Caring for Persons Living With Dementia During the COVID-19 Pandemic: Advocacy Perspectives From India

Challenges faced by older people with dementia during the COVID-19 pandemic as perceived by professionals: a qualitative study with interviews

BACKGROUND

Previous studies have highlighted a decline in the mental health of older adults over the course of the coronavirus disease 2019 (COVID-19) pandemic. Few studies have determined the possible causes of behavioural and psychological symptoms of dementia during COVID-19 in a comprehensive manner. We aimed to identify the challenges faced by older adults with dementia during the COVID-19 pandemic.

METHODS

This study adopted a qualitative approach to understanding the perceptions of healthcare professionals, such as regarding the negative effects of COVID-19 on the mental health of people with dementia. Between January and March 2022, the authors conducted individual in-depth interviews on how COVID-19 affected the stress levels, care, and self-determination of people with dementia. Qualitative data from the individual interviews were data cleansed to ensure the clarity and readability of the transcripts. The qualitative data were then analyzed by inductive manual coding using a qualitative content analysis approach. The grouping process involved reading and comparing individual labels to cluster similar labels into categories and inductively formulate themes.

RESULTS

Qualitative analysis extracted 61 different semantic units that were duplicated. Seven categories were inductively extracted using a grouping process. These were further integrated to extract the following four themes: fear of personal protective equipment (PPE), loneliness, dissatisfaction with behavioural restrictions and limitations of video calls, and family interference with service use.

DISCUSSION

People with dementia often faced mental distress during the pandemic owing to preventive measures against COVID-19, and a lack of awareness and understanding of such preventive measures worsened their distress. They experienced a severe sense of social isolation and loneliness. Findings also indicated that families tended to ignore the needs of people with dementia and their decisions and opinions regarding healthcare service use.

Ad Hoc Modifications to a High Dependency Psychiatric Unit for People With Dementia During the COVID-19 Period

The COVID-19 pandemic led to behavioral exacerbations in people with dementia. Increased hospitalizations and lack of bed availability in specialized dementia wards at a tertiary psychiatric hospital in Singapore resulted in lodging people with dementia in the High Dependency Psychiatric Unit (HDPCU). Customizations to create a dementia-friendly environment at the HDPCU included: (1) environmental modifications to facilitate orientation and engender familiarity; (2) person-centered care to promote attachment, inclusion, identity, occupation, and comfort; (3) risk management for delirium; and (4) training core competencies. Such practical solutions can also be implemented elsewhere to help overcome resource constraints and repurpose services to accommodate increasing populations of people living with dementia.

Ways of interdisciplinary approaches to advocating for nursing home residents with dementia

AIM

To explore how nursing home staff advocate for residents with dementia.

DESIGN

Phenomenographic qualitative research.

METHODS

Twenty nursing home staff from four disciplines (six nurses, four physical therapists, five social workers and five care workers) were purposively recruited from three different nursing homes. Data were collected through semi-structured interviews conducted from February 2023 to March 2023, and the analysis followed the sequential steps of phenomenographic analysis.

RESULTS

The analysis identified five categories of description: focusing on what happened, finding the gaps in perspectives, how to bridge for finding a common perspective, how to tailor care such that each resident receives equitable care and how to establish interdisciplinary sharing for a consistent advocative pattern. Their structural relationship was also identified as an outcome space.

CONCLUSION

The cyclical advocacy structure illustrated that nursing home staff engage in an ongoing process of advocacy during conflict situations as part of interdisciplinary care, emphasizing continuity of care rather than separate occurrences of care.

IMPLICATIONS FOR THE PROFESSION

This study revealed that, in advocating for residents with dementia, nursing home staff adopted an approach that fosters consistent care and proactive prevention, achieved through the formation of shared knowledge applicable uniformly across similar situations.

IMPACT

This study contributes significantly to the continuing education or training of interdisciplinary staff in nursing homes. The revelations of the study hold significance not only for the practical application but also for the theoretical advancement of concepts related to safeguarding the dignity, human rights and personhood of residents with dementia, with the ultimate goal of enhancing their quality of life within nursing homes.

REPORTING METHOD

Reporting complied with the COREQ criteria for qualitative research.

PATIENT OR PUBLIC CONTRIBUTION

Nursing home directors have contributed to the validation of data analysis and interpretation.

Pathways to care for people with dementia in India: An exploratory study using case vignettes

BACKGROUND

Limited evidence exists on how people living with dementia and their family/unpaid carers navigate care and support in India.

AIM

This study used case vignettes to illustrate likely pathways to care for dementia, from receiving a diagnosis to long-term support, in India and to highlight gaps and challenges associated with current care provision for persons living with dementia.

METHODS

As part of the Strengthening Responses to Dementia in Developing Countries (STRiDE) project, and to contribute to an analysis of dementia care policies and systems in India, case vignettes were used to illustrate the diverse situations that people with dementia and their families may experience when seeking care in the Indian context. Eight hypothetical, but realistic cases of people with dementia were created by a multi-disciplinary team with experience in dementia care in India, to map out the likely care journeys of each case.

RESULTS

Investigating eight diverse care trajectories of people living with dementia highlighted important patterns relevant to the Indian context. We identified delays in dementia diagnosis to be attributed to low awareness of dementia among the general public and medical professionals in addition to a critical shortage of specialist services involved in facilitating dementia diagnosis. Post-diagnosis, support was recognized as limited and associated with considerable out-of-pocket (OOP) costs. Families primarily provide long-term care for people with dementia till end of life.

CONCLUSIONS AND RECOMMENDATIONS

Several steps need to be taken in order to improve dementia care in India. Increasing dementia awareness among both medical professionals and general public is essential. Shortages in dementia specialists can be addressed in part through appropriate task shifting. Lastly, more research is needed to develop evidence-based community interventions to support informal care provision for persons with dementia in India.

COVID-19: Experiences of Social Workers Supporting Older Adults With Dementia in Nigeria

Amidst the COVID-19 pandemic, numerous public health protocols were instituted by government agencies to safeguard individuals with dementia, their family caregivers, and formal care providers. While these preventive measures were implemented with good intentions, they inadvertently imposed significant challenges on medical social workers in Nigeria. This paper explored the experiences of medical social workers caring for people with dementia during the COVID-19 pandemic in Nigeria. Twenty-six medical social workers from 6 government hospitals in Southwestern Nigeria participated in an in-depth interview. The research reveals 3 pivotal aspects: Firstly, the escalating demands within the work environment, where medical social workers grapple with the intricate task of conveying sensitive information about dementia diagnosis and COVID-19 prevention protocol, managing expectations regarding dementia diagnoses, and navigating resource constraints for individuals with dementia during the pandemic. Secondly, discernible impacts on the work climate and interprofessional relationships shed light on the challenges these professionals face in collaborating with other healthcare providers. Lastly, the reverberations on social workers' personal lives underscore the pandemic's toll on their well-being. Thus, the findings underscore the need for proactive measures to equip medical social workers to face the distinctive challenges in dementia care during future pandemics. Recognizing the potential resurgence of global health crises, the research highlights the need for strategic preparedness to mitigate the impact of future pandemics on the well-being of individuals with dementia and the professionals dedicated to their care.

Predictors of loneliness during the Covid-19 pandemic in people with dementia and their carers in England: findings from the DETERMIND-C19 study

OBJECTIVES

To identify factors that predict the risk of loneliness for people with dementia and carers during a pandemic.

METHODS

People with dementia and their carers completed assessments before (July 2019-March 2020; 206 dyads) and after (July-October 2020) the first Covid-19 'lockdown' in England. At follow-up, the analytic sample comprised 67 people with dementia and 108 carers. We built a longitudinal path model with loneliness as an observed outcome. Carer type and social contacts at both measurements were considered. Other social resources (quality of relationship, formal day activities), wellbeing (anxiety, psychological wellbeing) and cognitive impairment were measured with initial level and change using latent growth curves. We adjusted for socio-demographic factors and health at baseline.

RESULTS

In carers, higher levels of loneliness were directly associated with non-spouse coresident carer type, level and increase of anxiety in carer, more formal day activities, and higher cognitive impairment in the person with dementia. In people with dementia, non-spouse coresident carer type, and higher initial levels of social resources, wellbeing, and cognitive impairment predicted the changes in these factors; this produced indirect effects on social contacts and loneliness.

CONCLUSION

Loneliness in the Covid-19 pandemic appears to be shaped by different mechanisms for people with dementia and their carers. The results suggest that carers of those with dementia may prioritize providing care that protects the person with dementia from loneliness at the cost of experiencing loneliness themselves. Directions for the promotion of adaptive social care during the Covid-19 pandemic and beyond are discussed.

Intersections of ageism toward older adults and other isms during the COVID-19 pandemic

The COVID-19 pandemic is a significant global issue that has exacerbated pre-existing structural and social inequalities. There are concerns that ageism toward older adults has intensified in conjunction with elevated forms of other "isms" such as ableism, classism, heterosexism, racism, and sexism. This study offers a systematic review (PRISMA) of ageism toward older adults interacting with other isms during the COVID-19 pandemic. Articles were searched in 10 databases resulting in 354 ageism studies published between 2019 and August 2022 in English, French, Portuguese, or Spanish. Only 32 articles met eligibility criteria (ageism together with other ism(s); focus on the COVID-19 pandemic); which were mostly review papers (n = 25) with few empirical papers (n = 7), reflecting almost all qualitative designs (n = 6). Articles discussed ageism with racism (n = 15), classism (n = 11), ableism (n = 9), sexism (n = 7), and heterosexism (n = 2). Authors represented numerous disciplines (gerontology, medicine, nursing, psychology, social work, and sociology) and countries (n = 14) from several continents. Results from this study underscore that ageism intersects with other isms in profoundly negative ways and that the intersections of ageism and other isms are understudied, requiring more research and intervention efforts.

Perceived access to general and mental healthcare in primary care in Colombia during COVID-19: A cross-sectional study

Introduction

The COVID-19 pandemic has had an impact both in general and mental healthcare, challenged the health systems worldwide, and affected their capacity to deliver essential health services. We aimed to describe perceived changes in ease of access to general and mental healthcare among patients with a diagnosis of depression and/or unhealthy alcohol use in Colombia.

Methods

This study is embedded in the DIADA project, a multicenter implementation research study aimed at evaluating the integration of mental healthcare in primary care in Colombia. Between November 2020 and August 2021, we conducted a COVID-19 pandemic impact assessment in a cohort of participants with newly diagnosed depression and/or unhealthy alcohol use part of DIADA project. We assessed the ease of access and factors related to perceived ease of access to general or mental healthcare, during the COVID-19 pandemic.

Results

836 participants completed the COVID-19 pandemic impact assessment. About 30% of participants considered their mental health to be worse during the pandemic and 84.3% perceived access to general healthcare to be worse during the pandemic. Most of participants (85.8%) were unable to assess access to mental health services, but a significant proportion considered it to be worse. Experiencing worse ease of access to general healthcare was more frequent among women, patients with diagnosis of depression, and patients with comorbidities. Experiencing worse ease of access to mental healthcare was more frequent among patients aged between 30 and 49.9 years, from socioeconomic status between 4 and 6, affiliated to the contributive social security regime, attending urban study sites, and those who perceived their mental health was worse during the pandemic.

Discussion

Despite the overall perception of worse mental health during the pandemic, the use of mental healthcare was low compared to general healthcare. Ease of access was perceived to be worse compared to pre-pandemic. Ease of access and access were affected by geographical study site, socioeconomic status, age and gender. Our findings highlight the need for improved communication between patients and institutions, tailored strategies to adapt the healthcare provision to patients' characteristics, and continued efforts to strengthen the role of mental healthcare provision in primary care.

Exploring the Paradox of COVID-19 in Neurological Complications with Emphasis on Parkinson’s and Alzheimer’s Disease

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a human coronavirus (HCoV) that has created a pandemic situation worldwide as COVID-19. This virus can invade human cells via angiotensin-converting enzyme 2 (ACE2) receptor-based mechanisms, affecting the human respiratory tract. However, several reports of neurological symptoms suggest a neuroinvasive development of coronavirus. SARS-CoV-2 can damage the brain via several routes, along with direct neural cell infection with the coronavirus. The chronic inflammatory reactions surge the brain with proinflammatory elements, damaging the neural cells, causing brain ischemia associated with other health issues. SARS-CoV-2 exhibited neuropsychiatric and neurological manifestations, including cognitive impairment, depression, dizziness, delirium, and disturbed sleep. These symptoms show nervous tissue damage that enhances the occurrence of neurodegenerative disorders and aids dementia. SARS-CoV-2 has been seen in brain necropsy and isolated from the cerebrospinal fluid of COVID-19 patients. The associated inflammatory reaction in some COVID-19 patients has increased proinflammatory cytokines, which have been investigated as a prognostic factor. Therefore, the immunogenic changes observed in Parkinson's and Alzheimer's patients include their pathogenetic role. Inflammatory events have been an important pathophysiological feature of neurodegenerative diseases (NDs) such as Parkinson's and Alzheimer's. The neuroinflammation observed in AD has exacerbated the Aβ burden and tau hyperphosphorylation. The resident microglia and other immune cells are responsible for the enhanced burden of Aβ and subsequently mediate tau phosphorylation and ultimately disease progression. Similarly, neuroinflammation also plays a key role in the progression of PD. Several studies have demonstrated an interplay between neuroinflammation and pathogenic mechanisms of PD. The dynamic proinflammation stage guides the accumulation of α-synuclein and neurodegenerative progression. Besides, few viruses may have a role as stimulators and generate a cross-autoimmune response for α-synuclein. Hence, neurological complications in patients suffering from COVID-19 cannot be ruled out. In this review article, our primary focus is on discussing the neuroinvasive effect of the SARS-CoV-2 virus, its impact on the blood-brain barrier, and ultimately its impact on the people affected with neurodegenerative disorders such as Parkinson's and Alzheimer's.

A Robot-Mediated Activity Using the Nao Robot to Promote COVID-19 Precautionary Measures among Older Adults in Geriatric Facilities

Precautionary measures (e.g., social distancing, mask wearing, washing hands regularly) to limit the transmission of the Coronavirus 19 (COVID-19) have been put in place worldwide. However, a limited understanding of precautionary measures and low compliance with them has been observed in older adults with neurocognitive disorders, persons with intellectual disability, or mental illness. The objective of this study is to create and evaluate a robot-mediated activity to deliver information on COVID-19 precautionary measures in an accessible and engaging way using the humanoid robot Nao. An interactive scenario explaining and demonstrating COVID-19 precautionary measures is created using the verbal and non-verbal behaviours of the robot. The scenario (≈5 min) is presented to 124 users of a geriatric hospital, including the following: older patients (n = 45), accompanying persons (n = 39), and health professionals (n = 40). The data regarding perceived usefulness, acceptability, and accessibility are collected using a questionnaire. A video analysis of the participants' behaviour during the interaction with the robot is performed to examine the quality of engagement in the activity. The results show a good acceptance, satisfaction, and perceived usefulness of the robot-mediated activity. These findings suggest that robot-mediated interventions using humanoid robots can be an effective tool for the delivery of health promotion information.

Emotional Function, Negative Thoughts about the Pandemic, and Adaptability Skills among Dementia Caregivers during the COVID-19 Pandemic

Background: It can be easily inferred that dementia caregivers were severely affected by the general home confinement, or ‘lockdown’, due to their caregiving roles. Aim: The aim of the current study is to investigate how the quarantine measures applied during the COVID-19 pandemic affected the emotional function (specifically the emotional management, emotional experience, and stress symptoms) and the negative thoughts, as well as the adaptability skills, of Greek dementia caregivers. Materials andMethods: In total, 303 participants (138 in the non-caregiving adults-control group; 165 in the dementia caregivers-experimental group) were recruited from the day centers of the Greek Association of Alzheimer Disease and Related Disorders (GAADRD) from June 2020 to January 2021 in Thessaloniki, Greece. The caregiving population was split into group 1 (those who participated in support groups) and group 2 (those who did not participate in support groups). A self-reported questionnaire was created for research purposes and was digitally administered to participants via Google forms. Results: During the quarantine period, dementia caregivers had more difficulties in emotional management, especially in regards to stress symptoms, which was measured via the Beck Anxiety Inventory (BAI), in comparison to the control group. In regards to the caregiving populations, caregivers from group 1 were more able to manage their emotions according to their self-reports, but had increased agony and loneliness. Moreover, statistical significance was found between emotional management, negative feelings, and stress symptoms in those from group 2 who self-reported that the PwD deteriorated. This evidence was not found in group 1. Finally, there were no differences in the means of negative thoughts about the pandemic, as well as in the adaptation skills, both in dementia caregivers and in the control group, according to their self-reports. Discussion: It seems that different emotional aspects were affected in the dementia caregivers’ population, and, therefore, future psychotherapeutic interventions should focus on those most severely affected by the restrictive measures imposed.

Coronavirus disease-2019: Challenges, opportunities, and benefits in India

BACKGROUND

The human coronavirus was first identified in 1965, belongs to the same family of Viruses as SARS, MERS-Co. The current virus that affected worldwide came into existence in late 2019, recently found in Wuhan, China, and caused a global pandemic called coronavirus disease-2019 (COVID-19). This disease became a quick global pandemic due to the rapid transmission of the virus from one human to another. In the history of humankind, people were inside the four walls for more than a month. The COVID-19 pandemic has posed significant problems in a variety of fields. The current pandemic created many changes that are seen as challenges worldwide. However, it created opportunities and benefits for many, extend a helping hand towards the people in need, in the society, community, and the nation. This paper focuses on challenges, opportunities, and benefits during the (COVID-19) pandemic in India.

MATERIALS AND METHODS

Online search engines like PubMed and Google Scholar were used to conduct the research. The review article's dates were not restricted in any way. A total of 48 articles were chosen. The data was tabulated based on the kind of study and the outcomes. There are just a few papers available that demonstrate the necessity for more study.

RESULTS

COVID-19 caused unforeseen changes in the health care industry, unequal distribution of health care, and consequences on mental health, according to the review studies. Teleconsultation, Internet use, and E-learning have all become more accessible. A period of transitory economic collapse and an increase in the number of migrants left many despondent. Improvement in family bonding, use of a face mask, and hygiene measures to adapt to the current scenario. There was also an impact on water sources, waste management systems, and environmental resource conservation.

CONCLUSION

Difficult conditions can provide both problems and opportunities and advantages to the people during a pandemic outbreak.

Psychodrama with persons with dementia on zoom: Proof of concept

COVID-19 pandemic and subsequent lockdowns created a global public health crisis generating mental health problems including social isolation, stress, and anxiety especially for persons with dementia and their carers. This article reports on the use of digital technology to maintain social connectivity via a virtual group session that focused on the topic of "what is home." Participants in this session included 16 day-care center clients representing an immigrant community identified with mild to moderate cognitive impairment. A trained psychodrama therapist conducted the virtual group meeting based on five key techniques: spectrogram, role reversal, doubling, mirroring, and soliloquy. The NVivo software was used for the qualitative analysis of the transcribed video recording to identify key themes based on grounded theory methodology. Zooming from home, clients engaged in significant social interaction. Findings of the NVivo analysis identified the following themes of "what is home": Emotions and home, Home is family, Home is community, and Reminiscence (with objects and traditions). Findings suggest that digital interactive technologies, like Zoom, enhance social connectivity thus mitigating the negative impact of social isolation for persons with dementia especially during pandemic lockdowns. Our pilot findings based on virtual group meetings from home demonstrate that participants can express significant emotive capacity and enhanced connectivity with one another despite a diagnosis of mild to moderate dementia. While larger studies are needed to confirm these findings, we suggest that this methodology may be used to support persons with dementia not only in times of pandemics but also as an addition to other community and home care services. Changes in reimbursement policies to include these innovative home services may be helpful in building more resilient communities for the more highly vulnerable populations.

Resilience in Informal Caregivers of People Living with Dementia in the Face of COVID-19 Pandemic-Related Changes to Daily Life

Abstract. Informal caregivers of people living with dementia (PwD) are at increased risk for the development of stress-related physical and mental illness. Nevertheless, because of differing resilience, they show interindividual differences in their ability to cope. Particularly during the COVID-19 pandemic, with the associated pandemic control measures and pandemic-related changes to daily life, resilience might be further challenged, and stress might consequently increase. Therefore, we review the evidence on informal caregivers’ experience during the COVID-19 pandemic regarding effects of the pandemic control measures on (a) the caregiver’s health, (b) the care recipient’s health, (c) the stability of the care situation, and (d) coping in daily life. We conclude with implications on how to strengthen resilience and reduce stress in terms of environmental, social, and individual resources.

Experience of the Healthcare System for Caregivers of Persons with Dementia

Background:

Persons with dementia are generally older and often have multiple other chronic conditions, necessitating several healthcare visits each year. Most live in the community supported by unpaid family caregivers who often assist with healthcare management. Little is known about caregiver and person with dementia experience engaging with the healthcare system, which may be more complicated in the context of cognitive changes such as memory loss.

Methods:

This is a targeted subanalysis of a major code, experience of the healthcare system, which emerged from a qualitative study investigating perspectives of family caregivers (N = 24) of community-dwelling persons with dementia about telemedicine.

Results:

Caregivers were asked to describe their experiences taking persons with dementia to medical visits. Caregivers’ detailed descriptions of the process resulted in three categories related to their experience of the healthcare system: Preparing for Visits, Visit-Related Time and Travel, and In-Visit Experience. Categories revealed the complexity of dyads’ participation in healthcare both in and around actual clinic visits. Findings also highlighted the often-negative impact of person with dementia cognitive symptoms on various stages of the process, which was partly offset by perceived benefits related to social participation and interactions with care teams.

Conclusions:

This study improves our understanding of the experience of engaging with the healthcare system for caregivers and persons with dementia. By explicating the complex factors involved with participating in healthcare visits outside the bounds of clinic walls, this study offers insights for clinicians and systems supporting persons with dementia and caregivers.

Care for dementia patients and caregivers amid COVID-19 pandemic

BACKGROUND

Multiple efforts have been taken across the world to bridge gaps in evidence and provide recommendations for dementia care and caregiver support during the COVID-19 pandemic. We aimed to review the available literature on measures used to alleviate the negative impacts of the pandemic on dementia care.

METHODS

We searched three databases: PubMed, CINAHL and PsycINFO to identify studies that described strategies that were recommended or taken to provide care and support to persons with dementia and their caregivers during the COVID-19 pandemic.

RESULTS

We included a total of 37 papers, originating from high, middle and low-income countries. We also included 6 papers exploring safety of COVID-19 vaccinations. Infection prevention recommendations predominantly involved providing consistent reminders to persons with dementia to engage in infection prevention measures and included measures to restrict wandering in long-term care settings to reduce spread of infection. Medical care included tele and video consultations to maintain and monitor clinical stability. Guidance for continuing rehabilitation activities for persons with dementia through remotely conducted cognitive stimulating activities, physical exercises and environmental modifications were further highlighted by multiple studies/articles. In addition, strategies to support caregivers were also advised and included teleconsultations and psycho-educational programs.

CONCLUSION

The COVID-19 pandemic has exposed gaps in health and social care systems across the world, but has also revealed the enduring dedication of clinicians, expert groups and dementia support organizations to modify and adapt existing dementia care services to meet the needs of persons with dementia and their caregivers during periods of emergency.

COVID-19 and Dementia; Hard to Forget Yet Haunting Forgetfulness!

The current pandemic has affected almost everyone worldwide. Although the majority of people survive the illness, bad cognitive repercussions might last a long time, resulting in a lower quality of life and disability, particularly in severe cases. We tried to understand and bring together the various possible mechanisms leading to dementia in COVID-19. The link between COVID-19 and dementia will help public health workers plan and allocate resources to provide better care for a community suffering from sickness and improve quality of life. A conceptual framework for care of infected people in the older age group and care of dementia people is proposed.

The Experiences of People with Dementia and Informal Carers Related to the Closure of Social and Medical Services in Poland during the COVID-19 Pandemic-A Qualitative Study

Older people with dementia are particularly at risk of COVID-19; however, relatively little is known about the indirect impact of the pandemic on the lives of those living with, and/or caring for someone with, dementia. The aim of this study was to investigate the experiences of people with dementia and informal carers during the closure of available social and medical services in Poland during the COVID-19 pandemic. A qualitative thematic analysis of semi-structured interviews with people with dementia (n = 5) and informal carers (n = 21) was performed between June and August 2020 after the first wave of COVID-19 in Poland. Three overarching themes were identified: (1) care re-organization; (2) psychological responses; (3) emerging needs. The factor underlying all these elements was reliance on other people. Social support and engagement are vital to the ongoing health and well-being of people living with dementia and their informal carers. Services need to be strengthened to provide ongoing provision to those living with dementia to reach pre-pandemic levels, if not better. Within the post-pandemic environment, people with dementia and their informal carers need reassurance that they can rely on external institutional and social support able to meet their needs.