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Pickett AC, Valdez D, Sinclair KL, Kochell WJ, Fowler B, Werner NE. Social Media Discourse Related to Caregiving for Older Adults Living With Alzheimer Disease and Related Dementias: Computational and Qualitative Study. JMIR Aging 2024; 7:e59294. [PMID: 38896462 PMCID: PMC11222768 DOI: 10.2196/59294] [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: 04/08/2024] [Revised: 05/19/2024] [Accepted: 05/26/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND In the United States, caregivers of people living with Alzheimer disease and Alzheimer disease-related dementias (AD/ADRD) provide >16 billion hours of unpaid care annually. These caregivers experience high levels of stress and burden related to the challenges associated with providing care. Social media is an emerging space for individuals to seek various forms of support. OBJECTIVE We aimed to explore the primary topics of conversation on the social media site Reddit related to AD/ADRD. We then aimed to explore these topics in depth, specifically examining elements of social support and behavioral symptomology discussed by users. METHODS We first generated an unsupervised topic model from 6563 posts made to 2 dementia-specific subreddit forums (r/Alzheimers and r/dementia). Then, we conducted a manual qualitative content analysis of a random subset of these data to further explore salient themes in the corpus. RESULTS The topic model with the highest overall coherence score (0.38) included 10 topics, including caregiver burden, anxiety, support-seeking, and AD/ADRD behavioral symptomology. Qualitative analyses provided added context, wherein users sought emotional and informational support for many aspects of the care experience, including assistance in making key care-related decisions. Users expressed challenging and complex emotions on Reddit, which may be taboo to express in person. CONCLUSIONS Reddit users seek many different forms of support, including emotional and specific informational support, from others on the internet. Users expressed a variety of concerns, challenges, and behavioral symptoms to manage as part of the care experience. The unique (ie, anonymous and moderated) nature of the forum allowed for a safe space to express emotions free from documented caregiver stigma. Additional support structures are needed to assist caregivers of people living with AD/ADRD.
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Affiliation(s)
- Andrew C Pickett
- Department of Health & Wellness Design, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Danny Valdez
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Kelsey L Sinclair
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Wesley J Kochell
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Boone Fowler
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Nicole E Werner
- Department of Health & Wellness Design, School of Public Health, Indiana University, Bloomington, IN, United States
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Piamjariyakul U, Wang K, Smith M, Young S, Shafique S, Navia RO, Williams K. Family Caregiving of Patients With Heart Failure and Vascular Dementia in Rural Appalachia: A Mixed-Methods Study. West J Nurs Res 2024; 46:344-355. [PMID: 38551329 PMCID: PMC11182019 DOI: 10.1177/01939459241242536] [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] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Vascular dementia and heart failure (HF) are common co-existing conditions among adult populations. Each condition requires extensive home caregiving from family caregivers, especially those in rural Appalachia. This study aimed to assess caregivers' burden and their physical and mental health status, as well as explore their experiences and needs. METHODS This study used an exploratory mixed-methods design combining quantitative and qualitative research (N = 20 caregivers). We collected data using questionnaires, short-answered interviews, and focus group discussions. The multivariable generalized linear model (GLiM) was used to analyze quantitative data; content analysis was used for qualitative data. RESULTS The average age of family caregivers was 64.95 years. The generalized linear model showed that the caregiving burden was associated with caregivers' depression/anxiety (r = 0.68, P < .001) and their number of dementia caregiving years (r = 0.54, P < .05). Caregivers' poor physical health status was associated with better preparedness for HF and dementia home caregiving (r = 0.52, P < .05) and male caregivers (r = -0.46, P < .01). Caregivers' mental health status was associated with depression/anxiety (r = -0.80, P < .001). The qualitative data identified key caregiving themes: emotional impact and physical demands of caregiving, lack of help in rural areas, dealing with multiple disease progression, and relationship changes with their loved ones. CONCLUSION Caregiving burden was associated with caregivers' home care responsibilities and the need for support. Nurse-led home caregiving preparedness interventions tailored for family caregivers of patients with HF and dementia in rural areas are recommended.
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Affiliation(s)
| | - Kesheng Wang
- School of Nursing, West Virginia University, Morgantown, WV, USA
| | - Marilyn Smith
- School of Nursing, West Virginia University, Morgantown, WV, USA
| | - Stephanie Young
- School of Nursing, West Virginia University, Morgantown, WV, USA
| | - Saima Shafique
- School of Nursing, West Virginia University, Morgantown, WV, USA
| | - R. Osvaldo Navia
- Department of Medicine, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Kristine Williams
- School of Nursing, The University of Kansas Medical Center, Kansas City, KS, USA
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Taylor JO, Child CE, Sharma RK, Asirot MG, Miller LM, Turner AM. Supportive care decision-making processes of persons with dementia and their caregivers. DEMENTIA 2023; 22:1695-1717. [PMID: 37656956 PMCID: PMC10688994 DOI: 10.1177/14713012231193139] [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] [Indexed: 09/03/2023]
Abstract
Little is known about the decision-making processes around seeking more supportive care for dementia. Persons with dementia are often left out of decision-making regarding seeking more supportive care as their dementia progresses. This paper provides a description of findings from the Decision-making in Alzheimer's Research project (DMAR) investigating the process of decision-making about transitions to more supportive care. We conducted 61 qualitative interviews with two stakeholder groups: 24 persons with dementia, and 37 informal caregivers to explore supportive care decisions and associated decision-making factors from the perspectives of persons with dementia and their caregivers. We identified four main decisions that persons with dementia and their informal caregivers played a role in: (1) sharing household responsibilities; (2) limiting routine daily activities; (3) bringing in formal support; and (4) moving to a care facility. Based on our findings we developed a schematized roadmap of decision-making that we used to guide the discussion of our findings. Four crosscutting themes emerged from our analysis: unknowns and uncertainties, maintaining life as you know it, there's no place like home and resource constraints. These results will be incorporated into the development of instruments whose goal is to identify preferences of persons with dementia and their caregivers, in order to include persons with dementia in care decisions even as their dementia progresses.
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Affiliation(s)
- Jean O Taylor
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Claire E Child
- Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Rashmi K Sharma
- Division of General Internal Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Mary Grace Asirot
- Department of Neurology, School of Medicine, University of Washington, Seattle, WA, USA
| | | | - Anne M Turner
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle, WA, USA
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Fan Q, DuBose L, Ory MG, Lee S, Hoang MN, Vennatt J, Kew CL, Doyle D, Falohun T. Financial, Legal, and Functional Challenges of Providing Care for People Living With Dementia and Needs for a Digital Platform: Interview Study Among Family Caregivers. JMIR Aging 2023; 6:e47577. [PMID: 37526513 PMCID: PMC10509746 DOI: 10.2196/47577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/30/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Alzheimer disease and Alzheimer disease-related dementia represent complex neuropathologies directly challenging individuals, their families, and communities in the United States. To support persons living with dementia, family or informal caregivers often encounter complex financial, psychological, and physical challenges. A widely used solution such as a consolidated web-based assistance or guidance platform is missing, compounding care challenges. OBJECTIVE In preparation for designing an internet-based artificial intelligence-driven digital resource platform, a qualitative interview study was conducted to characterize the challenges and needs of family caregivers in the United States. METHODS A semistructured interview topic guide in English was developed by engaging community partners and research partnerships. Family caregiver participants were purposefully recruited via various means, such as word of mouth, local dementia community service providers, digital recruitment emails, flyers, and social media. Interested individuals were first invited to complete an eligibility screening survey, and eligible individuals were then contacted to arrange a web-based in-depth interview via Zoom (Zoom Video Communications) from January 1, 2022, to May 31, 2022. A follow-up survey was administered in May 2022 to provide an overview of the participants' demographics, socioeconomic characteristics, and caregiving information. Thematic analysis in a framework approach was used to identify and organize themes and the study findings. RESULTS Following the prescreening of 150 eligible respondents, 20% (30/150) individuals completed both the interviews and follow-up survey, allowing for an in-depth look into the challenges, experiences, and expectations of primary caregivers of people living with dementia. Most participants (20/30, 67%) were primary caregivers of persons with dementia, and 93% (28/30) had provided care for at least a year. Most participants were aged >50 years (25/30, 83%), female (23/30, 77%), White (25/30, 83%), and non-Hispanic (27/30, 90%) and held a bachelor's or graduate degree (22/30, 73%). Collectively, all participants acknowledged challenges in caring for people living with dementia. Thematic analyses elicited the challenges of caregiving related to functional care needs and financial and legal challenges. In addition, participants identified the need for an integrative digital platform where information could be supplied to foster education, share resources, and provide community support, enabling family caregivers to improve the quality of care and reducing caregiver burden. CONCLUSIONS This study emphasized the difficulties associated with the family caregiver role and the expectations and potential for a supportive web-based platform to mitigate current challenges within the caregiving role.
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Affiliation(s)
- Qiping Fan
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, TX, United States
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Logan DuBose
- Internal Medicine, George Washington University, Washington, DC, United States
| | - Marcia G Ory
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, United States
| | - Shinduk Lee
- Division of Health Systems and Community-Based Care, College of Nursing, University of Utah, Salt Lake City, UT, United States
| | - Minh-Nguyet Hoang
- School of Medicine, Texas A&M University, College Station, TX, United States
| | - Jeswin Vennatt
- School of Medicine, Texas A&M University, College Station, TX, United States
| | - Chung Lin Kew
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, TX, United States
| | - David Doyle
- College of Medicine, Central Michigan University, Mt Pleasant, MI, United States
| | - Tokunbo Falohun
- Department of Biomedical Engineering, Texas A&M University, College Station, TX, United States
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Amiri P, Pirnejad H, Bahaadinbeigy K, Baghini MS, Khazaee PR, Niazkhani Z. A qualitative study of factors influencing ePHR adoption by caregivers and care providers of Alzheimer's patients: An extension of the unified theory of acceptance and use of technology model. Health Sci Rep 2023; 6:e1394. [PMID: 37425233 PMCID: PMC10323167 DOI: 10.1002/hsr2.1394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 05/06/2023] [Accepted: 06/21/2023] [Indexed: 07/11/2023] Open
Abstract
Background and Aims As the nowadays provision of many healthcare services relies on technology, a better understanding of the factors contributing to the acceptance and use of technology in health care is essential. For Alzheimer's patients, an electronic personal health record (ePHR) is one such technology. Stakeholders should understand the factors affecting the adoption of this technology for its smooth implementation, adoption, and sustainable use. So far, these factors have not fully been understood for Alzheimer's disease (AD)-specific ePHR. Therefore, the present study aimed to understand these factors in ePHR adoption based on the perceptions and views of care providers and caregivers involved in AD care. Methods This qualitative study was conducted from February 2020 to August 2021 in Kerman, Iran. Seven neurologists and 13 caregivers involved in AD care were interviewed using semi-structured and in-depth interviews. All interviews were conducted through phone contacts amid Covid-19 imposed restrictions, recorded, and transcribed verbatim. The transcripts were coded using thematic analysis based on the unified theory of acceptance and use of technology (UTAUT) model. ATLAS.ti8 was used for data analysis. Results The factors affecting ePHR adoption in our study comprised subthemes under the five main themes of performance expectancy, effort expectancy, social influence, facilitating conditions of the UTAUT model, and the participants' sociodemographic factors. From the 37 facilitating factors and 13 barriers identified for ePHR adoption, in general, the participants had positive attitudes toward the ease of use of this system. The stated obstacles were dependent on the participants' sociodemographic factors (such as age and level of education) and social influence (including concern about confidentiality and privacy). In general, the participants considered ePHRs efficient and useful in increasing neurologists' information about their patients and managing their symptoms in order to provide better and timely treatment. Conclusion The present study gives a comprehensive insight into the acceptance of ePHR for AD in a developing setting. The results of this study can be utilized for similar healthcare settings with regard to technical, legal, or cultural characteristics. To develop a useful and user-friendly system, ePHR developers should involve users in the design process to take into account the functions and features that match their skills, requirements, and preferences.
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Affiliation(s)
- Parastoo Amiri
- Student Research CommitteeKerman University of Medical SciencesKermanIran
| | - Habibollah Pirnejad
- Patient Safety Research Center, Clinical Research InstituteUrmia University of Medical SciencesUrmiaIran
- Erasmus School of Health Policy and ManagementErasmus University RotterdamRotterdamThe Netherlands
| | - Kambiz Bahaadinbeigy
- Medical Informatics Research Center, Institute of Futures Studies in HealthKerman University of Medical SciencesKermanIran
| | - Mahdie Shojaei Baghini
- Medical Informatics Research Center, Institute of Futures Studies in HealthKerman University of Medical SciencesKermanIran
| | | | - Zahra Niazkhani
- Nephrology and Kidney Transplant Research Center, Clinical Research InstituteUrmia University of Medical SciencesUrmiaIran
- Health Care Governance, Erasmus School of Health Policy and ManagementErasmus University RotterdamRotterdamThe Netherlands
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Abaasa C, Obua C, Wakida EK, Rukundo GZ. A qualitative investigation of the psychosocial services utilised by care-givers of patients with Alzheimer's disease and related dementias in southwestern Uganda. AGEING & SOCIETY 2023; 43:1603-1616. [PMID: 37680685 PMCID: PMC10482049 DOI: 10.1017/s0144686x21001276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Individuals with Alzheimer's disease and related dementias often require substantial support from other people. Much of the care-giving is from family members who eventually experience physical, emotional and financial stress, depression and fatigue. In Uganda, families are a cornerstone in providing care to individuals with dementia. However, little is known about the psychosocial supports available to the care-givers in their care-giving role. We assessed the psychosocial supports available to care-givers of individuals with Alzheimer's disease and related dementias in southwestern Uganda. We conducted 34 in-depth interviews at three referral hospitals at which care-givers identified by the treating clinicians were approached for informed consent. The interviews were conducted until thematic saturation was reached, and the interviews were translated and transcribed. Thematic content analysis was used to analyse the data. Care-giver supports were structured into two major themes: medical supports utilized and supports beyond the medical care system. Medical supports highlighted information provided by medical professionals. Supports beyond the medical care system included emotional and instrumental supports provided by religious leaders, the local communities and family members. Care-givers for individuals with dementia in southwestern Uganda receive educational support from medical practitioners, and unstructured emotional and instrumental supports from the family and community.
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Affiliation(s)
- Catherine Abaasa
- Department of Medical Laboratory Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Celestino Obua
- Department of Pharmacology and Therapeutics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edith K. Wakida
- Office of Research Administration, Mbarara University of Science and Technology Mbarara, Uganda
| | - Godfrey Zari Rukundo
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
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Weiler DT, Lingg AJ, Eagan BR, Shaffer DW, Werner NE. Quantifying the qualitative: exploring epistemic network analysis as a method to study work system interactions. ERGONOMICS 2022; 65:1434-1449. [PMID: 35258441 PMCID: PMC9489604 DOI: 10.1080/00140139.2022.2051609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 02/28/2022] [Indexed: 06/04/2023]
Abstract
Studying interactions faces methodological challenges and existing methods, such as configural diagramming, have limitations. This work demonstrates Epistemic Network Analysis (ENA) as an analytical method to construct configural diagrams. We demonstrated ENA as an analytical tool by applying this method to study dementia caregiver work systems. We conducted 20 semi-structured interviews with caregivers to collect caregiving experiences. Guided by the Patient Work System model, we conducted a directed content analysis to identify work system components and used ENA to study interactions between components. By using ENA to create configural diagrams, we identified five frequently occurring interactions, compared work system configurations of caregivers providing care at home and away from home. Although we were underpowered to determine statistically significant differences, we identified visual and qualitative differences. Our results demonstrate the capability of ENA as an analytical method for studying work system interactions through configural diagramming. Practitioner summary: A new methodology, Epistemic Network Analysis (ENA), was presented to better support the study of work system interactions through configural diagramming. ENA was applied to qualitative data to demonstrate the capabilities of this method to construct configural diagrams of the work system. This study successfully demonstrated that ENA can visually represent and describe work system configurations.
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Affiliation(s)
- Dustin T. Weiler
- Department of Industrial & Systems Engineering, University of Wisconsin-Madison, USA
| | - Aloysius J. Lingg
- Department of Industrial & Systems Engineering, University of Wisconsin-Madison, USA
| | - Brendan R. Eagan
- Department of Educational Psychology and Wisconsin Center for Education Research, University of Wisconsin-Madison, USA
| | - David W. Shaffer
- Department of Educational Psychology and Wisconsin Center for Education Research, University of Wisconsin-Madison, USA
| | - Nicole E. Werner
- Department of Industrial & Systems Engineering, University of Wisconsin-Madison, USA
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Perez H, Miguel-Cruz A, Daum C, Comeau AK, Rutledge E, King S, Liu L. Technology Acceptance of a Mobile Application to Support Family Caregivers in a Long-Term Care Facility. Appl Clin Inform 2022; 13:1181-1193. [PMID: 36257602 PMCID: PMC9771689 DOI: 10.1055/a-1962-5583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 10/15/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Family caregivers are unpaid individuals who provide care to people with chronic conditions or disabilities. Family caregivers generally do not have formal care-related training. However, they are an essential source of care. Mobile technologies can benefit family caregivers by strengthening communication with care staff and supporting the monitoring of care recipients. OBJECTIVE We conducted a mixed-method study to evaluate the acceptance and usability of a mobile technology called the Smart Care System. METHODS Using convenience sampling, we recruited 27 family caregivers to evaluate the mobile Smart Care System (mSCS). In the quantitative phase, we administered initial and exit questionnaires based on the Unified Theory of Acceptance and Use of Technology. In the qualitative phase, we conducted focus groups to explore family caregivers' perspectives and opinions on the usability of the mSCS. With the quantitative data, we employed univariate, bivariate, and partial least squares analyses, and we used content analysis with the qualitative data. RESULTS We observed a high level of comfort using digital technologies among participants. On average, participants were caregivers for an average of 6.08 years (standard deviation [SD] = 6.63), and their mean age was 56.65 years (SD = 11.62). We observed a high level of technology acceptance among family caregivers (7.69, SD = 2.11). Behavioral intention (β = 0.509, p-value = 0.004) and facilitating conditions (β = 0.310, p-value = 0.049) were statistically significant and related to usage behavior. In terms of qualitative results, participants reported that the mobile application supported care coordination and communication with staff and provided peace of mind to family caregivers. CONCLUSION The technology showed high technology acceptance and intention to use among family caregivers in a long-term care setting. Facilitating conditions influenced acceptance. Therefore, it would be important to identify and optimize these conditions to ensure technology uptake.
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Affiliation(s)
- Hector Perez
- Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
| | - Antonio Miguel-Cruz
- Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
- Faculty of Rehabilitation Medicine, University of Alberta. Edmonton, Alberta, Canada
- Glenrose Rehabilitation Research, Innovation & Technology (GRRIT) Hub, Glenrose Rehabilitation Hospital. Edmonton, Alberta, Canada
| | - Christine Daum
- Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
- Faculty of Rehabilitation Medicine, University of Alberta. Edmonton, Alberta, Canada
| | - Aidan K. Comeau
- Faculty of Rehabilitation Medicine, University of Alberta. Edmonton, Alberta, Canada
| | - Emily Rutledge
- Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
| | - Sharla King
- Faculty of Education, University of Alberta. Edmonton, Alberta, Canada
| | - Lili Liu
- Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
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Werner NE, Rutkowski RA, Holden RJ, Ponnala S, Gilmore-Bykovskyi A. A human factors and ergonomics approach to conceptualizing care work among caregivers of people with dementia. APPLIED ERGONOMICS 2022; 104:103820. [PMID: 35689868 PMCID: PMC9392469 DOI: 10.1016/j.apergo.2022.103820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
Society relies upon informal (family, friend) caregivers to provide much of the care to the estimated 43.8 million individuals living with Alzheimer's disease and related dementias globally. Caregivers rarely receive sufficient training, resources, or support to meet the demands associated with dementia care, which is often associated with increased risk of suboptimal outcomes. Human factors and ergonomics (HFE) can address the call for new approaches to better understand caregiving and support caregiver performance through systematic attention to and design of systems that support the work of caregivers- their care work. Thus, our objective was to perform a work system analysis of care work. We conducted a qualitative study using a Critical Incident Technique interviewing approach and Grounded Dimensional Analysis analytic procedures. Our findings introduce a new conceptual framework for understanding the care work system of dementia caregivers and suggest that care work is influenced by interactions among distinct caregiver goals, the task demands of the care needs of the person with dementia, daily life needs of the caregiver and family, and contextual factors that shape caregivers' perceptions surrounding care. The initial work system model produced by this study provides a foundation from which future work can further elucidate the care work system, determine how the care work system intersects and coordinates with other work systems such as the patient work system, and design systems that address caregivers' individual caregiving context.
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Affiliation(s)
- Nicole E Werner
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, USA.
| | - Rachel A Rutkowski
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, USA.
| | | | - Siddarth Ponnala
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, USA.
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Boutilier JJ, Loganathar P, Linden A, Scheer E, Noejovich S, Elliott C, Zuraw M, Werner NE. A Web-Based Platform (CareVirtue) to Support Caregivers of People Living With Alzheimer Disease and Related Dementias: Mixed Methods Feasibility Study. JMIR Aging 2022; 5:e36975. [PMID: 35925654 PMCID: PMC9389379 DOI: 10.2196/36975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/29/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND People living with Alzheimer disease and related dementias (ADRD) require prolonged and complex care that is primarily managed by informal caregivers who face significant unmet needs regarding support for communicating and coordinating across their informal care network. To address this unmet need, we developed CareVirtue, which provides (1) the ability to invite care network members; (2) a care guide detailing the care plan; (3) a journal where care network members can document, communicate, and coordinate; (4) a shared calendar; and (5) vetted geolocated caregiver resources. OBJECTIVE This study aims to evaluate CareVirtue's feasibility based on: (1) Who used CareVirtue? (2) How did caregivers use CareVirtue? (3) How did caregivers perceive the acceptability of CareVirtue? (4) What factors were associated with CareVirtue use? METHODS We conducted a feasibility study with 51 care networks over a period of 8 weeks and used a mixed methods approach that included both quantitative CareVirtue usage data and semistructured interviews. RESULTS Care networks ranged from 1 to 8 members. Primary caregivers were predominantly female (38/51, 75%), White (44/51, 86%), married (37/51, 73%), college educated (36/51, 71%), and were, on average, 60.3 (SD 9.8) years of age, with 18% (9/51) living in a rural area. CareVirtue usage varied along 2 axes (total usage and type of usage), with heterogeneity in how the most engaged care networks interacted with CareVirtue. Interviews identified a range of ways CareVirtue was useful, including practically, organizationally, and emotionally. On the Behavioral Intention Scale, 72% (26/36) of primary caregivers reported an average score of at least 3, indicating an above average intention to use. The average was 81.8 (SD 12.8) for the System Usability Scale score, indicating "good" usability, and 3.4 (SD 1.0) for perceived usefulness, suggesting above average usefulness. The average confidence score increased significantly over the study duration from 7.8 in week 2 to 8.9 in week 7 (P=.005; r=0.91, 95% CI 0.84-0.95). The following sociodemographic characteristics were associated with posting in the journal: retired (mean 59.5 posts for retired caregivers and mean 16.9 for nonretired caregivers), income (mean 13 posts for those reporting >US $100K and mean 55.4 for those reporting CONCLUSIONS This study establishes the acceptability and feasibility of CareVirtue among ADRD care networks and highlights the importance of designing flexible, multicomponent interventions that allow care networks to tailor their engagement according to their needs. The results will be used to improve CareVirtue feasibility and acceptability in preparation for a subsequent randomized trial to test CareVirtue's effectiveness in improving caregiver outcomes.
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Affiliation(s)
- Justin J Boutilier
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Priya Loganathar
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Anna Linden
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Eleanore Scheer
- Department of Engineering Systems and Environment, University of Virginia, Charlottesville, VA, United States
| | - Sofia Noejovich
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | | | - Matthew Zuraw
- Whiplash Technology, Inc, Palm Springs, CA, United States
| | - Nicole E Werner
- Department of Health and Wellness Design, Indiana University School of Public Health-Bloomington, Bloomington, IN, United States
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Hargreaves S, Sbaffi L, Ford N. Information seeking amongst informal caregivers of people with dementia: a qualitative study. JOURNAL OF DOCUMENTATION 2022. [DOI: 10.1108/jd-03-2022-0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThis paper both supports previous findings relating to, and presents new insights into: the information needs and the information seeking processes of a sample of informal caregivers of people with dementia (in relation to their own needs and the interrelated needs of the people they are caring for); the extent to which such information needs are and are not being met; and the factors facilitating and hindering access to the right information.Design/methodology/approachThe study adopted a qualitative approach in the form of a thematic analysis of in-depth, semi-structured interviews with a sample of 20 informal caregivers from a range of different age groups, genders and caring roles.FindingsThematic analysis identified significant informational challenges, with a common perception that information seeking was onerous, requiring a proactive approach. Further challenges arose from a perceived lack of focus on carer needs coming up against the boundaries of professional knowledge and inconsistent information provision across the sample. Distance carers faced specific issues. A second theme of negative impacts described burdens arising from: difficulties in accessing information from a complex array of support services closure or change in services and unfulfilled information needs. Participants employed strategies to enable access to information, for example, being open about their caring role; and building formal or informal support networks. It is important to address emotional as well as cognitive dimensions of information needs.Practical implicationsThis research highlights a need for health and social care, practice and policy to acknowledge and address information needs of this diverse population and build resilience. Above all, information seeking and sharing must be understood within the context of the emotional impact of caring, and recognition of these twin needs is crucial.Originality/valueWhilst previous research has focussed on identifying specific needs and knowledge acquisition at cross-sections, a more holistic understanding of experiences is underexplored. This approach is needed to take into account broader contexts, diversity of experiences and different caring roles, e.g. primary and secondary carers, and in situ and distance carers.
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Weiler DT, Lingg AJ, Wilkins DM, Militello L, Werner NE. Exploring how caregivers for people living with dementia use strategies to overcome work system constraints. APPLIED ERGONOMICS 2022; 101:103689. [PMID: 35065428 PMCID: PMC8897249 DOI: 10.1016/j.apergo.2022.103689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 05/03/2023]
Abstract
Informal caregivers for persons living with dementia (PLWD) require interventions that incorporate caregiving context. We used the Patient Work System model to characterize caregiving context by identifying work system constraints experienced by caregivers during dementia care events (e.g., managing behavioral symptoms of dementia) and strategies used to overcome constraints. We conducted twenty semi-structured interviews with caregivers. We performed upward abstraction and strategy mapping and identified seven work system constraints and eight strategies used to overcome constraints across three care events. We found that strategies used by caregivers either directly modified a constraint or emphasized other positive work system components to overcome a constraint. For example a caregiver modified their bathroom to support the PLWD in bathing themselves properly and safely. These findings provide an understanding of how real-world context influences how caregivers deliver dementia care and the design and implementation of systems that support dementia caregivers.
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Affiliation(s)
- Dustin T Weiler
- Department of Industrial & Systems Engineering, University of Wisconsin-Madison, USA
| | - Aloysius J Lingg
- Department of Industrial & Systems Engineering, University of Wisconsin-Madison, USA
| | - David M Wilkins
- Department of Industrial & Systems Engineering, University of Wisconsin-Madison, USA
| | | | - Nicole E Werner
- Department of Industrial & Systems Engineering, University of Wisconsin-Madison, USA.
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Kim J, Song JA, Jung S, Cheon H, Kim J. Korean Family Caregivers' Experiences With Managing Behavioral and Psychological Symptoms of Dementia: Keeping Harmony in Daily Life. Res Gerontol Nurs 2022; 15:141-150. [PMID: 35357982 DOI: 10.3928/19404921-20220324-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Behavioral and psychological symptoms of dementia (BPSD) are symptoms of dementia that family care-givers find difficult to manage. Competence in managing BPSD differs according to individual family caregiver. The current study investigated the competence in managing BPSD, focusing on family caregivers who were recognized as managing them well. Twenty-four Korean family caregivers (83% female, mean age = 67 years) living with persons with dementia (PWD) were interviewed. Four themes were derived from the content analysis: Entering and Looking into the World of PWD, Keeping Daily Life in Harmony With BPSD, Becoming an Expert in BPSD, and Balancing Between Caregiving and Myself. Family caregivers minimized the impact of BPSD and maintained life balance. As a result, they were able to continue a harmonious life with PWD. [Research in Gerontological Nursing, xx(x), xx-xx.].
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Werner NE, Brown JC, Loganathar P, Holden RJ. Quality of Mobile Apps for Care Partners of People With Alzheimer Disease and Related Dementias: Mobile App Rating Scale Evaluation. JMIR Mhealth Uhealth 2022; 10:e33863. [PMID: 35348467 PMCID: PMC9006134 DOI: 10.2196/33863] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/16/2022] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Background Over 11 million care partners in the United States who provide care to people living with Alzheimer disease and related dementias (ADRD) cite persistent and pervasive unmet needs related to their caregiving role. The proliferation of mobile apps for care partners has the potential to meet care partners’ needs, but the quality of apps is unknown. Objective This study aims to evaluate the quality of publicly available apps for care partners of people living with ADRD and identify design features of low- and high-quality apps to guide future research and user-centered app development. Methods We searched the US Apple App and Google Play stores with the criteria that included apps needed to be available in the US Google Play or Apple App stores, accessible to users out of the box, and primarily intended for use by an informal (family or friend) care partner of a person living with ADRD. We classified and tabulated app functionalities. The included apps were then evaluated using the Mobile App Rating Scale (MARS) using 23 items across 5 dimensions: engagement, functionality, aesthetics, information, and subjective quality. We computed descriptive statistics for each rating. To identify recommendations for future research and app development, we categorized rater comments on score-driving factors for each MARS rating item and what the app could have done to improve the item score. Results We evaluated 17 apps. We found that, on average, apps are of minimally acceptable quality. Functionalities supported by apps included education (12/17, 71%), interactive training (3/17, 18%), documentation (3/17, 18%), tracking symptoms (2/17, 12%), care partner community (3/17, 18%), interaction with clinical experts (1/17, 6%), care coordination (2/17, 12%), and activities for the person living with ADRD (2/17, 12%). Of the 17 apps, 8 (47%) had only 1 feature, 6 (35%) had 2 features, and 3 (18%) had 3 features. The MARS quality mean score across apps was 3.08 (SD 0.83) on the 5-point rating scale (1=inadequate to 5=excellent), with apps scoring highest on average on functionality (mean 3.37, SD 0.99) and aesthetics (mean 3.24, SD 0.92) and lowest on average on information (mean 2.95, SD 0.95) and engagement (mean 2.76, SD 0.89). The MARS subjective quality mean score across apps was 2.26 (SD 1.02). Conclusions We identified apps whose mean scores were more than 1 point below minimally acceptable quality, whereas some were more than 1 point above. Many apps had broken features and were rated as below acceptable for engagement and information. Minimally acceptable quality is likely to be insufficient to meet care partner needs. Future research should establish minimum quality standards across dimensions for care partner mobile apps. Design features of high-quality apps identified in this study can provide the foundation for benchmarking these standards.
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Affiliation(s)
- Nicole E Werner
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Janetta C Brown
- Indiana University School of Medicine, Indianapolis, IN, United States
| | - Priya Loganathar
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Richard J Holden
- Department of Health & Wellness Design, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
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Dementia caregiving across Latin America and the Caribbean and brain health diplomacy. LANCET HEALTHY LONGEVITY 2021; 2:e222-e231. [PMID: 34790905 PMCID: PMC8594860 DOI: 10.1016/s2666-7568(21)00031-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The prevalence of dementia in Latin America and the Caribbean is growing rapidly, increasing the burden placed on caregivers. Exacerbated by fragile health-care systems, unstable economies, and extensive inequalities, caregiver burden in this region is among the highest in the world. We reviewed the major challenges to caregiving in Latin America and the Caribbean, and we propose regional and coordinated actions to drive future change. Current challenges include the scarcity of formal long-term care, socioeconomic and social determinants of health disparities, gender-biased burdens, growing dementia prevalence, and the effect of the current COVID-19 pandemic on families affected by dementia. Firstly, we propose local and regional short-term strategic recommendations, including systematic identification of specific caregiver needs, testing of evidence-based local interventions, contextual adaptation of strategies to different settings and cultures, countering gender bias, strengthening community support, provision of basic technology, and better use of available information and communications technology. Additionally, we propose brain health diplomacy (ie, global actions aimed to overcome the systemic challenges to brain health by bridging disciplines and sectors) and convergence science as frameworks for long-term coordinated responses, integrating tools, knowledge, and strategies to expand access to digital technology and develop collaborative models of care. Addressing the vast inequalities in dementia caregiving across Latin America and the Caribbean requires innovative, evidence-based solutions coordinated with the strengthening of public policies.
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Kimzey M, Howe CJ, Martin C, McLarty J, Baucham R. Development of health literacy in persons and caregivers living with dementia: A qualitative directed content analysis. DEMENTIA 2021; 21:540-555. [PMID: 34654330 DOI: 10.1177/14713012211049691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Persons living with dementia and their caregivers need health information to understand and manage daily life. Previous studies focused on the associations of health literacy and cognitive impairment with less exploring if and how individuals develop health literacy during the course of the disease. PURPOSE This descriptive qualitative study aimed to explore the development of health literacy competencies among persons living with dementia and their caregivers. METHODS Directed content analysis of six focus groups conducted in the community setting (15 persons living with dementia and 28 caregivers) was completed, using predetermined categories from the Integrated Model of Health Literacy: access, understand, appraise, and apply health information. FINDINGS Participants described developing health literacy competencies over time, moving from a dependence on health care providers to becoming their own experts. Although health care providers were involved in the diagnosis and medication management, most participants admitted that they provided very little information on how to manage their daily life with dementia and often failed to inform them of community resources. CONCLUSION Participants seemed to find dementia resources on their own for both education and support, often stumbling upon them by accident. Health care providers should promote the health literacy competencies of their patients and caregivers by more intentionally providing dementia health and community resource information.
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Affiliation(s)
- Michelle Kimzey
- Harris College of Nursing and Health Sciences, 16049Texas Christian University, Fort Worth, TX, USA
| | - Carol J Howe
- Harris College of Nursing and Health Sciences, 16049Texas Christian University, Fort Worth, TX, USA
| | - Chelsea Martin
- Harris College of Nursing and Health Sciences, 16049Texas Christian University, Fort Worth, TX, USA
| | - Jim McLarty
- Harris College of Nursing and Health Sciences, 16049Texas Christian University, Fort Worth, TX, USA
| | - Ramona Baucham
- Harris College of Nursing and Health Sciences, 16049Texas Christian University, Fort Worth, TX, USA
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Bastoni S, Wrede C, da Silva MC, Sanderman R, Gaggioli A, Braakman-Jansen A, van Gemert-Pijnen L. Factors Influencing Implementation of eHealth Technologies to Support Informal Dementia Care: Umbrella Review. JMIR Aging 2021; 4:e30841. [PMID: 34623314 PMCID: PMC8538023 DOI: 10.2196/30841] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 01/26/2023] Open
Abstract
Background The worldwide increase in community-dwelling people with dementia underscores the need for innovative eHealth technologies that aim to provide support to both patients and their informal caregivers in the home setting. However, sustainable implementation of eHealth technologies within this target group can be difficult. Objective The goal of this study was to gain a thorough understanding of why it is often difficult to implement eHealth technologies in practice, even though numerous technologies are designed to support people with dementia and their informal caregivers at home. In particular, our study aimed to (1) provide an overview of technologies that have been used and studied in the context of informal dementia care and (2) explore factors influencing the implementation of these technologies. Methods Following an umbrella review design, five different databases were searched (PubMed, PsycINFO, Medline, Scopus, and Cochrane) for (systematic) reviews. Among 2205 reviews retrieved, 21 were included in our analysis based on our screening and selection procedure. A combination of deductive and inductive thematic analyses was performed, using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework for organizing the findings. Results We identified technologies designed to be used “by informal caregivers,” “by people with dementia,” and “with people with dementia.” Within those groups, most of the represented technologies included, respectively: (i) devices for in-home monitoring of lifestyle, health, and safety; (ii) technologies for supporting memory, orientation, and day structure; and (iii) technologies to facilitate communication between the informal caregiver and person with dementia. Most of the identified factors influencing implementation related to the condition of dementia, characteristics of the technology, expected/perceived value of users, and characteristics of the informal caregiver. Considerably less information has been reported on factors related to the implementing organization and technology supplier, wider institutional and sociocultural context of policy and regulations, and continued adaptation of technology over time. Conclusions Our study offers a comprehensive overview of eHealth technologies in the context of informal dementia care and contributes to gaining a better understanding of a broad range of factors influencing their implementation. Our results uncovered a knowledge gap regarding success factors for implementation related to the organizational and broader context and continuous adaptation over the long term. Although future research is needed, the current findings can help researchers and stakeholders in improving the development and implementation of eHealth technologies to support informal dementia care.
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Affiliation(s)
- Sofia Bastoni
- Department of Psychology, Health & Technology, Centre for eHealth and Wellbeing Research, University of Twente, Enschede, Netherlands
| | - Christian Wrede
- Department of Psychology, Health & Technology, Centre for eHealth and Wellbeing Research, University of Twente, Enschede, Netherlands
| | - Marcia Cristina da Silva
- Department of Psychology, Health & Technology, Centre for eHealth and Wellbeing Research, University of Twente, Enschede, Netherlands
| | - Robbert Sanderman
- Department of Psychology, Health & Technology, Centre for eHealth and Wellbeing Research, University of Twente, Enschede, Netherlands.,Department of Health Psychology, University Medical Center Groningen, Groningen, Netherlands
| | - Andrea Gaggioli
- Department of Psychology, Universitá Cattolica del Sacro Cuore, Milan, Italy.,Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Milan, Italy
| | - Annemarie Braakman-Jansen
- Department of Psychology, Health & Technology, Centre for eHealth and Wellbeing Research, University of Twente, Enschede, Netherlands
| | - Lisette van Gemert-Pijnen
- Department of Psychology, Health & Technology, Centre for eHealth and Wellbeing Research, University of Twente, Enschede, Netherlands
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Sbaffi L, Hargreaves S. The information trust formation process for informal caregivers of people with dementia: a qualitative study. JOURNAL OF DOCUMENTATION 2021. [DOI: 10.1108/jd-01-2021-0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
This paper provides new insights on trust formation during information-seeking processes of informal caregivers of people with dementia and identifies the sources of information deemed as trustworthy by caregivers.
Design/methodology/approach
The study adopts a phenomenological qualitative approach in the form of in-depth, semi-structured interviews with a sample of 20 informal caregivers.
Findings
Caregivers trust sources that are perceived as authoritative and particularly value the information and advice provided by other caregivers. Trust in information can be divided into subjective and objective, but both are important precursors to the actual use of the information. The information available to caregivers is sufficient in quantity but inadequate in terms of ease of use, clarity and usefulness. Often, some key information needs remain unsatisfied due to the lack of timeliness, relevance and personalisation of the information.
Practical implications
This paper provides recommendations for information and healthcare providers on how to improve communication and information relevance for informal caregivers of people with dementia.
Originality/value
This paper contributes to a more comprehensive perspective on caregivers’ information trust formation processes, which takes into account both the characteristics of the information and caregivers’ individual factors.
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Scerpella DL, Bouranis NG, Webster MJ, Dellapina M, Koeuth S, Parker LJ, Kales HC, Gitlin LN. Using Geographic Information Systems (GIS) for Targeted National Recruitment of Community-Dwelling Caregivers Managing Dementia-Related Behavioral and Psychological Symptoms: A Recruitment Approach for a Randomized Clinical Trial. JOURNAL OF GEOGRAPHIC INFORMATION SYSTEM 2021; 13:302-317. [PMID: 34484851 PMCID: PMC8415725 DOI: 10.4236/jgis.2021.133017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Over 16 million caregivers of people living with dementia require support in a range of issues, including self-care, disease education, and guidance for how to manage behavioral and psychological symptoms of dementia (BPSD). Non-pharmacological interventions are needed to address these areas, and online applications have been shown to be safe and effective. To ensure the efficacy of such interventions, racially, ethnically, geographically, and socioeconomically diverse participants must be recruited to increase the generalizability of study outcomes. This protocol paper describes a recruitment plan using Geographic Information Systems (GIS) to reach a representative sample of caregivers across the United States for a national Phase III clinical study. Using publicly available census data from the American Community Survey (ACS), combined with location data for local aging resources such as Area Agencies on Aging (AAA), recruitment will be derived from data analysis conducted in ESRI ArcGIS v10.7.1. Datasets including age, gender, income, and education will be assessed nationally at the county and census tract spatial scale in a nine-step process to develop recruitment priority areas containing high concentrations of eligible participants living in the community. Overall, the current protocol will demonstrate the value of GIS in tailoring targeted outreach strategies to recruit community-dwelling populations through local resource institutions. This novel approach may have far-reaching implications in future recruitment initiatives and help to secure racially/ethnically diverse samples.
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Affiliation(s)
| | - Nicole G Bouranis
- College of Nursing and Health Professions, Drexel University, Philadelphia, USA
| | - Melinda J Webster
- College of Nursing and Health Professions, Drexel University, Philadelphia, USA
| | - Maria Dellapina
- College of Nursing and Health Professions, Drexel University, Philadelphia, USA
| | - Sokha Koeuth
- College of Nursing and Health Professions, Drexel University, Philadelphia, USA
| | - Lauren J Parker
- School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Helen C Kales
- Department of Psychiatry, University of California-Davis, Sacramento, USA
| | - Laura N Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, USA
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20
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Rodriguez K, Fugard M, Amini S, Smith G, Marasco D, Shatzer J, Guerrero M, Garvan C, Davis J, Price C. Caregiver Response to an Online Dementia and Caregiver Wellness Education Platform. J Alzheimers Dis Rep 2021; 5:433-442. [PMID: 34368629 PMCID: PMC8293668 DOI: 10.3233/adr-200292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Web-based educational interventions are emerging as a potential solution to improve caregiver dementia knowledge and overall well-being. OBJECTIVE To assess the feasibility of delivering a web-based intervention for dementia caregivers by examining: 1) engagement with the online platform, 2) skill implementation, and 3) changes on outcome metrics over the 30-day study period. METHODS Enrolled participants were onboarded by a trained research coordinator and provided 24/7 access to the platform over 30 days. At study onset and completion, caregivers completed assessments of care recipient dementia severity and neuropsychiatric symptoms along with instruments which measured dementia knowledge, caregiver burden, and carer experience. RESULTS Of 84 referrals, 60 caregivers met study inclusion criteria and 55 completed pre and post study measures. Caregivers completed an average of 8 hours of learning over the 30-day web-based intervention, with 84.4%of participants reporting using at least one skill they learned from the online platform. Eighty-nine percent of participants reported high satisfaction with the web-based educational intervention. There were small effect sizes for decreases in NPIQ neuropsychiatric symptom severity and caregiver distress scores from pre- to post-intervention. Small effect sizes were observed for changes in caregiver burden from pre- to post-intervention among caregivers who perceived their care recipient as having high global deterioration. CONCLUSION Findings show online educational programs are feasible for informal family caregivers of dementia and have perceived value. Future studies should address caregiver response to online education in less severe versus more severe care recipients, and explore the value of caregiver online platforms in diverse caregiver samples.
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Affiliation(s)
- Katie Rodriguez
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Perioperative Cognitive Anesthesia Network for Alzheimer’s Disease and Related Dementias, University of Florida, Gainesville, FL, USA
| | | | - Shawna Amini
- Perioperative Cognitive Anesthesia Network for Alzheimer’s Disease and Related Dementias, University of Florida, Gainesville, FL, USA
- Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Glenn Smith
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | | | | | | | - Cynthia Garvan
- Perioperative Cognitive Anesthesia Network for Alzheimer’s Disease and Related Dementias, University of Florida, Gainesville, FL, USA
- Anesthesiology, University of Florida, Gainesville, FL, USA
| | | | - Catherine Price
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Perioperative Cognitive Anesthesia Network for Alzheimer’s Disease and Related Dementias, University of Florida, Gainesville, FL, USA
- Anesthesiology, University of Florida, Gainesville, FL, USA
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Gitlin LN, Bouranis N, Kern V, Koeuth S, Marx KA, McClure LA, Lyketsos CG, Kales HC. WeCareAdvisor, an Online Platform to Help Family Caregivers Manage Dementia-Related Behavioral Symptoms: an Efficacy Trial in the Time of COVID-19. ACTA ACUST UNITED AC 2021; 7:33-44. [PMID: 33786370 PMCID: PMC7994055 DOI: 10.1007/s41347-021-00204-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/11/2021] [Accepted: 03/19/2021] [Indexed: 11/13/2022]
Abstract
Dementia-related behavioral and psychology symptoms (BPSD) are undertreated and have negative consequences. However, families do not have access to disease information, tailored problem-solving and effective management strategies, and with COVID-19, are more socially isolated and distressed. To address this dementia care gap, we describe a Phase III efficacy trial testing an online platform, WeCareAdvisor, and design modifications necessitated by COVID-19. WeCareAdvisor provides caregivers with disease information, daily tips, and a systematic approach for describing behaviors, investigating underlying causes, creating tailored strategies, and evaluating their effectiveness (DICE). The trial will enroll 326 caregivers nationwide, randomly assign them to immediately receive WeCareAdvisor (treatment), or a 3-month waitlist (control) and evaluate short (1- and 3-month) and long-term (6-month) outcomes for caregiver distress with and confidence managing BPSD, and BPSD occurrences. We will also evaluate utilization patterns with different prompting conditions: high-intensity (telephone and email reminders), low-intensity (email reminders), or no reminders to use WeCareAdvisor. COVID-19 necessitated design modifications resulting in greater inclusivity of caregivers from diverse races, ethnicities, and geographic areas. Key modifications include shifting from in-home, in-person interviewing to telephone; adjusting tool functionality from operating on a grant-funded iPad to caregivers’ personal internet-capable devices; and expanding recruitment from one metropolitan area to nationwide. Study modifications necessitated by COVID-19 facilitate national outreach, easier tool adoption, and enable more diverse caregivers to participate. This study addresses a critical dementia care need, and design modifications may shorten timeline from efficacy testing to commercialization.
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22
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Flanagan J, Post K, Hill R, DiPalazzo J. Feasibility of a Nurse Coached Walking Intervention for Informal Dementia Caregivers. West J Nurs Res 2021; 44:466-476. [PMID: 33745386 DOI: 10.1177/01939459211001395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study's purpose was to determine the feasibility of a nurse coached walking intervention for informal caregivers of persons with dementia. Participants were randomly assigned to a nurse coached intervention or a control group. Five male and 27 female caregivers (n = 32) participated. Measures included steps, walked well-being, and perceived stress. For steps walked, each group experienced a statistical difference (p = .01 control; p = .02 intervention) and large effect size (0.90). Neither group had a statistical difference in well-being (p = .38 control; p = .08 intervention) or perceived stress (p = .56 control; p = .18 intervention). The intervention group achieved a large effect size in well-being (1.38) and moderate effect size in perceived stress (0.51). A 0.94 pedometer adherence, self-reported user ease with technology and 100% retention rate support feasibility. Many participants described feelings of loneliness and grief, but reported the pedometer motivated them to walk.
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Affiliation(s)
- Jane Flanagan
- Boston College, Chestnut Hill, MA, USA.,Massachusetts General Hospital (MGH), Boston, MA, USA
| | - Kathryn Post
- Massachusetts General Hospital (MGH), Boston, MA, USA
| | - Rebecca Hill
- Boston College, Chestnut Hill, MA, USA.,MGH Institute of Health Professions, Boston, MA, USA
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Gilmore-Bykovskyi A, Cotton Q, Morgan J, Block L. Diverse perspectives on hospitalisation events among people with dementia: protocol for a multisite qualitative study. BMJ Open 2021; 11:e043016. [PMID: 33550256 PMCID: PMC7925923 DOI: 10.1136/bmjopen-2020-043016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION People living with dementia (PLWD) are more likely to experience hospitalisation events (hospitalisation, rehospitalisation) than those without dementia. Many hospitalisation events, particularly rehospitalisation within 30 days of discharge, are thought to be avoidable. Yet our understanding of dementia-specific risk and protective factors surrounding avoidable hospitalisation is limited to specific intersetting transitions and predominantly clinician perspectives. Broader insights are needed to design accessible and effective solutions for reducing avoidable hospitalisations. We have designed the Stakeholders Understanding of Prevention Protection and Opportunities to Reduce HospiTalizations (SUPPORT) Study to address these gaps. The objectives of the SUPPORT Study are to elicit and examine family caregiver, community and hospital providers' perspectives on avoidable hospitalisation events among PLWD, and to identify opportunities for effective prevention. METHODS AND ANALYSIS We will conduct a multisite, descriptive qualitative study to interview around 100 family caregivers, community and hospital providers. We will identify and sample from regions and communities with higher socio-contextual disadvantage and hospital utilisation, and will aim to recruit individuals representing diverse racial/ethnic backgrounds. Interviews will follow a descriptive qualitative design in conjunction with constant comparison techniques to sample divergent situations and events. We will employ a range of analytical approaches to address specific research questions including thematic (inductive and deductive), comparative and dimensional analysis. Interviews will be conducted individually or in focus groups and follow a semistructured interview guide. ETHICS AND DISSEMINATION The study is approved by the University of Wisconsin-Madison Institutional Review Board. Informed consent procedures will incorporate steps to evaluate capacity to provide informed consent in the event that participants express concerns with thinking or memory or demonstrate challenges recalling study details during the consent process to ensure capacity to consent to participation. A series of publicly available reports, seminars and symposia will be undertaken in collaboration with collaborating organisation partners.
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Affiliation(s)
- Andrea Gilmore-Bykovskyi
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Division of Geriatrics, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Quinton Cotton
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jennifer Morgan
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Laura Block
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Weinberger N, Weis A, Pohlmann S, Brändle C, Zentek T, Ose D, Szecsenyi J. A New Method for Structured Integration of User Needs in Two Health Technology Development Projects: Action Sheets. Inform Health Soc Care 2021; 46:113-125. [PMID: 33406954 DOI: 10.1080/17538157.2020.1865968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
An early integration of users and stakeholders is needed for a successful innovation process. Nonetheless, the integration of users is often hard to realize - especially when dealing with persons with chronic diseases. In addition, patients or users in general often are not able to formulate the requirements in a technical manner. Therefore, even if user requirements are collected, it is not certain that the developers know or understand 'what is really wanted'. To overcome these 'gaps', we have developed so-called Action Sheets (AS). This article presents the use of AS in two projects: the development of health technologies for people with cancer (INFOPAT) and dementia (QuartrBack). Depending on the project context, group sessions were conducted with different stakeholders to identify the needs of (potential) users. Within the INFOPAT project, ten focus groups were conducted with patients, physicians and other healthcare professionals. In QuartrBack stakeholders like e.g. care professionals, technical assistance organizations and citizens participated in two focus groups and three world cafés. Their requirements were then 'fed' into the technology development by the use of AS. AS appear to be a promising tool to make user needs based on social values more tangible and implementable into technology development processes. In addition, it shows up that four phases seem to be necessary for transferring identified user and stakeholder needs into AS, which can therefore be seen as essential to translate non-technically formulated requirements into technically feasible ones. The case study shows as lessons learned that despite the successful integration of user needs, context-sensitive adjustments are still necessary.
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Affiliation(s)
- Nora Weinberger
- Institute for Technology Assessment and Systems Analysis, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - Aline Weis
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabrina Pohlmann
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Claudia Brändle
- Institute for Technology Assessment and Systems Analysis, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - Tom Zentek
- Center for Telemedicine e.V., Bad Kissingen, Germany
| | - Dominik Ose
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.,Department of Population Health, University of Utah, Salt Lake City, USA
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
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Gilmore-Bykovskyi A, Mullen S, Block L, Jacobs A, Werner NE. Nomenclature Used by Family Caregivers to Describe and Characterize Neuropsychiatric Symptoms. THE GERONTOLOGIST 2020; 60:896-904. [PMID: 31688933 DOI: 10.1093/geront/gnz140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Neuropsychiatric symptoms (NPS) are a core feature of Alzheimer's disease and related dementias that are characterized by a fluctuating course. NPS are challenging to manage and contribute to high rates of burden among family caregivers. Successful information exchange between clinicians and family caregivers is critical for facilitating effective management of NPS. However, this communication is often challenging due to inconsistent terminology and classification of symptoms and limited understanding of how family caregivers recognize and describe symptoms. The objective of this study was to examine the language family caregivers' use to describe and contextualize NPS. RESEARCH DESIGN AND METHODS Descriptive qualitative study of 20 family caregivers in a mostly urban county in the Midwestern United States using semistructured interviews. Caregiver descriptions of NPS were analyzed using directed content and text analysis to examine terminology, followed by a thematic analysis approach to examine contextualization of NPS. RESULTS Caregivers employed shared terminologies to describe NPS that differed substantially from clinical terminology used to classify symptoms. Caregivers frequently engaged sense-making as a strategy to explain NPS. This sense-making served to contextualize patterns in behavior and was characterized by explanatory, situational, and strategy-oriented frameworks for understanding behavior in terms of its purpose and meaning. Caregivers' descriptions of NPS reflected broad overlap between individual NPS (i.e., agitation and care resistance) that would generally be considered clinically distinct symptoms. DISCUSSION AND IMPLICATIONS Nomenclature surrounding NPS may vary considerably between family caregivers and clinicians, and should be evaluated in partnership with people with dementia and their caregivers to ensure supportive interventions and resources are responsive to caregivers' interpretation of symptoms and sense-making.
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Affiliation(s)
- Andrea Gilmore-Bykovskyi
- School of Nursing Madison, Wisconsin.,Division of Geriatrics, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin.,Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Hospital, United States Department of Veterans Affairs, Madison, Wisconsin
| | | | | | | | - Nicole E Werner
- Division of Geriatrics, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin.,Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin-Madison, Madison, Wisconsin
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Rutkowski RA, Ponnala S, Younan L, Weiler DT, Bykovskyi AG, Werner NE. A process-based approach to exploring the information behavior of informal caregivers of people living with dementia. Int J Med Inform 2020; 145:104341. [PMID: 33242761 DOI: 10.1016/j.ijmedinf.2020.104341] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/13/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND PURPOSE Informal caregivers of persons living with dementia have significant unmet information needs that, if met, would better equip them to provide effective care. Despite the existence of health information technologies, websites, resources, and organizations dedicated to dementia caregiving, caregivers continue to report unmet information needs. Caregivers' continued unmet information needs suggest a misalignment between information products, and caregivers' information behavior-how caregivers generate, acquire, manage, use, communicate, and seek information. Researchers have developed conceptual models for understanding caregivers' information behavior, but these models are limited in that they are task-oriented, and they assume that caregivers' information needs will be met if they engage in information behavior. To address these limitations, the present study sought to explore caregivers' information behavior as a sociotechnical-systems-based process. METHODS We conduced semi-structured interviews with 30 self-identified caregivers to explore their daily experience of caregiving activities, including their information behavior. We applied a process-based conceptual framework that takes into account inputs, processes, outputs, and feedback mechanisms within a sociotechnical system to guide analysis. The process of interest was caregivers' information behavior as modeled by the information-seeking and communication model (ISCM). We conducted a deductive content analysis guided by the components of the ISCM. We then used team-based affinity diagramming to collapse and categorize the ISCM components into inputs, processes, outputs, and feedback. RESULTS We developed a conceptual model to depict caregivers' information behavior as a sociotechnical-systems-based process of inputs, processes, and outputs that feedback into the system. The conceptual model consisted of three inputs (i.e., information users, information providers, and information products), three information seeking and communication processes (i.e., information access, information interaction, and information assessment and processing), two outputs (i.e., utility and credibility), and feedback. DISCUSSION AND CONCLUSION Building on and addressing the gaps in previous information behavior models, our conceptual framework advances the previous task-level understandings of caregivers' information behavior into a comprehensive feedback-driven, process-level perspective consisting of context-based inputs, information seeking and communication processes, outputs, and feedback. A sociotechnical-systems-based understanding of caregivers' information behavior allows for misalignments between information providers and products, and caregivers' information behavior not only to be illuminated, but systematically addressed.
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Affiliation(s)
- Rachel A Rutkowski
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, United States
| | - Siddarth Ponnala
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, United States
| | - Laura Younan
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, United States
| | - Dustin T Weiler
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, United States
| | | | - Nicole E Werner
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, United States.
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Bressan V, Visintini C, Palese A. What do family caregivers of people with dementia need? A mixed-method systematic review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:1942-1960. [PMID: 32542963 DOI: 10.1111/hsc.13048] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 05/10/2020] [Accepted: 05/13/2020] [Indexed: 06/11/2023]
Abstract
Caring for people with dementia is a major challenge for relatives and society worldwide. Understanding the family caregivers' needs is crucial to promote their care-giving role during the disease trajectory. The aim of this mixed-method systematic review was to identify and synthetise the existing literature on the needs of family caregivers of people with dementia at home. PubMed, CINAHL, Cochrane Database of Systematic Reviews and PsycINFO databases were systematically explored to find quantitative, qualitative and mixed-method studies published between 2009 and 2019. A total of 1,196 citations were retrieved and 34 studies were included in the review. The variety of interrelated needs emerged from studies has been summarised in four themes: (a) Being supported, (b) Receiving accessible and personalised information, (c) Being trained and educated to care for their beloved with dementia and (d) Finding a balance. Care-giving for individuals with dementia is an ever-changing process characterised by continuous adjustments to their needs. The majority of a family caregivers' needs are oriented towards receiving support, help in offering daily care and finding a balance between the care-giving role and their own personal needs. For family caregivers, receiving information is a priority to improve their knowledge and to develop coping abilities, care skills and strategies aimed at promoting a balance between care assistance duties and their own needs. They also need social, psychological and emotional support and access to flexible, tailored and timely formal care. Further studies are recommended to detect changes in family caregivers' needs throughout the disease progression in order to tailor formal care offered by social and healthcare services.
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Topaz M, Adams V, Wilson P, Woo K, Ryvicker M. Free-Text Documentation of Dementia Symptoms in Home Healthcare: A Natural Language Processing Study. Gerontol Geriatr Med 2020; 6:2333721420959861. [PMID: 33029550 PMCID: PMC7520927 DOI: 10.1177/2333721420959861] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/18/2020] [Accepted: 08/21/2020] [Indexed: 01/11/2023] Open
Abstract
Background Little is known about symptom documentation related to Alzheimer's disease and related dementias (ADRD) by home healthcare (HHC) clinicians. Objective This study: (1) developed a natural language processing (NLP) algorithm that identifies common neuropsychiatric symptoms of ADRD in HHC free-text clinical notes; (2) described symptom clusters and hospitalization or emergency department (ED) visit rates for patients with and without these symptoms. Method We examined a corpus of -2.6 million free-text notes for 112,237 HHC episodes among 89,459 patients admitted to a non-profit HHC agency for post-acute care with any diagnosis. We used NLP software (NimbleMiner) to construct indicators of six neuropsychiatric symptoms. Structured HHC assessment data were used to identify known ADRD diagnoses and construct measures of hospitalization/ED use during HHC. Results Neuropsychiatric symptoms were documented for 40% of episodes. Common clusters included impaired memory, anxiety and/or depressed mood. One in three episodes without an ADRD diagnosis had documented symptoms. Hospitalization/ED rates increased with one or more symptoms present. Conclusion HHC providers should examine episodes with neuropsychiatric symptoms but no ADRD diagnoses to determine whether ADRD diagnosis was missed or to recommend ADRD evaluation. NLP-generated symptom indicators can help to identify high-risk patients for targeted interventions.
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Affiliation(s)
- Maxim Topaz
- Columbia University, New York, NY, USA.,Visiting Nurse Service of New York, New York, NY, USA
| | | | - Paula Wilson
- Visiting Nurse Service of New York, New York, NY, USA
| | | | - Miriam Ryvicker
- Visiting Nurse Service of New York, New York, NY, USA.,Vital Statistics Consulting, New York, NY, USA
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29
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Hassan AYI. Challenges and Recommendations for the Deployment of Information and Communication Technology Solutions for Informal Caregivers: Scoping Review. JMIR Aging 2020; 3:e20310. [PMID: 32723720 PMCID: PMC7424480 DOI: 10.2196/20310] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 01/22/2023] Open
Abstract
Background Information and communication technology (ICT)–based solutions have the potential to support informal caregivers in home care delivery. However, there are many challenges to the deployment of these solutions. Objective The aim of this study was to review literature to explore the challenges of the deployment of ICT-based support solutions for informal caregivers and provide relevant recommendations on how to overcome these challenges. Methods A scoping review methodology was used following the Arksey and O’Malley methodological framework to map the relevant literature. A search was conducted using PubMed, IEEE library, and Scopus. Publication screening and scrutiny were conducted following inclusion criteria based on inductive thematic analysis to gain insight into patterns of challenges rising from deploying ICT-based support solutions for informal caregivers. The analysis took place through an iterative process of combining, categorizing, summarizing, and comparing information across studies. Through this iterative process, relevant information was identified and coded under emergent broader themes as they pertain to each of the research questions. Results The analysis identified 18 common challenges using a coding scheme grouping them under four thematic categories: technology-related, organizational, socioeconomic, and ethical challenges. These range from specific challenges related to the technological component of the ICT-based service such as design and usability of technology, to organizational challenges such as fragmentation of support solutions to socioeconomic challenges such as funding of technology and sustainability of solutions to ethical challenges around autonomy and privacy of data. For each identified challenge, recommendations were created on how to overcome it. The recommendations from this study can provide guidance for the deployment of ICT-based support solutions for informal caregivers. Conclusions Despite a growing interest in the potential offered by ICT solutions for informal caregiving, diverse and overlapping challenges to their deployment still remain. Designers for ICTs for informal caregivers should follow participatory design and involve older informal caregivers in the design process as much as possible. A collaboration between designers and academic researchers is also needed to ensure ICT solutions are designed with the current empirical evidence in mind. Taking actions to build the digital skills of informal caregivers early in the caregiving process is crucial for optimal use of available ICT solutions. Moreover, the lack of awareness of the potential added-value and trust toward ICT-based support solutions requires strategies to raise awareness among all stakeholders—including policy makers, health care professionals, informal caregivers, and care recipients—about support opportunities offered by ICT. On the macro-level, policies to fund ICT solutions that have been shown to be effective at supporting and improving informal caregiver health outcomes via subsidies or other incentives should be considered.
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Affiliation(s)
- Alhassan Yosri Ibrahim Hassan
- Centre for Socio-Economic Research on Ageing, Italian National Institute of Health & Science on Ageing, Ancona, Italy.,Department of Economics and Social Sciences, Faculty of Economics "Giorgio Fuà", Università Politecnica delle Marche, Ancona, Italy
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30
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Exploring dementia family caregivers' everyday use and appraisal of technological supports. Geriatr Nurs 2020; 41:909-915. [PMID: 32665095 DOI: 10.1016/j.gerinurse.2020.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/27/2020] [Accepted: 06/30/2020] [Indexed: 11/24/2022]
Abstract
Family caregivers provide the majority of care for people with dementia, often balancing multiple caregiving roles. Technology-based interventions have demonstrated strong potential for supporting family caregivers in navigating these roles, yet translational uptake of these interventions remains limited. A comprehensive understanding of how caregivers engage and evaluate everyday technological supports is necessary to foster broader adoption. Through semi-structured interviews with 20 caregivers, the present study aimed to explore caregivers' everyday use and appraisal of technological supports. We found that caregivers use specific technological supports to meet specific caregiving needs (e.g. coordination, information seeking, direct care), and exhibit unique technology use patterns (e.g. trial-and-error) shaped by the caregiving need. Caregivers shared positive appraisals of technological supports for caregiving, citing the role of perceived utility, existing familiarity, and social resources in their acceptance and uptake. These findings illustrate important perspectives regarding everyday technology with immediate relevance for intervention design and functionality.
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Werner NE, Tong M, Nathan-Roberts D, Arnott-Smith C, Tredinnick R, Ponto K, Melles M, Hoonakker P. A Sociotechnical Systems Approach Toward Tailored Design for Personal Health Information Management. PATIENT EXPERIENCE JOURNAL 2020; 7:75-83. [PMID: 34164575 DOI: 10.35680/2372-0247.1411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We used a sociotechnical systems approach-which conceptualizes a system of interacting people, technologies, and tasks, to identify individual differences in personal health information management (PHIM) that can inform the design for patient-friendly environments, tools and technologies. We conducted a secondary thematic analysis of data collected as part of a parent project, vizHOME. The goal of vizHOME was to improve health and health outcomes through identifying key features in the environment that will inform the design of consumer health information technology HIT. We analyzed interview data collected from 20 individuals with diabetes. We found seven dimensions of PHIM: (1) level of privacy preferred for PHIM; (2) amount of engagement in PHIM; (3) extent of guidance preferred for PHIM; (4) level of documentation preferred for PHIM; (5) degree of physical distribution of PHIM; (6) amount of flexibility in PHIM routine; and (7) use of external cues to manage PHIM. Our results suggest that each dimension exists as a continuum, which are anchored from low to high. Exploring the interaction between PHIM and the sociotechnical system in which PHIM is performed revealed key dimensions of PHIM as well as individual differences in those PHIM dimensions. Identification of individual differences in PHIM can support the creation of human-centered design considerations for tailored environments, products, processes, and technologies that support PHIM. Future research will seek to validate PHIM dimensions in a larger population and develop a PHIM-typing measure to identify PHIM types toward tailoring processes, products, and to individual needs in context.
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eHealth interventions to support caregivers of people with dementia may be proven effective, but are they implementation-ready? Internet Interv 2019; 18:100260. [PMID: 31890613 PMCID: PMC6926245 DOI: 10.1016/j.invent.2019.100260] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/26/2019] [Accepted: 07/21/2019] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES A variety of health services delivered via the Internet, or "eHealth interventions," to support caregivers of people with dementia have shown evidence of effectiveness, but only a small number are put into practice. This study aimed to investigate whether, how and why their implementation took place. METHODS This qualitative study followed up on the 12 publications included in Boots et al.'s (2014) widely cited systematic review on eHealth interventions for informal caregivers of people with dementia, in order to explore further implementation into practice. Publicly available online information, implementation readiness (ImpRess checklist scores), and survey responses were assessed. FINDINGS Two interventions were freely available online, two were available in a trial context, and one was exclusively available to clinical staff previously involved in the research project. The remaining seven were unavailable. All scores on the ImpRess checklist were at 50% or lower of the total, indicating that the interventions were not ready to implement at the time of the Boots et al. (2014) review, though some interventions were scored as more implementation-ready in subsequent follow-up publications. Responses to the survey were received from six out of twelve authors. Key learnings from the survey included the importance of the involvement of stakeholders at all stages of the process, as well as the flexible adaptation and commercialization of the intervention. CONCLUSIONS In general, low levels of implementation readiness were reported and often the information necessary to assess implementation readiness was unavailable. The only two freely available interventions had long-term funding from aging foundations. Authors pointed to the involvement of financial gatekeepers in the development process and the creation of a business model early on as important facilitators to implementation. Future research should focus on the factors enabling sustainable implementation.
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Christie HL, Bartels SL, Boots LM, Tange HJ, Verhey FR, de Vugt ME. A systematic review on the implementation of eHealth interventions for informal caregivers of people with dementia. Internet Interv 2018; 13:51-59. [PMID: 30206519 PMCID: PMC6112102 DOI: 10.1016/j.invent.2018.07.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/20/2018] [Accepted: 07/03/2018] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES The objectives were to (1) systematically review the literature on the implementation of eHealth interventions for informal caregivers of people with dementia, and (2) identify determinants of successful implementation. METHODS Online databases were searched for articles about eHealth interventions for informal caregivers of people with dementia, providing information on their implementation. Articles were independently screened and inductively analyzed using qualitative analysis. The analysis was mapped onto the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009). FINDINGS 46 articles containing 204 statements on implementation were included. The statements on implementation were grouped into four categories: Determinants associated with the eHealth application, informal caregiver, implementing organization, or wider context. Mapping of the determinants on the CFIR revealed that studies have focused mostly on characteristics of the intervention and informal caregiver. Limited attention has been paid to organizational determinants and the wider context. CONCLUSIONS Despite prolific effectiveness and efficacy research on eHealth interventions for caregivers of people with dementia, there is a critical dearth of implementation research. Furthermore, there is a mismatch between eHealth intervention research and implementation frameworks, especially concerning organizational factors and wider context. This review underscores the importance of future implementation research in bridging the gap between research and practice.
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Affiliation(s)
- Hannah L. Christie
- Department of Psychiatry and Neuropsychology and Alzheimer Centre Limburg, School for Mental Health and Neurosciences, Maastricht University, Postbus 616, 6200, MD, Maastricht, the Netherlands
- Corresponding author.
| | - Sara L. Bartels
- Department of Psychiatry and Neuropsychology and Alzheimer Centre Limburg, School for Mental Health and Neurosciences, Maastricht University, Postbus 616, 6200, MD, Maastricht, the Netherlands
| | - Lizzy M.M. Boots
- Department of Psychiatry and Neuropsychology and Alzheimer Centre Limburg, School for Mental Health and Neurosciences, Maastricht University, Postbus 616, 6200, MD, Maastricht, the Netherlands
| | - Huibert J. Tange
- Department of Family Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Postbus 616, 6200, MD, Maastricht, the Netherlands
| | - Frans R.J. Verhey
- Department of Psychiatry and Neuropsychology and Alzheimer Centre Limburg, School for Mental Health and Neurosciences, Maastricht University, Postbus 616, 6200, MD, Maastricht, the Netherlands
| | - Marjolein E. de Vugt
- Department of Psychiatry and Neuropsychology and Alzheimer Centre Limburg, School for Mental Health and Neurosciences, Maastricht University, Postbus 616, 6200, MD, Maastricht, the Netherlands
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Robinson JR, Anders SH, Novak LL, Simpson CL, Holroyd LE, Bennett KA, Jackson GP. Consumer health-related needs of pregnant women and their caregivers. JAMIA Open 2018; 1:57-66. [PMID: 30474071 PMCID: PMC6241505 DOI: 10.1093/jamiaopen/ooy018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 05/02/2018] [Accepted: 06/04/2018] [Indexed: 11/14/2022] Open
Abstract
Objectives To build effective applications, technology designers must understand consumer health needs. Pregnancy is a common health condition, and expectant families have unanswered questions. This study examined consumer health-related needs in pregnant women and caregivers and determined the types of needs that were not met. Materials and Methods We enrolled pregnant women <36 weeks’ gestational age and caregivers from advanced maternal–fetal and group prenatal care settings. Participant characteristics were collected through surveys, and health-related needs were elicited in semi-structured interviews. Researchers categorized needs by semantic type and whether they were met (ie, met, partially met, or unmet). Inter-rater reliability was measured by Cohen’s kappa. Results Seventy-one pregnant women and 29 caregivers participated and reported 1054 needs, 28% unmet, and 49% partially met. Need types were 66.2% informational, 15.9% logistical, 8.9% social, 8.6% medical, and 0.3% other. Inter-rater reliability was near perfect (κ=0.95, P < 0.001). Discussion Common topics of unmet needs were prognosis, life management, and need for emotional support. For pregnant women, these unmet needs focused around being healthy, childbirth, infant care, and being a good mother; caregivers’ needs involved caring for the mother, the natural course of pregnancy, and life after pregnancy. Conclusion Pregnant women and caregivers have a rich set of health-related needs with many not fully met. Caregivers’ needs differed from those of pregnant women and may not be adequately addressed by resources designed for mothers. Many unmet needs involved stress and life management. Knowledge about consumer health needs can inform the design of better technologies for pregnancy.
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Affiliation(s)
- Jamie R Robinson
- Department of Surgery, Vanderbilt University Medical Center, 1161 21st Ave S, CCC-4312 MCN, Nashville, Tennessee 37232-2730, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End, Suite 14107, Nashville, Tennessee 37203, USA
- Corresponding Author: Jamie R. Robinson, MD, MS, Department of Surgery, Vanderbilt University Medical Center, 1161 21st Ave S, CCC-4312 MCN, Nashville, TN 37232-2730, USA ()
| | - Shilo H Anders
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End, Suite 14107, Nashville, Tennessee 37203, USA
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, Tennessee 37232, USA
| | - Laurie L Novak
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End, Suite 14107, Nashville, Tennessee 37203, USA
| | - Christopher L Simpson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End, Suite 14107, Nashville, Tennessee 37203, USA
| | - Lauren E Holroyd
- School of Medicine, Vanderbilt University, 2215 Garland Avenue, Light Hall, Nashville, Tennessee 37203, USA
| | - Kelly A Bennett
- Department of Obstetrics and Gynecology, 1211 Medical Center Drive, Nashville, Tennessee 37232, USA
| | - Gretchen P Jackson
- Department of Surgery, Vanderbilt University Medical Center, 1161 21st Ave S, CCC-4312 MCN, Nashville, Tennessee 37232-2730, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End, Suite 14107, Nashville, Tennessee 37203, USA
- Department of Pediatrics, 1211 Medical Center Drive, Nashville, Tennessee 37232, USA
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Gilmore-Bykovskyi A, Johnson R, Walljasper L, Block L, Werner N. Underreporting of Gender and Race/Ethnicity Differences in NIH-Funded Dementia Caregiver Support Interventions. Am J Alzheimers Dis Other Demen 2018; 33:145-152. [PMID: 29281895 PMCID: PMC5809319 DOI: 10.1177/1533317517749465] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Women and racial/ethnic minority dementia caregivers have unique caregiving experiences and support needs. To ensure the identification of potentially important differences in outcomes within these groups, the amended National Institutes of Health (NIH) Policy on Inclusion of Women and Minorities mandates reporting by gender and race/ethnicity. The objective of this study was to determine the inclusion and reporting rates among NIH-funded dementia caregiver support interventions. A focused systematic literature review of studies published from 1994 to 2015 located 48 articles meeting inclusion criteria. The majority of studies included women and racial/ethnic minorities; however, 67% did not report results by gender or racial/ethnic group. Acknowledgment of underreporting was more common for race/ethnicity than gender. Our findings suggest limited NIH guideline compliance that may reflect a lack of awareness regarding potential gender disparities in caregiving roles. Ensuring NIH guideline compliance necessitates shared investments from researchers, editors, and reviewers to ensure group differences are systematically identified and reported.
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Affiliation(s)
- Andrea Gilmore-Bykovskyi
- University of Wisconsin-Madison School of Nursing, Madison, WI, USA
- Department of Medicine, Division of Geriatrics, University of Wisconsin-Madison School of Medicine & Public Health, Madison, WI, USA
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Hospital, United States Department of Veterans Affairs, Overlook Terrace, Madison, WI, USA
| | - Rachel Johnson
- University of Wisconsin-Madison School of Nursing, Madison, WI, USA
- Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, CA, USA
| | - Lily Walljasper
- University of Wisconsin-Madison School of Nursing, Madison, WI, USA
| | - Laura Block
- University of Wisconsin-Madison School of Nursing, Madison, WI, USA
| | - Nicole Werner
- Department of Medicine, Division of Geriatrics, University of Wisconsin-Madison School of Medicine & Public Health, Madison, WI, USA
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Hospital, United States Department of Veterans Affairs, Overlook Terrace, Madison, WI, USA
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
- Center for Quality and Productivity Improvement, College of Engineering, University of Wisconsin-Madison, Madison, WI, USA
- Living Environments Lab, Wisconsin Institutes for Discovery, University of Wisconsin-Madison, Madison, WI, USA
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Ewertzon M, Alvariza A, Winnberg E, Leksell J, Andershed B, Goliath I, Momeni P, Kneck Å, Skott M, Årestedt K. Adaptation and evaluation of the Family Involvement and Alienation Questionnaire for use in the care of older people, psychiatric care, palliative care and diabetes care. J Adv Nurs 2018; 74:1839-1850. [PMID: 29603762 DOI: 10.1111/jan.13579] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 11/27/2022]
Abstract
AIM To adapt the Family Involvement and Alienation Questionnaire (FIAQ) for use in the care of older people, psychiatric care, palliative care and diabetes care and to evaluate its validity and reliability. BACKGROUND Involvement in the professional care has proven to be important for family members. However, they have described feelings of alienation in relation to how they experienced the professionals' approach. To explore this issue, a broad instrument that can be used in different care contexts is needed. DESIGN A psychometric evaluation study, with a cross-sectional design. METHOD The content validity of the FIAQ was evaluated during 2014 by cognitive interviews with 15 family members to adults in different care contexts. Psychometric evaluation was then conducted (2015-2016). A sample of 325 family members participated, 103 of whom in a test-retest evaluation. Both parametric and non-parametric methods were used. RESULTS The content validity revealed that the questionnaire was generally understood and considered to be relevant and retrievable by family members in the contexts of the care of older people, psychiatric care, palliative care and diabetes care. Furthermore, the FIAQ (Revised), demonstrated satisfactory psychometric properties in terms of data quality, homogeneity, unidimensionality (factor structure), internal consistency and test-retest reliability. CONCLUSION The study provides evidence that the FIAQ (Revised) is reliable and valid for use in further research and in quality assessment in the contexts of the care of older people, psychiatric care, palliative care and diabetes care.
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Affiliation(s)
- Mats Ewertzon
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Anette Alvariza
- Department of Health Care Sciences/Palliative Research Centre, Ersta Sköndal Bräcke University College, Stockholm, Sweden
- Capio Palliative Care, Dalen Hospital, Stockholm, Sweden
| | - Elisabeth Winnberg
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Janeth Leksell
- School of Health and Social Sciences, Dalarna University, Falun, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Birgitta Andershed
- Facuilty of Health, Care and Nursing, Norwegian University of Science and Technology, Gjövik, Norway
| | - Ida Goliath
- Learning, Informatics, Management and Ethics, Medical Management Center, Karolinska Institutet, Stockholm, Sweden
- Ersta Hospital, Stockholm, Sweden
| | - Pardis Momeni
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Åsa Kneck
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Maria Skott
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Northern Stockholm Psychiatry, Stockholm County Hospital, Stockholm, Sweden
| | - Kristofer Årestedt
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Research, Kalmar County Hospital, Kalmar, Sweden
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Gitlin LN, Kales HC, Marx K, Stanislawski B, Lyketsos C. A randomized trial of a web-based platform to help families manage dementia-related behavioral symptoms: The WeCareAdvisor™. Contemp Clin Trials 2017; 62:27-36. [PMID: 28800895 PMCID: PMC6428066 DOI: 10.1016/j.cct.2017.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 08/02/2017] [Accepted: 08/07/2017] [Indexed: 11/23/2022]
Abstract
Dementia-related behavioral symptoms are challenging clinical features occurring across etiologies and disease progression. They are associated with increased healthcare utilization, nursing home placement, family upset and burden. Families typically manage behavioral symptoms without requisite knowledge, skills and guidance. We designed WeCareAdvisor™ as an easy-to-use, evidence-informed web-based platform. It provides families knowledge about dementia, daily tips, and a systematic approach to describe behaviors, investigate modifiable contributors, create treatment plans (WeCareAdvisor™ Prescription) consisting of management tips tailored to symptom presentation, and evaluate effectiveness. WeCareAdvisor™ is being tested in a randomized trial to assess acceptability, usability and immediate impact on caregiver confidence managing and upset with behavioral symptoms, and secondarily, frequency of behavioral occurrences. Fifty-seven caregivers will be enrolled from communities and medical clinics at two sites (University of Michigan; Johns Hopkins University). Families reporting behavioral symptoms in a telephone screen are consented and interviewed at home. Following the interview, an envelope is opened by interviewers to reveal group assignment (immediate vs one-month delayed treatment group). Those receiving WeCareAdvisor™ immediately are provided an iPad and instruction in its use; those in the delayed treatment group are informed of next study steps. All caregivers are reassessed at home one month from baseline. The delayed treatment group then receives iPad instructions and are re-interviewed one month thereafter. During treatment phase, participants receive 3 weekly check-in calls to encourage tool use and troubleshoot. Key outcomes include number of times using WeCareAdvisor™ and for which behaviors, self-efficacy and upset managing behavioral symptoms, and frequency of behavioral occurrences. Clinical trial registration #: NCT02420535.
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Affiliation(s)
- Laura N Gitlin
- Department of Community Public Health, School of Nursing, Center for Innovative Care in Aging, Johns Hopkins University, 525 Wolf Street, Baltimore, MD 21205, United States.
| | - Helen C Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States; Department of Veterans Affairs, HSR&D Center for Clinical Management Research (CCMR), Ann Arbor, MI, United States; Geriatric Research, Education and Clinical Center (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, MI, United States.
| | - Katherine Marx
- Department of Community Public Health, School of Nursing, Center for Innovative Care in Aging, Johns Hopkins University, 525 Wolf Street, Baltimore, MD 21205, United States.
| | - Barbara Stanislawski
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States; Department of Veterans Affairs, HSR&D Center for Clinical Management Research (CCMR), Ann Arbor, MI, United States; Geriatric Research, Education and Clinical Center (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, MI, United States.
| | - Constantine Lyketsos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview and Johns Hopkins University, Baltimore, MD, United States.
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