Boundary-crossers: How providers facilitate ethnic minority families' access to dementia services

Breaking the barriers: overcoming dementia-related stigma in minority communities

Dementia is a global health concern that affects individuals irrespective of their cultural or linguistic backgrounds. However, research has long recognized the pronounced stigma associated with dementia, particularly within Culturally and Linguistically Diverse (CALD) communities. This article seeks to summarize the underlying factors contributing to the heightened levels of dementia stigma within CALD communities, through a review of the literature. Our examination shows that cultural beliefs, language barriers, limited awareness, and the impact of migration on perceptions of aging and cognitive decline are contributing factors. Consequently, our analysis highlights the need for tailored, culturally appropriate interventions aimed at mitigating stigma and enhancing dementia care within CALD populations. Our proposed solutions, built on a social-ecological approach, highlights the critical role of collaborative efforts involving policymakers, healthcare providers, community organizations, and CALD community members in fostering a more dementia-inclusive society. This perspective piece aims to shed light on the distinct challenges faced by CALD communities, while advocating for a holistic approach to redefine perceptions and care strategies tailored to these populations.

A 3-UK-nation survey on dementia and the cost of living crisis: contributions of gender and ethnicity on struggling to pay for social care

OBJECTIVES

The aim of this 3-UK-nation online survey was to explore the impact of the cost of living crisis on the lives of people with dementia and their carers, specifically on their ability to access social care and support services, and the contributions of gender and ethnic background.

METHODS

A 3-UK-nation (England, Wales, Northern Ireland) 31-item online survey was conducted in October 2022 asking people with dementia, carers, and people knowing but not caring for someone with dementia about social care and support service access, cost of living crisis, and changes due to the cost of living crisis. Frequency analysis and Chi-square analysis were employed to assess whether forms of payment for services varied by gender. Pearson correlation analysis and binary logistic regression were used to assess whether gender and ethnicity were associated with struggling to pay for care since the crisis.

RESULTS

A total of 1,095 people with dementia, unpaid carers, and people who knew but not cared for someone with dementia participated. Of those, 745 people with dementia were utilising community-based social care and support services. Twenty percent of those with complete data had reduced their spending on care services since the crisis. Men and those from non-white ethnic backgrounds were at significantly increased odds of struggling to pay for care services.

CONCLUSIONS

The cost of living crisis has led to exacerbated inequalities in accessing and using dementia care. Men and those from non-white ethnic backgrounds in particular need to receive greater support in accessing care.

The MINDSET Study: Co-Designing Training for Interpreters in Dementia and Cognitive Assessments

There is a growing demand for interpreter-mediated cognitive assessments for dementia. However, most interpreters lack specialist knowledge of dementia and cognitive assessment tools. This can negatively affect the way instructions and responses are conveyed between clinicians and patients, undermining clinicians' ability to accurately assess for cognitive impairment. This article reports on the co-design of an online dementia training package, MINDSET, which aims to address this gap. Two iterative online co-design workshops were conducted in October and November 2021, using a World Café approach. Sixteen clinicians, interpreters, and multilingual family carers of a person with dementia participated. Based on these workshops, training and assessment materials were developed and tested with 12 interpreters from April to June 2022. The training package comprises online modules: 1) Knowledge of Dementia and Australia's Aged Care System, 2) Briefings and Introductions, 3) Interpreting Skills, 4) Interpreting Ethics, and 5) Cross-cultural Communication. The codesign process highlighted divergent perspectives between clinicians and interpreters on an interpreter's role during a cognitive assessment, but it also facilitated negotiation and consensus building, which enriched the training content. The training is now developed and will be evaluated in a randomized control trial and subsequent implementation study.

Culturally Adapting Evidence on Dementia Prevention for Ethnically Diverse Communities: Lessons Learnt from co-design

OBJECTIVES

40% of dementia cases can be prevented by addressing 12 lifestyle factors. These risk factors have increased presence in ethnic minorities, yet dementia prevention messages have not reached these communities. This article investigates the experience of co-designing a dementia prevention animated film with 9 ethnic groups in Australia.

METHODS

Evidence-based recommendations were adapted through an iterative process involving workshops with a stakeholder advisory committee and nine focus groups with 104 participants from the Arabic-, Hindi-, Tamil-, Cantonese-, Mandarin-, Greek-, Italian-, Spanish-, and Vietnamese-speaking communities. Data were analyzed using the Normalization Process Theory.

RESULTS

Cultural adaptation involves consideration of the mode of delivery, imagery and tone of the resource being developed; ensuring cultural adequacy; anticipating the need of the end-users; and managing linguistic challenges associated with working across multiple languages.

CONCLUSIONS

Learnings from this co-design process offer valuable insights for researchers and program developers who work with ethnic minority groups.

CLINICAL IMPLICATIONS

• Adaptation across cultures and languages is a negotiation not a consensus building exercise• Linguistic adaptation requires consideration of the education levels, and linguistic and intergenerational preferences of community members• Co-designing across multiple languages and cultures risks "flattening out" key aspects of cultural specificity.

Different senses of one's place: Exploring social adjustment to home-based care services among family caregivers from minority ethnic backgrounds who have relatives living with dementia

Western dementia care policies emphasise that family caregivers from minority ethnic backgrounds must become more engaged in healthcare services. However, research exploring experiences of receiving services such as home-based care, and thus adjustment to the service, among family caregivers from minority ethnic backgrounds who have relatives with dementia is still scarce. Therefore, inspired by Pierre Bourdieu's theoretical concepts of field, habitus and capital, we explored how family caregivers from different minority ethnic backgrounds justified decisions about whether to receive home-based care and their social adjustment to the service. Using empirical data from semi-structured interviews with nine family caregivers from different minority ethnic backgrounds, we demonstrated that different mindsets and available social resources gave rise to various actions. Although some family caregivers were optimistic about receiving home-based care, our findings point to tensions between the ideals of care practices and the organisational structures surrounding home-based care as a service. Among those who had experiences with home-based care, we found that organisational limitations, particularly in terms of efficiency demands and time constraints, influenced their behaviours and thus their social adjustments to the service. For some, these limitations eventually resulted in cancellation of the service. However, not all had the same opportunities to make these decisions, indicating that, although family caregivers from minority ethnic backgrounds receive home-based care, this does not necessarily entail a deficiency-free service. Furthermore, we argue that public discourses on this subject can be challenged by encouraging one to look beyond ethnic and cultural labels towards other factors, such as organisational structures, that might largely influence the use of home-based care among these family caregivers.

Good practice in needs-based post-diagnostic support for people with young onset dementia: findings from the Angela Project

Evidence on post-diagnostic support for people with young onset dementia is scarce. Previous studies have employed a problem-focused approach; however, evidence on ‘what works’ in real-life practice is essential to develop recommendations for service design and delivery. This study aimed to provide insight into ‘what works’ from the perspectives of people with young onset dementia and their supporters. We gathered free-text responses on positive service experiences via a UK cross-sectional survey. Inductive thematic analysis was used to identify the objectives of positive services and the needs these met. Follow-up interviews enabled in-depth insights from people with diverse diagnoses, ages and social situations. These were analysed using a template drawn from the survey. The 233 survey respondents gave 856 examples of positive support. Analysis of 24 follow-up interviews led to 16 themes clustered under three superordinate themes: ‘maintaining autonomy’, ‘being myself’ and ‘togetherness’. We found that positive services address the disruptions to sense of agency, selfhood and meaningful relationships that are experienced by those with young onset dementia. The study provides an in-depth understanding of the needs met by positive services for younger people with dementia. Our nuanced findings on good practice can inform age-specific guidelines for young onset dementia and indicate how personalisation can work in practice to help people with young onset dementia to maintain identity, autonomy and connections.

Focused Attention on Positive Aspects of Dementia Care in Culturally and Linguistically Diverse Communities: Qualitative Insights from Australia

OBJECTIVES

Dementia care scholarship focuses on care challenges and less on positive aspects of care, especially among culturally and linguistically diverse (CALD) carers outside the United States. This article investigates positive aspects of dementia care across eight CALD groups in Australia.

METHODS

We analyzed interviews of 112 family carers using a four-domain framework covering: a sense of personal growth, feelings of mutuality, increases in family cohesion, and a sense of personal accomplishment.

RESULTS

Positive associations with care are derived from past relationships, feelings of mutual obligation, valuing changed relationships and enjoying spending time with the person with dementia. Positive aspects of care were not associated with increased family cohesion except in Vietnamese and Arab families; neither was use of ethno-specific residential aged care, except for Greek and Italian families. Religion and spirituality as a coping and comforting mechanism was inconsistently expressed.

CONCLUSIONS

The study reveals the multi-dimensional nature of care, what resonates, and diverges across CALD populations. Knowing which parts of the framework apply and which do not is useful for interventions seeking to enhance positive aspects of care.

CLINICAL IMPLICATIONS

Migrant populations are varied and dynamic, and practitioners should be mindful of differences within and between ethnic minority groups.

The experience of structural burden for culturally and linguistically diverse family carers of people living with dementia in Australia

Evidence suggests that family carers of culturally and linguistically diverse (CALD) people living with dementia experience higher stress and unmet need than the general Australian population. These disparities are often framed as the result of CALD communities failing to seek formal support. Challenging this, we draw on the concept of 'structural burden' to explore how the complexity of health and aged systems contribute to the burden that CALD carers experience. We conducted semi-structured interviews with 104 family carers for CALD people with dementia in Australia, followed by thematic analysis of transcripts. Additional to structural burdens encountered by the general older population, CALD carers faced challenges understanding Australia's Anglo-centric aged care system, locating culturally appropriate care and were required to translate the languages and operations of health and aged care systems into terms their family members understood. This burden was mitigated by the presence of ethno-specific organisations and other navigation support. Australia's aged care system has moved towards centralised governance and consumer-directed care provision. This system involves a confusing array of different programmes and levels, bureaucratic applications and long waiting times. Carers' encounters with these systems demonstrates how some CALD people are being left behind by the current aged care system. While ethno-specific services can reduce this burden, not all CALD groups are represented. Consequently, improving access to dementia care among CALD populations requires entry point and navigation support that is culturally appropriate and linguistically accessible.

The use of formal care for dementia from a professional perspective: a scoping review

Background and objectives

The progressive character of dementia usually leads to a continuously increasing need for support. There is some evidence of late use of professional support during the disease course. We aim to provide an overview of aspects influencing access and use of formal care in dementia from the perspective of health and social care professionals. Additionally, the perspectives of professionals and people with dementia/informal carers will be compared.

Methods

We conducted a scoping review with a systematic literature search in Medline via Ovid in January 2019 and updated this in April 2020 and in May 2021. Publications were considered eligible when focusing on influencing aspects of the use of formal care or support for people with dementia in an outpatient setting from the perspective of health professionals. Included publications were critically appraised using the Mixed Method Appraisal Tool. We identified aspects of access to and use of formal care and support services. A consultation exercise with three specialised trained dementia care nurses was conducted to validate our results.

Results

We included 29 studies: n = 20 qualitative, n = 6 quantitative-descriptive, n = 3 mixed-methods. Various support services were identified, but a focus was on services for diagnostic and treatment of dementia. A wide range of influencing aspects (n = 15) describe the access to and use of formal care services. Aspects related to the complexity and structure of the healthcare system and the competence of professionals were frequently addressed. Second, attitudes and expectations of professionals, and experiences with people with dementia and their informal carers were identified. The dementia care nurses highlighted the importance of coordinated care to enhance dementia-specific competencies.

Conclusions

Health and social care professionals still describe barriers in accessing and using formal care due to various influences. Ways to improve access to and use of professional support in dementia should consider individual and system-level activities, as well as overarching aspects. Important topics are therefore education and training of professionals and coordinated dementia-specific care to provide adequate support for people with dementia and their relatives. Several professions may be involved in this increasingly important field, e.g., nurses with a dementia-specific training like dementia care nurses.

Cultural adaptation of World Health Organization iSupport for Dementia program for Chinese-Australian caregivers

BACKGROUND

Home-based dementia care is common in the Chinese-Australian community. However, dementia education programs for Chinese-Australians in the language of their choice are scarce. The World Health Organization has developed iSupport for Dementia, an online education program for informal caregivers. Cultural adaptation of the program for Chinese-Australian caregivers is an opportunity to address this gap in caregiver support.

AIM

The aims of the study were (1) to understand stakeholders' perspectives on the cultural and linguistic appropriateness of the Chinese iSupport for Dementia content and design and (2) to explore factors affecting the future implementation of the Chinese iSupport program in Australia.

METHODS

A qualitative descriptive design was applied to address the aims of the study. Focus group discussions with Chinese-Australian caregivers and community aged care workers were conducted to collect data. Thematic analysis was used to analyse data.

RESULTS

In total, six focus groups were conducted with 18 Chinese-Australian caregivers and 17 care workers. Six themes were identified and described as follows: (1) appropriateness of the Chinese iSupport content; (2) acceptability of the online Chinese iSupport design; (3) motivations to engage in the iSupport program; (4) desire to interact with peers and professional facilitators; (5) concerns about program accessibility; and (6) the need to extend the iSupport program to care workers.

CONCLUSIONS

Engagement with Chinese-Australian caregivers and care workers will inform further revisions of the Chinese iSupport program contents to ensure the program is culturally congruent to Chinese-Australian caregivers. Factors affecting the implementation of the program identified in the study will be considered in the intervention phase of the program.

Experiences of older immigrants living with dementia and their carers: a systematic review and meta-synthesis

OBJECTIVE

To systematically review and synthesise evidence on the experiences of older immigrants living with dementia and their carers.

DESIGN

A systematic review and meta-synthesis of qualitative studies.

METHODS

Studies exploring the experiences of older immigrants living with dementia and their carers were eligible. Databases were searched including CINAHL, MEDLINE, PsycINFO, PubMed, Embase, Web of Science and Cochrane Library from January 2000 to April 2021. Quality assessment was undertaken using the Critical Appraisal Skills Programme checklist for qualitative studies. Data were then synthesised using the thematic synthesis approach.

RESULTS

The results of this meta-synthesis were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and Enhancing transparency in reporting the synthesis of qualitative research statement. A total of 3857 studies were returned from the database search. Eighteen studies were included for meta-synthesis. Five synthesised findings were identified: living with dementia and caregiving; family relationships; barriers to dementia care services; stigma and discrimination; and legal and financial issues. The experiences of living with dementia and caregiving presented multiple challenges for older immigrants living with dementia and their families. However, there seems to be very little difference between the experiences of those who have migrated to a new country and those who were born and aged in the same country, but the ability to access and use the available services is different.

CONCLUSION

A lack of culturally appropriate dementia services, language barriers and dementia stigma can impede access to dementia care for older immigrants. Strategies to mitigate these barriers are urgently needed to ensure people from culturally and linguistically diverse backgrounds with dementia and their families have the information, education and support to access dementia services, in addition to research that explores the experiences of culturally and linguistically diverse populations.

PROSPERO REGISTRATION NUMBER

CRD42021277913.

The impact of training on communication quality during interpreter‐mediated cognitive assessments: Study protocol for a randomized controlled trial

Introduction

Methods

Results

Discussion

Highlights

"The mind may go, but the heart knows": Emotional care by ethnic minority carers of people living with dementia

Drawing on the sociology of emotions, this article investigates the socially and culturally mediated nature of emotions and emotional care within 93 ethnic minority carers' narratives of dementia care. Adding to the cross-cultural literatures on the sociology of emotions and dementia care respectively, our analysis showed that 'signals' of dementia to family carers were often emotional outbursts of anger by the person with dementia. These displays, in turn, created conflict, and aroused emotions such as shame, anger, and depression among carers. To mitigate these tendencies, carers enacted emotional management, which centered on reducing the gravity of negative emotions felt by the person with dementia, and affording them the social space to maintain a positive disposition. To create this positive emotional space, carers deployed different strategies. Some mobilized medical discourses to diffuse the emotional and moral significance of their relative's behavior and enable emotional distantiation. Others conceived of people with dementia as 'childlike' and requiring their protection from emotional negativity. Although, such efforts work took a toll on carers' emotional energies, it was considered enabling, therapeutic, and integral to care. Such emotional work departs from academic and advocacy efforts that see such behavior as patronizing and infantilizing, and underscores the need for more nuanced discussion around emotions and dementia care in ethnic minority families.