contained numerous methodological weaknesses that compromised the reliability and validity of findings. Available studies suggest poor health and high burden among Indigenous relative to non-Indigenous caregivers. However, high levels of positive aspects of caregiving were reported in one study. A single intervention study suggests that poor health outcomes among Indigenous caregivers can be alleviated, though the quality and focus of this study was sub-optimal.

CONCLUSIONS

Overall, there is very little quality evidence around Indigenous caregiver functioning. Future research in this area would benefit from greater adherence to the standards of research that contribute to a strong and reliable evidence base.

The relationship between geographical and social space and approaches to care among rural and urban caregivers caring for a family member with Dementia: a qualitative study

Knowledge about family caregivers in rural areas remains sparse. No studies to date have addressed the sociocultural aspects in caregiving, thus neglecting potentially significant data. This study aimed to explore and better understand family caregivers’ experiences in rural and urban areas and the sociocultural spheres that these two areas represent. How do family caregivers approach their caregiving situation? A hermeneutical approach was chosen to uncover the underlying meanings of experiences. Open-ended in-depth interviews were conducted. The ontological and epistemological roots are based on hermeneutic philosophy, where a human being’s existence is viewed as socially constructed. The study followed a purposeful sampling. Semi-structured in-depth interviews were conducted with 12 rural and 11 urban family caregivers to persons with dementia. These were then analyzed in accordance with the hermeneutical process. The findings provide insight into the variations of family caregiver approaches to caregiving in rural and urban areas of Sweden. There seemed to be a prevalence of a more accepting and maintaining approach in the rural areas as compared to the urban areas, where caregiving was more often viewed as an obligation and something that limited one’s space. Differences in the construction of family identity seemed to influence the participants approach to family caregiving. Therefore, community-based caregiving for the elderly needs to become aware of how living within a family differs and how this affects their views on being a caregiver. Thus, support systems must be individually adjusted to each family’s lifestyles so that this is more in tune with their everyday lives.

Association of Filial Responsibility, Ethnicity, and Acculturation Among Japanese American Family Caregivers of Older Adults

Challenges of filial caregiving practices by 1st-generation immigrants due to differences in caregiving values between their home and host countries are well documented. This study explored the filial responsibility of later generation Japanese American caregivers of older adults. Acculturation and filial responsibility were measured using the Suinn-Lew Asian Self Identity Acculturation scale and Filial Values Index, respectively. A qualitative interview guide was developed using Gordon's assimilation theory, and 21 caregivers ( M age = 68 years, 86% female, seven in each generation) were interviewed. Despite the 3rd-generation caregivers' high acculturation level, their filial responsibility scores remained high. Qualitative interviews also revealed later generation caregivers' strong filial responsibility and continued caregiving involvement. Unexpectedly, caregivers' own future expectancy of care included placement in mainstream residential facilities rather than ethnic-specific settings. Findings point to the need to develop caregiver services that consider later generation caregivers' culture and level of assimilation.

A Review of Ethnicity, Culture, and Acculturation Among Asian Caregivers of Older Adults (2000-2012)

This review identified domains of care experiences among studies of Chinese, Filipino, Japanese, Korean, and Vietnamese caregivers in the United States and Canada between 2000 and 2012. Using a narrative approach, 46 peer-reviewed journal articles were found through electronic databases and references. Considering caregivers' assimilation to host countries, attention was given to their culture, socioeconomic resources, immigrant status, filial responsibility, generation, and acculturation. Three primary domains were identified across subgroups. The caregivers' experiences domain was a strong sense of filial responsibility and its varied effects on caregiving experience; in the cultural values domain, reciprocity, and familism. In the acculturation domain, caregivers' generations influenced their experiences. Because our society is rapidly changing demographically and culturally, studies of older adults and their caregivers that are not only inclusive of all racial/ethnic groups but also sensitive to specific racial/ethnic and cultural subgroup differences are necessary to inform policy and practice.

Clarifying and measuring filial concepts across five cultural groups

Literature on responsibility of adult children for aging parents reflects lack of conceptual clarity. We examined filial concepts across five cultural groups: African-, Asian-, Euro-, Latino-, and Native Americans. Data were randomly divided for scale development (n = 285) and cross-validation (n = 284). Exploratory factor analysis on 59 items identified three filial concepts: Responsibility, Respect, and Care. Confirmatory factor analysis on a 12-item final scale showed data fit the three-factor model better than a single factor solution despite substantial correlations between the factors (.82, .82 for Care with Responsibility and Respect, and .74 for Responsibility with Respect). The scale can be used in cross-cultural research to test hypotheses that predict associations among filial values, filial caregiving, and caregiver health outcomes.

Stress and grief among family caregivers of older adults with cancer: a multicultural comparison from Hawai'i

In this study the authors investigated stress, anticipatory mourning, and cultural practices among family caregivers from independent and interdependent cultural groups. Focus groups were used to collect data from 56 caregivers providing care to family members with terminal cancer, representing four cultural groups in Hawai'i: Chinese, European Americans, Japanese, and Native Hawaiians. Participants from all four cultural groups identified similar stressors and agreed that support groups helped them cope with the stresses and sadness they were experiencing and differed in culturally based motivations for caregiving, perceived roles, and processing of grief. The findings of this study indicated a need for additional conceptual models of the caregiving trajectory and more culturally sensitive strategies, particularly indirect methods, for working with diverse populations of caregivers.