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Blomberg O, Svedin F, Farrand P, Brantnell A, von Essen L, Patriksson Karlsson J, Åberg AC, Woodford J. Adaptation of a guided low-intensity behavioral activation intervention for people with dementia in Sweden: a qualitative study exploring the needs and preferences of key stakeholders. BMC Geriatr 2024; 24:113. [PMID: 38291349 PMCID: PMC10826011 DOI: 10.1186/s12877-023-04606-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/15/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Despite depression being prevalent in people with dementia, contributing to negative health outcomes and placing increased burden on individuals and family members, access to psychological interventions is limited. A potential solution is guided low-intensity behavioral activation, supported by informal caregivers and guided by healthcare professionals. However, it is necessary to adapt interventions to meet the needs and preferences of key stakeholders to enhance acceptability and relevance. Study objectives were to: (1) explore needs and preferences concerning the content and delivery model of the guided low-intensity behavioral activation intervention; and (2) adapt the intervention to ensure cultural appropriateness, relevancy, and acceptability to people with dementia and their caregivers in Sweden. METHODS Semi-structured interviews and focus group discussions were conducted with key stakeholders, including healthcare professionals (n = 18), community stakeholders (n = 7), people with dementia (n = 8), and informal caregivers (n = 19). A draft of the written low-intensity behavioral activation intervention and a description of the proposed intervention delivery model were provided to participants. Open-ended questions explored the perceived relevance of the intervention, alongside needs and preferences concerning content and delivery. A manifest content analysis approach was adopted. RESULTS Content analysis resulted in three categories: Content, Delivery procedures, and Illness trajectory. Results highlighted a need to consider the intervention Content via increased cultural adaptation to the Swedish context, and increasing the inclusiveness of intervention content. Delivery procedures were identified as needing to be flexible given the unpredictable nature of caring for people with dementia, with the provision of additional guidance to informal caregivers supporting the intervention. Illness trajectory was viewed as essential to consider, with the intervention regarded as suitable for those early in the dementia trajectory, alongside a need to reduce workbook text to minimize burden given dementia symptomology. CONCLUSIONS The intervention and proposed delivery model were generally well received by all stakeholders. We were able to identify key adaptations to enhance cultural appropriateness, relevancy, and acceptability for a currently neglected population. Results will inform a feasibility study to explore the feasibility and acceptability of the intervention and study procedures to inform the design of a future superiority randomized controlled trial. TRIAL REGISTRATION/PROTOCOL Not applicable.
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Affiliation(s)
- Oscar Blomberg
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 85, Sweden
| | - Frida Svedin
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 85, Sweden
| | - Paul Farrand
- Clinical Psychology, Education, Development and Research (CEDAR), Psychology, University of Exeter, Perry Road, EX4 4QG, Devon, UK
| | - Anders Brantnell
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 85, Sweden
- Industrial Engineering and Management, Department of Civil and Industrial Engineering, Uppsala University, Uppsala, 751 21, Sweden
| | - Louise von Essen
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 85, Sweden
| | - Johanna Patriksson Karlsson
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 85, Sweden
| | - Anna Cristina Åberg
- Department of Medical Science, School of Health and Welfare, Dalarna University, Falun, 791 88, Sweden
- Clinical Geriatrics, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, 751 22, Sweden
| | - Joanne Woodford
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 85, Sweden.
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Svedin F, Brantnell A, Farrand P, Blomberg O, Coumoundouros C, von Essen L, Åberg AC, Woodford J. Adapting a guided low-intensity behavioural activation intervention for people with dementia and depression in the Swedish healthcare context (INVOLVERA): a study protocol using codesign and participatory action research. BMJ Open 2021; 11:e048097. [PMID: 34272221 PMCID: PMC8287613 DOI: 10.1136/bmjopen-2020-048097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Dementia is a worldwide health concern with incident rates continuing to increase. While depression prevalence is high in people with dementia and psychological interventions such as cognitive behavioural therapy (CBT) are effective, access to psychological interventions remains limited. Reliance on traditional CBT for people with dementia and depression may present difficulties given it is a complex psychological approach, costly to deliver, and professional training time is lengthy. An alternative approach is behavioural activation (BA), a simpler psychological intervention for depression. The present study seeks to work with people with dementia, informal caregivers, community stakeholders, and healthcare professionals, to adapt a guided low-intensity BA intervention for people with dementia and depression, while maximising implementation potential within the Swedish healthcare context. METHODS AND ANALYSIS A mixed methods study using codesign, principles from participatory action research (PAR) and normalisation process theory to facilitate the cultural relevance, appropriateness and implementation potential of the intervention. The study will consist of four iterative PAR phases, using focus groups with healthcare professionals and community stakeholders, and semi-structured interviews with people with dementia and informal caregivers. A content analysis approach will be adopted to analyse the transcribed focus groups and semi-structured interviews recordings. ETHICS AND DISSEMINATION The study will be conducted in accordance with the Declaration of Helsinki and data handled according to General Data Protection Regulation. Written informed consent will be obtained from all study participants. In accordance with the Swedish Health and Medical Services Act, capacity to consent will be examined by a member of the research team. Ethical approval has been obtained from the Swedish Ethical Review Authority (Dnr: 2020-05542 and Dnr: 2021-00925). Findings will be published in an open access peer-reviewed journal, presented at academic conferences, and disseminated among lay and healthcare professional audiences.
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Affiliation(s)
- Frida Svedin
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Anders Brantnell
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Division of Industrial Engineering and Management, Department of Civil and Industrial Engineering, Uppsala University, Uppsala, Sweden
| | - Paul Farrand
- Clinical Education Development and Research (CEDAR), University of Exeter, Exeter, Devon, UK
| | - Oscar Blomberg
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Chelsea Coumoundouros
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Louise von Essen
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Anna Cristina Åberg
- Geriatrics, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
- Medical Science, School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
| | - Joanne Woodford
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Design and Usability Testing of the Stroke Caregiver Support System: A Mobile-Friendly Website to Reduce Stroke Caregiver Burden. Rehabil Nurs 2021; 45:166-177. [PMID: 30418319 DOI: 10.1097/rnj.0000000000000196] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE The purpose of this study was to design a mobile-friendly, Internet-based website, modeled on previously described websites for Alzheimer caregivers, to equip stroke caregivers and potentially reduce caregiver burden. DESIGN A mixed-methods study was performed to design and test the usability of the Stroke Caregiver Support System (SCSS). METHODS An iterative, user-centered design approach was employed in three phases: (I) Focus Groups, (II) Structured Interviews, and (III) Usability Testing. Phase I and Phase II provided information for the development of the SCSS website, whereas Phase III helped in gathering data regarding the usability and efficacy of the newly implemented SCSS website. FINDINGS Qualitative data on caregiving and the content and design of the SCSS were obtained from focus groups and interviews. In the usability test, the nine caregivers who completed Phase III (78% women, mean age = 46, SD = 17) exhibited a high level of burden and depressive symptoms (median [Q1, Q3] Zarit burden score = 18 [16, 23], Center of Epidemiologic Studies-Depression Scale = 15 [8, 17]). Caregivers conveyed the usability of the SCSS but also expressed several needed improvements. CONCLUSIONS Participants reported the value of the SCSS, but further refinements are needed to maximize its usability and potential efficacy. CLINICAL RELEVANCE The SCSS has potential to reduce caregiver burden in stroke.
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Supported cognitive-behavioural therapy self-help versus treatment-as-usual for depressed informal caregivers of stroke survivors (CEDArS): feasibility randomised controlled trial. COGNITIVE BEHAVIOUR THERAPIST 2020. [DOI: 10.1017/s1754470x20000239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract
Demands placed on informal caregivers can result in an increased likelihood of experiencing common mental health difficulties that may affect their ability to undertake the caring role. Currently, however, few evidence-based interventions have been specifically developed for informal caregivers and available interventions are difficult to access. The Improving Access to Psychological Therapies (IAPT) programme aims to improve access to evidence-based psychological therapies for all groups and may therefore present an opportunity to meet informal caregiver needs. Located within the MRC Complex Intervention Framework, a Phase II feasibility randomised controlled trial (RCT) examines key methodological, procedural and clinical uncertainties associated with running a definitive Phase III RCT of an adapted written cognitive behavioural therapy (CBT) self-help intervention for informal caregivers of stroke survivors. Recruitment was low despite different recruitment strategies being adopted, highlighting significant challenges moving towards a Phase III RCT until resolved. Difficulties with study recruitment may reflect wider challenges engaging informal caregivers in psychological interventions and may have implications for IAPT services seeking to improve access for this group. Further attempts to develop a successful recruitment protocol to progress to a Phase III RCT examining effectiveness of the adapted CBT self-help intervention should be encouraged.
Key learning aims
After reading this article, readers should be able to:
(1)
Consider key feasibility issues with regard to recruitment and attrition when running a randomised controlled trial of an adapted written cognitive behavioural therapy (CBT) self-help intervention for informal caregivers of stroke survivors.
(2)
Understand potential barriers experienced by an informal caregiving population to accessing psychological interventions.
(3)
Appreciate implications for clinical practice to enhance access to IAPT services and low-intensity CBT working with an informal caregiver population.
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Woodford J, Farrand P, Watkins ER, LLewellyn DJ. "I Don't Believe in Leading a Life of My Own, I Lead His Life": A Qualitative Investigation of Difficulties Experienced by Informal Caregivers of Stroke Survivors Experiencing Depressive and Anxious Symptoms. Clin Gerontol 2018; 41:293-307. [PMID: 29185911 DOI: 10.1080/07317115.2017.1363104] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Health and social care services are increasingly reliant on informal caregivers to provide long-term support to stroke survivors. However, caregiving is associated with elevated levels of depression and anxiety in the caregiver that may also negatively impact stroke survivor recovery. This qualitative study aims to understand the specific difficulties experienced by caregivers experiencing elevated symptoms of anxiety and depression. METHODS Nineteen semi-structured interviews were conducted with caregivers experiencing elevated levels of depression and anxiety, with a thematic analysis approach adopted for analysis. RESULTS Analysis revealed three main themes: Difficulties adapting to the caring role; Uncertainty; and Lack of support. CONCLUSIONS Caregivers experienced significant difficulties adapting to changes and losses associated with becoming a caregiver, such as giving up roles and goals of importance and value. Such difficulties persisted into the long-term and were coupled with feelings of hopelessness and worry. Difficulties were further exacerbated by social isolation, lack of information and poor long-term health and social care support. CLINICAL IMPLICATIONS A greater understanding of difficulties experienced by depressed and anxious caregivers may inform the development of psychological support targeting difficulties unique to the caring role. Improving caregiver mental health may also result in health benefits for stroke survivors themselves.
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Affiliation(s)
- Joanne Woodford
- a Clinical Education Development and Research (CEDAR), Psychology: College of Life and Environmental Sciences , University of Exeter , Exeter , United Kingdom
| | - Paul Farrand
- a Clinical Education Development and Research (CEDAR), Psychology: College of Life and Environmental Sciences , University of Exeter , Exeter , United Kingdom
| | - Edward R Watkins
- b Mood Disorders Centre, Psychology: College of Life and Environmental Sciences , University of Exeter , Exeter , United Kingdom
| | - David J LLewellyn
- c University of Exeter Medical School, University of Exeter , Exeter , United Kingdom.,d The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula (NIHR PenCLAHRC) , Exeter, United Kingdom
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Farrand P, Woodford J, Llewellyn D, Anderson M, Venkatasubramanian S, Ukoumunne OC, Adlam A, Dickens C. Behavioural activation written self-help to improve mood, wellbeing and quality of life in people with dementia supported by informal carers (PROMOTE): a study protocol for a single-arm feasibility study. Pilot Feasibility Stud 2016; 2:42. [PMID: 27965860 PMCID: PMC5153814 DOI: 10.1186/s40814-016-0083-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 06/25/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Increases in life expectancy have resulted in a global rise in dementia prevalence. Dementia is associated with poor wellbeing, low quality of life and increased incidence of mental health difficulties such as low mood or depression. However, currently, there is limited access to evidence-based psychological interventions for people with dementia experiencing low mood and poor wellbeing. Behavioural activation-based self-help, supported by informal carers and guided by mental health professionals, may represent an effective and acceptable solution. METHODS/DESIGN The present study is a phase II (feasibility) single-arm trial informed by the Medical Research Council complex interventions research methods framework. Up to 50 dementia participant/informal carer dyads will be recruited from a variety of settings including primary care, dementia-specific health settings and community outreach. People living with dementia will receive behavioural activation-based self-help and be supported by their informal carer who has received training in the skills required to support the self-help approach. In turn, during the use of the intervention, the informal carer will be guided by mental health professionals to help them work through the materials and problem solve any difficulties. Consistent with the objectives of feasibility studies, outcomes relating to recruitment from different settings, employment of different recruitment methods, attrition, data collection procedures, clinical delivery and acceptability of the intervention will be examined. Clinical outcomes for people with dementia (symptoms of depression and quality of life) and informal carers (symptoms of depression and anxiety, carer burden and quality of life) will be measured pre-treatment and at 3 months post-treatment allocation. DISCUSSION This study will examine the feasibility and acceptability of a novel behavioural activation-based self-help intervention designed to promote wellbeing and improve low mood in people living with dementia, alongside methodological and procedural uncertainties associated with research-related procedures. As determined by pre-specified progression criteria, if research procedures and the new intervention demonstrate feasibility and acceptability, results will then be used to inform the design of a pilot randomised controlled trial (RCT) to specifically examine remaining methodological uncertainties associated with recruitment into a randomised controlled design. TRIAL REGISTRATION Current Controlled Trials ISRCTN42017211.
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Affiliation(s)
- Paul Farrand
- Clinical Education Development and Research (CEDAR), Psychology: College of Life and Environmental Sciences, University of Exeter, Washington Singer Labs, Perry Road, Exeter, EX4 4QG UK
| | - Joanne Woodford
- Clinical Education Development and Research (CEDAR), Psychology: College of Life and Environmental Sciences, University of Exeter, Washington Singer Labs, Perry Road, Exeter, EX4 4QG UK
| | - David Llewellyn
- University of Exeter Medical School, St. Luke's Campus, Exeter, EX1 2LU UK
| | - Martin Anderson
- Clinical Education Development and Research (CEDAR), Psychology: College of Life and Environmental Sciences, University of Exeter, Washington Singer Labs, Perry Road, Exeter, EX4 4QG UK
| | - Shanker Venkatasubramanian
- Clinical Education Development and Research (CEDAR), Psychology: College of Life and Environmental Sciences, University of Exeter, Washington Singer Labs, Perry Road, Exeter, EX4 4QG UK
| | - Obioha C Ukoumunne
- NIHR CLAHRC South West Peninsula, University of Exeter Medical School, St. Luke's Campus, Exeter, EX1 2LU UK
| | - Anna Adlam
- Clinical Education Development and Research (CEDAR), Psychology: College of Life and Environmental Sciences, University of Exeter, Washington Singer Labs, Perry Road, Exeter, EX4 4QG UK
| | - Chris Dickens
- University of Exeter Medical School, St. Luke's Campus, Exeter, EX1 2LU UK
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