Migrant care workers as protective factor against caregiver burden: results from a longitudinal analysis of the EUROFAMCARE study in Italy

Self-Assessment Instruments for Supporting Family Caregivers: An Integrative Review

Family caregivers take on a variety of tasks when caring for relatives in need of care. Depending on the situation and the intensity of care, they may experience multidimensional burdens, such as physical, psychological, social, or financial stress. The aim of the present study was to identify and appraise self-assessment instruments (SAIs) that capture the dimensions of family caregivers' burdens and that support family caregivers in easily identifying their caregiving role, activities, burden, and needs. We performed an integrative review with a broad-based strategy. A literature search was conducted on PubMed, Google Scholar, Google, and mobile app stores in March 2020. After screening the records based on the eligibility criteria, we appraised the tools we found for their usefulness for family care and nursing practice. From a total of 2654 hits, 45 suitable SAIs from 274 records were identified and analyzed in this way. Finally, nine SAIs were identified and analyzed in detail based on further criteria such as their psychometric properties, advantages, and disadvantages. They are presented in multi-page vignettes with additional information for healthcare professionals. These SAIs have proven useful in assessing the dimensions of caregiver burden and can be recommended for application in family care and nursing practice.

Home care and quality of life among community-dwelling dependent older adults in Israel: a multiple mediator model

PURPOSE

To examine the association between home care provision (combined paid formal home care and non-paid family-only home care) versus non-paid family-only home care with quality of life (QoL) of older adults, as well as the mediating effects of loneliness, social isolation and satisfaction with family relationships and support.

METHODS

A convenience sample of 360 Israeli dependent adults aged 65 + responded to questionnaires. Using bootstrapping, we tested the strength and significance of the conditional indirect effects of the four simultaneous mediators.

RESULTS

Using combined home care provision (paid formal home care and non-paid family-only home care) versus non-paid family-only home care for older adults was associated with lower QoL of care-recipients (B = - 4.57, t = - 2.24, p = 0.001, 95% CI - 8.58, - 0.56; R2 = 0.37), and was fully and strongly mediated by feelings of loneliness (B = - 1.92, p = 0.001, 95% CI - 3.66, - 0.79), social isolation (B = - 0.54, p = 0.001, 95% CI - 1.47, - 0.07) and satisfaction with family support (B = - 1.09, p = 0.001, 95% CI - 2.57, - 0.16). However, the indirect effect through satisfaction with family relationships was not significant. The highest proportion of the indirect effect size was (B = 0.42, 95% CI 0.13, 1.97) for loneliness, followed by satisfaction with family support (B = 0.23, 95% CI 0.01, 1.07), and social isolation (B = 0.11, 95% CI 0.01, 0.66), respectively.

CONCLUSIONS

Using combined formal home care might reduce the QoL of care-recipients by increasing their feelings of loneliness, social isolation and reduced perceived family support. Practitioners should encourage family members to continue with family regular support and contact alongside the use of formal home care in order to maintain satisfaction and QoL of older relatives.

Cohort profile: The ENTWINE iCohort study, a multinational longitudinal web-based study of informal care

Informal care is a key pillar of long-term care provision across Europe and will likely play an even greater role in the future. Thus, research that enhances our understanding of caregiving experiences becomes increasingly relevant. The ENTWINE iCohort Study examines the personal, psychological, social, economic, and geographic factors that shape caregiving experiences. Here, we present the baseline cohort of the study and describe its design, recruitment methods, data collection procedures, measures, and early baseline findings. The study was conducted in nine countries: Germany, Greece, Ireland, Israel, Italy, the Netherlands, Poland, Sweden, and the United Kingdom. The study comprised a web-based longitudinal survey (baseline + 6-month follow-up) and optional weekly diary assessments conducted separately with caregivers and care recipients. From 14 August 2020 to 31 August 2021, 1872 caregivers and 402 care recipients were enrolled at baseline. Participants were recruited via Facebook and, to a lesser extent, via the study website or caregiver/patient organisations. Caregiver participants were predominantly female (87%) and primary caregivers (82%), with a median age of 55 years. A large proportion (80%) held at least post-secondary education, and two-thirds were married/partnered. Over half of the caregivers were employed (53%) and caring for a person with multiple chronic conditions (56%), and nearly three-quarters were caring for either a parent (42%) or a spouse/partner (32%). About three-quarters of care recipient participants were female (77%), not employed (74%), and had at least post-secondary education (77%), with a median age of 55 years. Over half of the care recipients were married/partnered (59%), receiving care primarily from their spouses/partners (61%), and diagnosed with multiple chronic conditions (57%). This study examining numerous potential influences on caregiving experiences provides an opportunity to better understand the multidimensional nature of these experiences. Such data could have implications for developing caregiving services and policies, and for future informal care research.

Bound in an Imbalanced Relationship: Family Caregivers and Migrant Live-In Care-Workers of Frail Older Persons in Israel

Migrant care-workers (MCWs) are often the main caregivers for frail older persons. We examined the complex relationship between MCWs and primary family caregivers (PFCs) in Israel to better understand how MCWs and PFCs perceive the formal and informal nature of their relationship. Given the high prevalence of two-income families who are unavailable for caregiving, the relationships among MCWs, PFCs, and care-recipients warrants examination, particularly when PFCs serve as managers of care and the care-recipient has dementia. The sample of 116 MCWs and 117 PFCs included 92 MCW-PFC pairs who were part of a larger study on home care for frail older persons. A mixed-methods approach was used involving quantitative (correlations/paired t-tests) and qualitative (grounded theory framework) analyses conducted on data obtained from structured interviews. A significant correlation was found between ratings of the quality of the relationship by MCWs and PFCs, although PFCs rated it significantly more positively than MCWs. MCWs' ratings of their relationship with the PFCs were significantly correlated with their ratings of the quality of their relationship with the care-recipient. Four main thematic categories emerged from the qualitative analysis: (1) communication, (2) dependence, (3) relationship quality, and (4) triad: MCW-PFC-care-recipient. For each theme, we present perspectives of MCWs and PFCs, reflecting either "closeness" or "distance" in their relationship. The findings highlight the complexity of such relationships, with the potential for a meaningful positive bond or mistrust or abuse. The study provides a basis for testing methods for ameliorating the negative experiences described by some participants.

Predictors of Migrant Live-in Care Workers' Burden/Burnout and Job Satisfaction When Caring for Frail Older Persons in Israel

OBJECTIVES

To clarify how work characteristics affect migrant live-in care workers' burden/burnout as well as their job satisfaction.

METHODS

Data from 116 migrant live-in care workers were collected in 2013-2014 in Tel Aviv and Jerusalem through structured interviews about their job satisfaction and their degree of burden/burnout. Due to the conceptual and empirical similarity (zero-order correlation and joint internal reliability), of burden and burnout, the 2 were combined into one variable. These outcome measures were examined in connection with the older person's level of disability, care workers' relationship with the older person, and their employment conditions.

RESULTS

According to the regression models, work characteristics (care recipients' functional status and care workers' relationship with the care recipient) had a direct impact on burden/burnout. Employment-related variables (employment conditions and satisfaction with those conditions) had an indirect effect. A combination of work characteristics (relationship with the older person) together with the care worker's response to employment conditions (satisfaction with employment conditions) had a direct influence on the care workers' job satisfaction. Problematic employment conditions had an indirect effect.

DISCUSSION

The results suggest that fostering better relationships and improving employment conditions could help reduce care workers' burden/burnout as well as improve their degree of satisfaction.

Innovating Long-Term Care Provision in Mediterranean Welfare States: A Comparison Between Italy and Israel

Social innovations in long-term care (LTC) may be useful in more effective responses to the challenges of population aging for Western societies. One of the most investigated aspects in this regard is the role of family/informal care and strategies to improve its integration into the formal care system, yielding a more holistic care approach that may enhance opportunities for aging in place. This article reports the findings of a comparative research focusing on the Italian and Israeli LTC systems as representative of the Mediterranean "family-based" care model. To analyze the innovative solutions that have been adopted or are needed to improve LTC provision in these two contexts, focus groups and expert interviews have been carried out in both countries to identify the most relevant challenges and responses to them and to highlight promising policies and strategies to be adopted or up-scaled in the future. These include multidisciplinary case and care management, a stronger connection between prevention and LTC provision, and more systematic recognition of the role and limits of informal caregivers' contributions.

Representações sociais do cuidado e da velhice no Brasil e Itália

RESUMO: Este estudo objetivou comparar as representações sociais de brasileiros e italianos acerca do cuidado ao idoso e velhice. Foram entrevistadas 40 pessoas acima de 65 anos, 20 brasileiros e 20 italianos. Os resultados mostraram que as representações sociais da velhice e do cuidar da pessoa idosa, enfatizam a relevância da autonomia e manutenção da atividade, trazendo o contexto de doenças e dependência como algo indesejável. A vivência da velhice e o cuidar da pessoa idosa parecem mais difíceis em situação de doença, quando os agravos impõe a necessidade de um “cuidador”, o que abala a independência da pessoa idosa. Torna-se necessário a implementação de políticas de educação para a saúde, que levem em consideração as necessidades dos idosos.

Can domestic helpers moderate distress of offspring caregivers of cognitively impaired older adults?

OBJECTIVE

This study examined the moderating effect of domestic helpers on distress of offspring caring for parents with cognitive impairments and with or without behavioural problems.

METHOD

This secondary analysis of data involved 5086 Hong Kong Chinese adults aged 60 or older applying for public long-term care services from 2010 to 2012. All variables were measured using the mandatory Hong Kong version of the Minimum Data Set-Home Care 2.0.

RESULTS

Regarding taking care of parents with cognitive impairments, 10.7% of offspring primary caregivers were aided by domestic helpers, 55.54% reported distress, and 75.70% lived with their parents. Assistance from domestic helpers reduced offspring caregiver distress if the offspring provided psychological support to parents (ratio of OR = 0.655, p < .05) and were not living with parents (ratio of OR = 1.183, p < .01).

CONCLUSION

These findings might suggest: a) the positive effects of audience on psychological responses to stress; b) caregiving is usually less stressful for informal caregivers not residing with care recipients. Conversely, having a domestic helper could add to caregiving distress if offspring caregivers live with their parents, most likely because offspring may witness difficulties that domestic helpers face in providing dementia care.

Being lonely later in life: a qualitative study among Albanians and Moroccans in Italy

This study focuses on the social wellbeing of older migrants in Italy, an important yet neglected topic in the Italian political and scholarly debate. Knowledge about the lived experience of loneliness and its perceived causes was gathered by means of 34 in-depth interviews with Albanian and Moroccan migrants aged 50 and above living in the Marche region. Our findings show that the participants are surrounded by family and are largely satisfied with the contact they have with relatives; this protects them from social isolation but not from loneliness. Although they rarely express this to their spouse and friends (men) or their children (men and women), feelings of loneliness are widely experienced among the participants. The root of their loneliness largely relates to a lack of meaningful relationships with non-related age peers – having a chat, remembering old times, socialising with others when family members are busy, talking about intimate matters they cannot or will not share with relatives – which supports the argument of loneliness scholars that different types of relationships serve different functions and fulfil different needs. Having more contact with people outside the family circle, especially with co-ethnic peers, could reduce these feelings of loneliness substantially, but factors such as discrimination and lack of Italian language proficiency, free time, financial resources and nearby contact facilities are hindrances. These factors offer clues for public loneliness interventions.

The UP-TECH project, an intervention to support caregivers of Alzheimer's disease patients in Italy: preliminary findings on recruitment and caregiving burden in the baseline population

OBJECTIVES

The paper describes recruitment results and characteristics of the UP-TECH clinical trial sample, including level of care services use, informal caregiver burden and its determinants.

METHODS

UP-TECH is designed to test innovative care solutions for community-dwelling patients with moderate stage Alzheimer's disease and their caregivers in Italy. Four hundred and fifty patient-caregiver dyads were randomized into three arms receiving different combinations of services, composed of case management interventions, nurse visits, assistive technology and educational brochures. The research nurses administered a questionnaire comprising an in-depth socio-demographic assessment and several clinical scales, such as Novak's Caregiver Burden Inventory. Analyses of baseline data were conducted using uni- and bi-variate statistics. Linear regressions were computed to identify de-confounded correlates of caregiver burden.

RESULTS

Four hundred and thirty-eight patient-caregiver dyads were recruited and randomized. In our sample, patients are predominantly women (71.5%), with an average age of 81.5 years and a mean Mini-Mental State Examination score of 16.2. Caregivers are mostly women (66.2%) and offspring (55.7%), with a mean caregiver burden score of 27.6. They provide more than 50 hours of care per week, while receiving an almost negligible support from public services. Factors associated with caregiver burden are female gender, kinship and the patient's behavioral disturbances. The most important factor associated with lower burden is the employment of a live-in care worker.

CONCLUSION

The paper provides a comprehensive description of moderate stage Alzheimer's disease patients and their caregivers, suggesting useful markers of caregiver burden. The well-balanced randomization assures the reliability of the study data-set for prospective evaluation of care strategies.

Measuring the impact of informal elderly caregiving: a systematic review of tools

PURPOSE

To classify and identify the main characteristics of the tools used in practice to assess the impact of elderly caregiving on the informal carers' life.

METHODS

A systematic review of literature was performed searching in Embase, MEDLINE, PsycINFO, CINAHL, IBECS, LILACS, SiiS, SSCI and Cochrane Library from 2009 to 2013 in English, Spanish, Portuguese and French, and in reference lists of included papers.

RESULTS

The review included 79 studies, among them several in languages other than English. Their inclusion increased the variety of identified tools to measure this impact (n = 93) and allowed a wider analysis of their geographical use. While confirming their overlapping nature, instruments were classified according to the degree of integration of dimensions they evaluated and their specificity to the caregiving process: caregiver burden (n = 20), quality of life and well-being (n = 11), management and coping (n = 21), emotional and mental health (n = 29), psychosocial impact (n = 10), physical health and healthy habits (n = 2), and other measures. A high use in practice of tools not validated yet and not caregiver-specific was identified.

CONCLUSIONS

The great variety and characteristics of instruments identified in this review confirm the complexity and multidimensionality of the effects of elderly caregiving on the informal carer's life and explain the difficulties to assess these effects in practice. According to the classification provided, caregiver burden and emotional and mental health are the most evaluated dimensions. However, further work is required to develop integrated and caregiving focused procedures that can appraise this complexity across different countries and cultures.

The economic impact of moderate stage Alzheimer's disease in Italy: evidence from the UP-TECH randomized trial

BACKGROUND

There is consensus that dementia is the most burdensome disease for modern societies. Few cost-of-illness studies examined the complexity of Alzheimer's disease (AD) burden, considering at the same time health and social care, cash allowances, informal care, and out-of-pocket expenditure by families.

METHODS

This is a comprehensive cost-of-illness study based on the baseline data from a randomized controlled trial (UP-TECH) enrolling 438 patients with moderate AD and their primary caregiver living in the community.

RESULTS

The societal burden of AD, composed of public, patient, and informal care costs, was about €20,000/yr. Out of this, the cost borne by the public sector was €4,534/yr. The main driver of public cost was the national cash-for-care allowance (€2,324/yr), followed by drug prescriptions (€1,402/yr). Out-of-pocket expenditure predominantly concerned the cost of private care workers. The value of informal care peaked at €13,590/yr. Socioeconomic factors do not influence AD public cost, but do affect the level of out-of-pocket expenditure.

CONCLUSION

The burden of AD reflects the structure of Italian welfare. The families predominantly manage AD patients. The public expenditure is mostly for drugs and cash-for-care benefits. From a State perspective in the short term, the advantage of these care arrangements is clear, compared to the cost of residential care. However, if caregivers are not adequately supported, savings may be soon offset by higher risk of caregiver morbidity and mortality produced by high burden and stress. The study has been registered on the website www.clinicaltrials.org (

TRIAL REGISTRATION NUMBER

NCT01700556).

Migrant care workers and rehospitalization among older patients discharged from acute care hospitals

AIM

The relationship between support at home and rehospitalization has not been extensively studied until now. In particular, little is known about the impact of being assisted by migrant care workers (MCW) and rehospitalization. We aimed at investigating such a relationship in a population of older patients discharged from hospitals.

METHODS

Our series consisted of 506 patients aged 65 years or older consecutively enrolled in a prospective observational study involving 11 acute care medical wards throughout Italy. The outcome of the study was the occurrence of at least one rehospitalization during 1-year follow up. Information derived from comprehensive geriatric assessment, discharge diagnoses and prescribed drugs were collected during the index hospitalization. Data about formal and informal assistance (spouse, son, other relative, MCW, home nursing) were collected. The relationship between study variables and rehospitalization was assessed using logistic regression.

RESULTS

Being assisted by MCW was independently associated with the outcome (OR 2.04, 95% CI 1.10-4.37), as were complete dependency (OR 2.49, 95% CI 1.28-5.79) and overall comorbidity (OR 1.23, 95% CI 1.10-1.43). Older age was associated with a lower likelihood of rehospitalization (age 75-84 vs <75 years OR 0.51, 95% CI 0.30-0.92; age≥85 vs <75 years OR 0.30, 95% CI 0.12-0.65).

CONCLUSIONS

Being assisted by MCW could contribute to an increase in the rate of use of hospital resources for older complex patients. This finding raises the need for educational efforts targeting MCW.

The UP-TECH project, an intervention to support caregivers of Alzheimer's disease patients in Italy: study protocol for a randomized controlled trial

BACKGROUND

The epidemic of Alzheimer's disease (AD) represents a significant challenge for the health care and social service systems of many developed countries. AD affects both patients and family caregivers, on whom the main burden of care falls, putting them at higher risk of stress, anxiety, mortality and lower quality of life. Evidence remains controversial concerning the effectiveness of providing support to caregivers of AD patients, through case management, counseling, training, technological devices and the integration of existing care services. The main objectives of the UP-TECH project are: 1) to reduce the care burden of family caregivers of AD patients; and 2) to maintain AD patients at home.

METHODS/DESIGN

A total of 450 dyads comprising AD patients and their caregivers in five health districts of the Marche region, Italy, will be randomized into three study arms. Participants in the first study arm will receive comprehensive care and support from a case manager (an ad hoc trained social worker) (UP group). Subjects in the second study arm will be similarly supported by a case manager, but in addition will receive a technological toolkit (UP-TECH group). Participants in the control arm will only receive brochures regarding available services. All subjects will be visited at home by a trained nurse who will assess them using a standardized questionnaire at enrollment (M0), 6 months (M6) and 12 months (M12). Follow-up telephone interviews are scheduled at 24 months (M24). The primary outcomes are: 1) caregiver burden, measured using the Caregiver Burden Inventory (CBI); and 2) the actual number of days spent at home during the study period, defined as the number of days free from institutionalizations, hospitalizations and stays in an observation unit of an emergency room.

DISCUSSION

The UP-TECH project protocol integrates previous evidence on the effectiveness of strategies in dementia care, that is, the use of case management, new technologies, nurse home visits and efforts toward the integration of existing services in an ambitious holistic design. The analysis of different interventions is expected to provide sound evidence of the effectiveness and cost of programs supporting AD patients in the community.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01700556.