Day Care for People with Dementia: A Qualitative Study Comparing Experiences from Norway and Scotland

Do people with dementia and carers get what they need? Barriers in social care and carers needs assessments

BACKGROUND

People with dementia and unpaid carers need to go through a social care or carers needs assessment to access and receive subsidised or fully-funded social care. With no previous evidence, this qualitative study aimed to provide insights into the access to, experiences of receiving and conducting social care or carers needs assessments, and access to social care.

METHODS

Unpaid carers of people with dementia and professionals conducting social care or carers needs assessment living or working in England were interviewed remotely about their experiences between April and August 2023. Topic guides were co-produced with two unpaid carers, and both were supported to code anonymised transcripts. Thematic analysis was used to analyse the data.

FINDINGS

Twenty-seven unpaid carers (n = 21) and professionals (n = 6) participated. Four themes were generated: (1) Issues with accessing needs assessments, not the process; (2) Knowledge of needs assessments and the health and social care system; (3) Expectations of unpaid carers; and (4) Post-assessment unmet needs. The most prominent barriers unpaid carers and their relatives with dementia encountered were awareness of and access to needs assessment. Unpaid carers were mostly unaware of the existence and entitlement to a needs assessment, and sometimes realised they had participated in one without their knowledge. Professionals described the pressures on their time and the lack of financial resources within services.

CONCLUSIONS

To facilitate improved access to dementia care and support for carers, the pathway to accessing needs assessments needs to be clearer, with better integration and communication between health and social care.

A scoping review on the psychosocial interventions used in day care service for people living with dementia

BACKGROUND

Adult Day care centres provide an important aspect of care provision through all phases of the dementia illness from diagnosis to the end of life (Dabelko HI 2008) supporting the well-being of both older people living with dementia and their care partners. Services within adult day care settings are designed to provide biopsychosocial health benefits to participants as well as care partner respite.

OBJECTIVE

To examine research studies, literature reviews and grey literature and identify and map the literature on psychosocial interventions used in day care services for older people living with dementia and chart their use, evaluation and outcomes. The research review question is "what are the psychosocial interventions used in day care service for older people living with dementia?" Psychosocial interventions are important non-pharmacological interventions which support people's wellbeing.

METHODS

Inclusion/Exclusion criteria were identified and guided the search strategy. Participants were people aged 60 years and over living with dementia attending day care services. The use of psychosocial interventions for this cohort was the focus of the review. Databases were searched (Cochrane Reviews, CINAHL, Embase, Medline EBSCO, Medline Ovid, Medline PubMed, PsycINFO, Scopus, Open Grey, Lenus and WHO Global Index Medicus databases) using keywords/terms with Boolean operators from 2011 to 2023. Rayyan was used to extract and manage the data.

RESULTS

The findings present a narrative and charting of the data from the 45 papers that met the review criteria, and this data is mapped onto the five objectives. Within this review, interventions were grouped into five broad types: nature (n = 6 papers), memory/cognitive (n = 11 papers), social (n = 17 papers), animal (n = 4 papers), or physical/sensory (n = 7 papers) based interventions.

CONCLUSIONS

This review has illustrated the wide variety in the types, range and facilitation of psychosocial interventions within adult day care services. This review highlights the potential benefits of these interventions. However, findings must be considered in the context that many were provided as brief intervention studies with little evidence of continuation after the study and further research is required given the complex and diverse range of interventions. Results will be of interest to practitioners planning to implement or evaluate psychosocial interventions used in day care services for older people living with dementia.

I want to be seen as myself: needs and perspectives of persons with dementia concerning collaboration and a possible future move to the nursing home in palliative dementia care

Introduction: Interprofessional collaboration (IPC) within and during movements between care settings is crucial for optimal palliative dementia care. The objective of this study was to explore the experiences of persons with dementia regarding collaboration with and between healthcare professionals (HCPs) and their perceptions of a possible future move to the nursing home (NH) in palliative dementia care. Method: We conducted a cross-sectional qualitative study and performed semi-structured interviews with a purposive sample of persons with dementia living at home (N = 18). Data analysis involved content analysis. Results: Our study demonstrated that even though most persons with dementia find it difficult to perceive the collaboration amongst HCPs, they could describe their perceived continuity of care (Theme 1. My perception of collaboration among HCPs). Their core needs in collaboration with HCPs were receiving information, support from informal caregivers, personal attention and tailored care (Theme 2. My needs in IPC). Regarding a possible future move to the NH, persons with dementia cope with their current decline, future decline and a possible future move to the NH (Theme 3. My coping strategies for a possible future move to the NH). They also prefer to choose the NH, and continue social life and activities in their future NH (Theme 4. My preferences when a NH becomes my possible future home). Conclusion: Persons with dementia are collaborative partners who could express their needs and preferences, if they are willing and able to communicate, in the collaboration with HCPs and a possible future move to the NH.

Impact of additional community services provision on dementia caregiver burden: an interrupted time-series analysis of 12-year interRAI assessments in Hong Kong

OBJECTIVES

To evaluate the impact of providing additional dementia caregiver support services on caregiver burden.

DESIGN

Interrupted time-series analysis using territory-wide panel data.

SETTINGS

All public-funded district elderly community centres in Hong Kong (HK).

PARTICIPANTS

Primary caregivers for older adults (age over 65 years) living with dementia assessed through International Residential Assessment in HK between 1 October 2004 and 31 September 2016. Paid caregivers were excluded.

INTERVENTIONS

In April 2014, US$280 million was allocated to provide additional psychological support, education and respite care for dementia caregivers in HK.

MAIN OUTCOME MEASURES

Caregiver burden was measured by two age-standardised rates: (1) caregivers in emotional distress; and (2) caregivers with long care time in a week (more than 20 hours a week). We fitted the two time-series into Autoregressive Integrated Moving Average models to evaluate intervention impacts, with follow-up analyses to consider a 6-month transition period of policy implementation. Segmented linear regressions and Holt-Winter exponential smoothening models were used as sensitivity analyses.

RESULTS

36 689 dementia caregivers were included in this study, of which 14.4% caregivers were distress and 31.9% were long-hours caregivers after the policy intervention in April 2014. Providing additional caregiver service significantly reduced standardised rates of caregivers in distress (β (95% CI)=-3.93 (-7.85 to -0.01), p<0.05), but the effect was not sustained (p=0.183). There was no significant impact on the level of age-standardised rates of caregiver with long care time (β (95 CI)=-4.25 (-9.61 to 1.10), p=0.120). Also, there was no significant delay of intervention impacts.

CONCLUSION

Our study finds that strengthening caregiver services provision could reduce distress rates among primary caregivers for older adults living with dementia. Expanding community services for caregiver could be a solution to the escalating burden of informal care for people living with dementia.

A social practice theory approach to exploring the ubiquity of quizzes in dementia care settings

Quizzes are a ubiquitous part of the dementia social care landscape. This article explores why. Using an ethnographic approach which draws on close analysis of communication, we examine dementia quizzes as a ‘social practice’, and what such a lens can tell us about their popularity in social care settings. Vignettes of real interactions drawn from ten different quizzes recorded in four different group settings attended by 28 people living with dementia and 15 staff members are presented to highlight particular issues. We show that the conditions of post-diagnosis dementia social care are uniquely well suited to an activity such as quizzes which are malleable, requiring little preparation or materials, and impose a communication framework which can help to organise the interactional space. Quizzes also draw on previously forged interactional competences, such as turn-taking and question–answer sequences, a skill that has been shown to persist even as dementia progresses. Finally, we argue that the meaning of quizzes with people with dementia feeds into wider societal values and associations attached to memory, dementia and personhood. The extent to which quizzes are akin to a ‘test’ or a fun and enjoyable social activity rests in how they are enacted. We suggest that practice can be adapted, developed and made more inclusive through input from people living with dementia themselves.

Intermediate care in caring for dementia, the point of view of general practitioners: A key informant survey across Europe

Background

Intermediate care is often defined as healthcare occurring somewhere between traditional primary (community) and secondary (hospital) care settings. High quality intermediate care is important in dementia, may prevent caregiver burnout and also lead to optimal care for people with dementia. However, very little is known about the point of intermediate care for persons with dementia in Europe.

Research questions

What intermediate care services exist and how are they utilized in the care of people with dementia in Europe?

Objective

This study aims at describing the point of view of General Practitioners on intermediate care services for people with dementia across Europe.

Methods

Key informant survey was sent to GPs via a self-developed questionnaire with space for open ended comments. 16 European countries participated to this cross-sectional mixed method study. Given the volunteer nature of the study, no minimum sample size requirements were applied to participation. Convenience sampling technique was used to address variations due to regional variations and regulations within the same country. Descriptive analyses of all intermediate care facilities groups by countries were performed. Qualitative analyses approach was used for the optional-free text to exemplify and/or complete the reasons contained in the closed response categories.

Results

The questionnaire was sent to 16 European countries. 583 questionnaires were analyzed. The responding physicians were 48 (± 11) years old on average and they had been in practice for an average of 18 (+ /11) years. The types of intermediate care considered were integrated at-home services, respite and relief services, day care centers and nursing homes. Their availability was considered very inhomogeneous by the majority of respondents. The main benefits of intermediate care cited were better medical care for the patient (78%), better quality of life for the caregiver (67%), prevention of the caregiver burden (73%) and a break for the caregiver (59%). The reported difficulties were: accessing these facilities due to limited financial support (76%) and cumbersome administrative procedures (67%). Many other facets of our findings were captured in the qualitative themes that emerged.

Conclusion

Intermediate care in Europe is diverse and heterogeneous. Major concerns of GPs are about the cost issues and the cumbersome administrative procedures to access them.

Self-reported quality of life in people with dementia attending a day-care programme in Norway: A 24-month quasi-experimental study

The objectives of the study were (a) to compare self-reported Quality of Life (QoL) in a 24-month follow-up of people with dementia attending day care designed for people with dementia (day-care group, DC) with people with dementia who did not attend day care (control group, CG) and (b) to explore factors associated with QoL. A quasi-experimental design with a 24-month follow-up period was used. The DC group included 181 participants recruited from 53 day-care services. The CG included 76 participants recruited from 19 municipalities with no available day care designed for people with dementia. The sample covered the four health regions of Norway and inclusion period lasted from December 2013 to July 2015. The Quality of Life in Alzheimer's Disease (QoL-AD) scale was used as the outcome measure. The differences in QoL between groups and the associations between participant characteristics and QoL, such as depressive symptoms and functional dependency, were examined using a linear mixed model. In the multiple model, the overall trend in QoL did not differ significantly between the DC and CG. However, the DC group exhibited significantly higher self-reported QoL than the CG at all time points (p < 0.001 at T0, p = 0.018 at T12, and p = 0.006 at T24). Participants with shallow or no awareness who attended day care had significantly higher scores on QoL-AD than persons with full awareness (p = 0.017). More depressive symptoms (p < 0.001) and higher functional dependency (p < 0.001) were associated with lower self-reported QoL. The study revealed higher scores of self-reported QoL among people attending day care compared with those who did not attend, showing that day care might have positive impact on the lives of people with dementia.

Resource allocation in dementia care: comparing the views of people with dementia, carers and health and social care professionals under constrained and unconstrained budget scenarios

BACKGROUND

People with dementia and their carers have a wide range of health and social care needs. People with dementia, carers and health and social care professionals (HSCPs) all have different perspectives on dementia care. Differences among these groups are important for commissioners of services and for front-line HSCPs.

OBJECTIVE

To compare the service recommendations of people with dementia and carers with those of HSCPs, under different budgetary conditions.

METHODS

A mixed-methods approach, which builds on the Balance of Care method, was used. Nine workshops were held with 41 participants from three groups: people with dementia, carers and HSCPs. Participants were asked to make decisions on a set of services for case types of dementia under two scenarios: a no budget constraint (NBC) scenario and a budget constraint (BC) scenario.

RESULTS

While each group allocated resources in broadly similar overall proportions, important differences in emphasis emerged: (i) people with dementia and carers placed more emphasis on psychosocial supports than HSCPs; (ii) carers put more emphasis on respite opportunities for carers; and (iii) carers identified residential care as the most suitable setting for the person with dementia more frequently than health care professionals.

CONCLUSION

Our findings suggest that the importance of psychosocial interventions, including counselling and peer support programmes, are currently underestimated by HSCPs. The provision of in-home respite is highly valued by carers. Even with unconstrained resources, some carers do not judge home care to be a viable option for dementia case types with high-level care needs.

Being sheltered from a demanding everyday life: experiences of the next of kin to people with dementia attending farm-based daycare

PURPOSE

Farm-based daycare (FDC) is a type of daycare service for people with dementia. The aim of the present study was to explore the next of kin's experiences with FDC and how the service may affect their daily life.

METHODS

The study has a qualitative, descriptive design. Eight semi-structured interviews with next of kin were conducted. The data were analysed in accordance with content analysis.

RESULTS

We identified three main categories: (1) I am fine when you are fine, (2) Significant aspects of the service at the farm, and (3) FDC as a part of the dementia trajectory. The findings were summarized in one overarching, latent theme: "Being sheltered from a demanding everyday life".

CONCLUSIONS

The findings indicate that next of kin's experience of respite is closely connected to the well-being of their relatives at the FDC and the quality of the service. FDC provides significant support through a part of the trajectory of dementia. Despite experiencing respite and support, next of kin continue to struggle with ethical and moral decisions about the futures of their relatives with dementia.

Virtual day center for people with dementia and their caregivers during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic suspended face-to-face assistance offered by community spaces, such as day centers (DCs). People with dementia (PwD) and their families were faced with the risks posed by social detachment and suspension of treatments.

Coping with Everyday Life for Home-Dwelling Persons with Dementia: A Qualitative Study

Aim

This study aimed to gain insight into factors that influence everyday coping strategies as described by persons with early to intermediate dementia.

Background

Living with dementia presents difficulties coping with everyday life. This study focuses on coping with everyday life for persons with mild to moderate dementia in order to facilitate their ability to live at home.

Design

A qualitative study.

Methods

Individual interviews with 12 persons with dementia were conducted in their own homes.

Findings

Coping with everyday life can be influenced by the experience of the diagnostic process and by information about dementia. It can also be affected by stigmatization of persons with dementia, as well as by challenges in everyday life. In addition, challenges in receiving help may include poor continuity of services and healthcare staff with limited competence. By contrast, person-centered care led to positive experiences that supported everyday coping skills. Most of the respondents wanted to participate in day care several days a week. Other positive experiences were making new friends and participating in meaningful activities; such experiences could enhance to coping strategies.

Conclusion

To strengthen everyday coping for persons with dementia living at home, there is a need for openness about the disease. Follow-up for persons with dementia must be carried out by reputable professionals trained and educated in dementia care. Finally, the municipalities must have contact persons, dementia coordinator/-team, who are available for persons with dementia at the time of diagnosis position and afterwards.

"A piece of paper is not the same as having someone to talk to": accessing post-diagnostic dementia care before and since COVID-19 and associated inequalities

Background

Social support services such as day care centres are important in post-diagnostic dementia care to enable people living with dementia stay at home for longer. Little research has addressed potential inequalities in access, with no research on variations before and since COVID-19. The aim of this study was to explore inequalities in social support service usage before and since the pandemic.

Methods

Unpaid carers and people living with dementia were interviewed over the phone about their experiences of accessing social support services before and since the COVID-19 pandemic. Transcripts were analysed for key themes using inductive and deductive thematic analysis.

Results

Fifty participants (42 unpaid carers; eight people living with dementia) were interviewed, and five themes identified: (1) Service issues; (2) Access issues; (3) Relying on own initiative; (4) New inequalities due to COVID-19; and (5) Missing out on the benefits of support services. Participants reported transport, finances, and location as factors reducing their ability to access support service pre-COVID, with inequalities remaining and at times exacerbated since. Carers and people living with dementia also reported struggling with accessing basic necessities during COVID, including food and medicines.

Conclusions

Considering the benefits of accessing support services, resourced procedures and facilities are needed to maintain access to support services with more accessible remote support provision, enabling people from all backgrounds to access the care they need.

Geographic availability and accessibility of day care services for people with dementia in Ireland

Background

Day care is an important service for many people with dementia and their carers. In Ireland, day care services for people with dementia are delivered by a mix of dementia-specific day care centres as well as generic day care centres that cater for people with dementia to various degrees. In this paper we examine the geographic distribution of day care services for people with dementia relative to potential need.

Methods

Using a national survey of day care centres, we estimate the current availability of day care services for people with dementia in the country. We use geographic information systems (GIS) to map day care provision at regional and sub-regional levels and compare this to the estimated number of people with dementia in local areas.

Results

There is significant variation across the country in the existing capacity of day care centres to cater for people with dementia. The number of places per 100 persons with dementia in the community varies from 14.2 to 21.3 across Community Health Organisation areas. We also show that 18% of people with dementia do not live within 15kms of their nearest day care centre.

Conclusion

Currently, day care centres, in many parts of the country, have limited capacity to provide a service for people with dementia who live in their catchment area. As the number of people with dementia increases, investment in day care centres should be targeted to areas where need is greatest. Our GIS approach provides valuable evidence that can help inform decisions on future resource allocation and service provision in relation to day care.

Non-use of community health-care services – an exploratory cross-sectional study among family care-givers for older, home-dwelling persons with dementia

Community health-care services for older, home-dwelling persons with dementia tend to be underutilised. Family care-givers provide substantial care, and they often arrange for and co-ordinate health-care services on behalf of persons with dementia. The aim of this study was to examine family care-givers’ knowledge of unused services and their self-reported reasons for non-use of such services. We gathered cross-sectional survey data from 430 family care-givers of older persons with dementia in Northern Norway. Multinomial logistic regression analysis was used to identify predictors of family care-givers’ knowledge of unused services. An open-ended question regarding reasons for non-use of services was analysed by thematic text analysis. Characteristics of family care-givers (e.g. education level) and factors related to the care-giving circumstances (e.g. negative impact of care-giving) predicted family care-givers’ knowledge of unused services. Reasons for non-use of services were multifaceted and complex, and were related to attributes of the person with dementia and/or the family care-giver (e.g. reluctance to use services) and/or the health-care services (e.g. low quality). Although services were unused, several family care-givers indicated substantial needs for the services. Strategies aimed at addressing the non-use of services should emphasise individuals’ and families’ needs and the adaptation of information about available services and their benefits for both care recipients and family care-givers. A relationship-centred care approach is thus recommended in dementia care.

Effectiveness of day care in supporting family caregivers of people with dementia: A systematic review

Day care (DC) provides a break in daily care as a support strategy for family caregivers (FC) of people with dementia (PwD).

Objective

to analyze the support strategies used by the DC for FC, their methodological and theoretical models, as well as the respective benefits for FC burden, coping strategies and quality of life.

Methods

a systematic review following the Prisma methodology was performed on PubMed, PsycInfo, Scopus and SciELO electronic databases in August, 2018. The search keywords were "day care", "dementia" or Alzheimer disease, "caregiver", "quality of life" and "psychological adaptation".

Results

twenty-one studies were included. No randomized controlled trials were found. The provision of education, counseling and support, access to information, the professionals' expertise and the quality of their relationship with DC users were highlighted by caregivers. Compared to standard programs centering on PwD, the integrated program focused on PwD and FC activities showed increased feelings of competence and self-confidence of FC to postpone institutionalization. Heterogeneity in the structure and organization of the DC programs, intervention strategies and theoretical basis was observed.

Conclusion

Integrated programs are a promising approach that addresses the needs and demands of PwD and their FC in a multidimensional manner.

Farm-based day care services - a prospective study protocol on health benefits for people with dementia and next of kin

Introduction

The increasing number of people with dementia will place a considerable challenge on the health care system and will necessitate innovation and new solutions. Day care services aim to provide meaningful activities and coping experiences for the target group. The aim of the present study is to explore the experience and potential health benefits for people with dementia attending farm-based day care services in Norway and their next of kin.

Methods and design

The present study is a prospective study organized into several qualitative and quantitative sub-studies. Study period will last from 2016-2020. We use a multi-method approach and both an empirical and a constructivist view on knowledge to explore this multi-facetted phenomenon.

Discussion

Several challenges are expected, for instance, the ability to include participants with dementia and keep them within the study for the whole study period. The functioning level of participants regarding language and understanding could challenge their ability to answer. Despite having several limitations, we believe that this study with its different approaches and methods will add important knowledge to the field. Knowledge from our study could be essential for creating day care services of good quality for people with dementia and such services could reduce the burden of care for their next of kin.

Facilitation of activities for people with dementia in day care: a qualitative study exploring the experiences of staff

Background: Day care service (day care) is recommended as an activity service for home-dwelling people with dementia in Norway. However, there is limited knowledge about strategies to promote engagement and participation in activities at day care. The aim of this study was to gain understanding of the staff’s experiences on how to enhance engagement and participation in activities for attendees.

Methods: The study has a qualitative design, using group interviews with staff and field observations at day care designed for people with dementia. Thematic content analysis was used to analyze interviews, and the findings from the observations were used to illuminate the findings in the interviews. Three group interviews including a total of 10 staff participants were conducted. Additionally, 35 attendees were observed during 2 days of field observations at each day care.

Results: The main theme that emerged from the analysis was the staff’s primary objective to make meaningful days for the attendees. To achieve this, the importance of having individual knowledge about the attendees to enhance relationships, creating a balanced group composition, personal competence and skills of the staff, and the importance of using activities in different ways, was highlighted. Most findings from the field observations coincide with those in the interviews. However, the observations revealed that the staff seemed to have insufficient knowledge of offering individual tailored and structured meaningful activities to the attendees. There is a potential of including the attendees even more in the ongoing activities.

Conclusion: Staff play an important role in promoting and facilitating activities to increase engagement and participation in activities. There is a potential for greater structured use of activities and cognitive stimulation. To avoid occupational injustice and the risk of decreased health and well-being among home-dwelling people with dementia, more differentiated and individual tailored services are needed.

The impact of attending day care designed for home-dwelling people with dementia on nursing home admission: a 24-month controlled study

BACKGROUND

Day care services offer meaningful activities, a safe environment for attendees and respite for family caregivers while being expected to delay the need for nursing home (NH) admission. However, previous research has shown inconsistent results regarding postponement of NH admission. The objective of the study was to explore the influence of a day care programme designed for home-dwelling people with dementia on NH admission.

METHOD

A quasi-experimental trial explored the proportion of patients permanently admitted to nursing homes after 24 months as the main outcome by comparing a group of day care attendees (DG) and a group of participants without day care (CG). In all, 257 participants were included (181 in DG and 76 in CG). A logistic regression model was developed with NH admission as the outcome. Participant group (DG or CG) was the main predictor, baseline patient and family caregiver characteristics and interactions were used as covariates.

RESULTS

The mean age of participants was 81.5 (SD 6.4), 65% were women and 53% lived alone. The mean MMSE score was 20.4 (SD 3.5). In all, 128 (50%) of the participants were admitted to a nursing home by the 24-month follow-up, 63 participants (25%) completed the follow-up assessment and 66 (26%) dropped out due to death (8%) and other reasons (18%). In the logistic unadjusted regression model for NH admission after 24 months, participant group (DG or CG) was not found to be a significant predictor of NH admission. The results from the adjusted model revealed that the participant group was associated with NH admission through the interactions with age, living conditions, affective symptoms, sleep symptoms and practical functioning, showing a higher probability for NH admission in DG compared to CG.

CONCLUSION

The study reveals no evidence to confirm that day care services designed for people with dementia postpone the need for NH admission. Admission to nursing homes seems to be based on a complex mix of personal and functional characteristics both in the person with dementia and the family caregivers. The findings should be considered in accordance with the limitation of inadequate power and the high drop-out rate.

TRIAL REGISTRATION

The study is registered in Clinical Trials ( NCT01943071 ).

Farm-based day care in Norway - a complementary service for people with dementia

Background

Day care services provide meaningful activities and coping experiences in a safe environment for people with dementia, as well as improve quality of life. Such services vary in types and settings. Farm-based day care (FDC) services are described as services that have been adapted from the farm setting, using farm resources to promote health. There is limited knowledge on the service offered in both FDC and regular day care services for people with dementia. The present study aims to investigate FDC in Norway and describe the services and the participants’ care environment.

Materials and methods

We mapped the existing farms offering day care in Norway by the spring 2017 (N=33) and collected information through two cross-sectional surveys (N=32) answered by the service providers at the farms.

Results

The farms included in this survey provided day care services to 227 people with dementia, located in most regions of Norway. The services varied in terms of group size and half of the services had young people with dementia (≤65 years) and people with dementia at an early stage as their primary target group. About half of the staff had health care education (47.5%), and there were staff with agricultural competence available in most FDCs. All farms reported that the participants spent time outdoors every day, and all services, except two, had animals. The providers highlighted the opportunity to choose activities that were individually tailored for each participant, as the diversity of resources in the farm made it possible to organize different activities.

Conclusion

FDC services have similarities in organization, daily structure, and number of health education personnel to other day care services, but differ in type of care environment with a wide range of activities and available resources like farm buildings, gardens, animals, and outdoor areas.