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Keramatikerman M, Varaei S, Vaezi M, Sayadi L. Peer support-based online education, burden of care and quality of life among family caregivers of patients with leukaemia: non-randomised clinical trial. BMJ Support Palliat Care 2024:spcare-2023-004610. [PMID: 38272654 DOI: 10.1136/spcare-2023-004610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/26/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE The responsibility of caring for patients with leukaemia places a heavy burden on family caregivers (FCs) and negatively impacts their quality of life (QoL). This study aimed to investigate the effects of peer support (PS)-based online education programme on the burden of care (BoC) and QoL of FCs of patients with leukaemia. METHODS This before-after study involved a total of 80 eligible FCs of patients with leukaemia (40 individuals per group). The participants received the necessary information from a researcher and peers through online sessions and WhatsApp group. To collect data, the Zarit Burden Interview and the Caregiver Quality of Life Index-Cancer (CQOLC) had been been completed once before the intervention and once 1 month after the intervention. RESULTS There was no significant difference between the two groups regarding baseline variables except the mean BoC that was significantly higher in the intervention group (IG) (p<0.001). However, after controlling for the effects of confounding variables, the mean BoC score of participants in IG was significantly lower than that of the control group (p<0.001). Additionally, there was no significant difference between the two groups in terms of CQOLC before (p=0.178) and after (p=0.538) the intervention. CONCLUSION The PS-based online education programme had a positive impact on reducing the care burden of FCs of patients with leukaemia. This programme can effectively reduce costs, particularly during emergencies and crises such as pandemics, as it eliminates the need for FCs and peers to physically visit hospitals. REGISTRATION The study was registered at the Iranian Registry of Clinical Trials on 18 July 2021 (IRCT registration number: IRCT20210507051209N1).
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Affiliation(s)
| | - Shokoh Varaei
- School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Vaezi
- Department of Internal Medicine, Tehran University of Medical Sciences, Tehran, Iran
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Research Institute for Oncology, Hematology and Cell Therapy Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Sayadi
- Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
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Lohrasebi F, Maghsoudi J, Alavi M, Akbari M. The Effect of the Web-Based Psychosocial Health Promotion Program on the Burden of Care in Family Caregivers of Patients with Chronic Mental Disorders. Iran J Nurs Midwifery Res 2023; 28:569-574. [PMID: 37869693 PMCID: PMC10588925 DOI: 10.4103/ijnmr.ijnmr_178_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 10/24/2023]
Abstract
Background Family members of Chronic Mental Disorders (CMD), who are responsible for patient care, face many physical, psychological, and social problems which make them face the burden of care. This study aimed to investigate the effect of a psychosocial health promotion program on the care burden of family caregivers of patients with CMD. Materials and Methods This is a quasi-experimental study that was conducted in two intervention and control groups in the form of pretest and posttest. This study was performed on 67 family caregivers of patients with CMD in Farabi and Noor centers in Isfahan, Iran. Participants in this study were randomly divided into two intervention and control groups. Data from the intervention and control groups were collected in two stages, before and after the intervention by demographic information form and Zarit burden questionnaire. The intervention group received a web-based psychosocial health promotion program in eight sessions in 4 weeks. At the end of the intervention, the Zarit questionnaire was completed by the intervention and control groups. Results The mean score of care burden between the intervention and control groups was not statistically significantly different before the implementation of the program (p = 0.534). But after the intervention, the mean score of care burden was significantly different between the two groups (t65 = 3.43, p = 0.001). Conclusions This study provides evidence for the benefits of web-based psychosocial health promotion program in reducing the perceived care burden of the caregiver of CMD.
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Affiliation(s)
- Fatemeh Lohrasebi
- PhD of Nursing, Department of Psychiatric Nurse, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Jahangir Maghsoudi
- PhD of Nursing, Associate Professor, Department of Psychiatric Nurse, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mousa Alavi
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Akbari
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
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Chandrasekaran N, Thulasingam M, Sahu SK, Sood V, Menon V. Effects of web-based training for carers in old age homes using WHO-iSupport for dementia, as a training tool - A mixed-method study. Asian J Psychiatr 2022; 78:103308. [PMID: 36368147 DOI: 10.1016/j.ajp.2022.103308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/04/2022] [Accepted: 10/21/2022] [Indexed: 11/28/2022]
Abstract
WHO recognized Dementia as public health priority and developed iSupport, a knowledge and skills training program for carers of people living with Dementia. This Mixed-Method study assessed the effectiveness of web-based training sessions among carers at old age homes in and around Puducherry, India, using WHO-iSupport for dementia hardcopy manual as a training tool. We registered the clinical trial protocol with Clinical Trial Registry-India (CTRI), CTRI/2020/11/029154. We determined the change in 35 carer's knowledge and attitude following the training sessions using pre and post-test questionnaires quantitatively. Further, we explored their learning experience by conducting eight descriptive one-to-one telephonic interviews. Due to the COVID-19 pandemic, we conducted this study online. i.e., obtained virtual consents, pre and post-test using Google forms, and training sessions through a webbased platform. We divided carers into groups where each carer attended two training sessions, and each session lasted for 2 h. Training sessions improved the carer's knowledge from a pre-test score of Median (IQR) 12 (9, 15) to a post-test score of 17 (16, 20) and attitude score from 30 (27.3, 34.8) to 33.5 (30.3, 39) in post-test. They perceived that the training sessions were helpful as they gained knowledge on dementia care, and their attitude has changed optimistically towards people living with Dementia. These findings suggest that web-based training has an effect and indicates the need for training among carers in various old age homes for betterment in providing care.
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Affiliation(s)
- Nithya Chandrasekaran
- JIPMER International School of Public Health (JISPH), Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry, India.
| | - Mahalakshmy Thulasingam
- Department of Preventive and Social Medicine, Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry, India.
| | - Swaroop Kumar Sahu
- Department of Preventive and Social Medicine, Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry, India.
| | - Vibhusha Sood
- JIPMER International School of Public Health (JISPH), Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry, India.
| | - Vikas Menon
- Department of Psychiatry, Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry, India.
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Karagiozi K, Margaritidou P, Tsatali M, Marina M, Dimitriou T, Apostolidis H, Tsiatsos T, Tsolaki M. Comparison of on Site versus Online Psycho Education Groups and Reducing Caregiver Burden. Clin Gerontol 2022; 45:1330-1340. [PMID: 34219617 DOI: 10.1080/07317115.2021.1940409] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The purpose of this project was to comparatively assess the benefit from the effects of the online versus onsite psychoeducative interventions on caregivers' emotional burden, including their sense of burden, anxiety, and depression. METHODS Seventy-one caregivers of Patients with Dementia (PwD) were divided in two groups, the online versus the onsite, and participated in the 4-month psychoeducational group intervention. Psychosocial assessment was performed using Beck Anxiety Inventory, Beck Depression Inventory and Zarit Burden Interview before and after the intervention. RESULTS No significant differences were found between the online and onsite groups in anxiety (p = .531), depression (p = .577) and sense of burden (p = .623) after the interventions. Both interventions showed significant reductions across emotional variables measured over the course of the treatment study and treatment interventions. CONCLUSIONS Both online and onsite interventions are effective at improving emotional health as they reduce the level of anxiety, depression, and sense of caregiver burden. CLINICAL IMPLICATIONS The use of online psychoeducative interventions is indicative for use by clinicians who work with dementia caregivers as compared to the onsite ones. Therefore, they may be assumed as having significant utility in dementia caregivers, especially when being adapted during the recent confinement measures due to the coronavirus disease pandemic (COVID-19).
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Affiliation(s)
- Konstantina Karagiozi
- Caregivers' Department, Greek Association of Alzheimer Disease and Related Disorders (GAADRD), Thessaloniki, Greece
| | - Petrina Margaritidou
- Caregivers' Department, Greek Association of Alzheimer Disease and Related Disorders (GAADRD), Thessaloniki, Greece
| | - Marianna Tsatali
- Caregivers' Department, Greek Association of Alzheimer Disease and Related Disorders (GAADRD), Thessaloniki, Greece
| | - Makri Marina
- Caregivers' Department, Greek Association of Alzheimer Disease and Related Disorders (GAADRD), Thessaloniki, Greece
| | - Tatiana Dimitriou
- Laboratory of Neurodegenerative Diseases, Center for Interdisciplinary Research and Innovation (CIRI- AUTh), Thessaloniki, Greece
| | | | - Thrasyvoulos Tsiatsos
- Department of Informatics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Magdalini Tsolaki
- Caregivers' Department, Greek Association of Alzheimer Disease and Related Disorders (GAADRD), Thessaloniki, Greece.,Laboratory of Neurodegenerative Diseases, Center for Interdisciplinary Research and Innovation (CIRI- AUTh), Thessaloniki, Greece
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Windle G, Flynn G, Hoare Z, Masterson-Algar P, Egan K, Edwards RT, Jones C, Spector A, Algar-Skaife K, Hughes G, Brocklehurst P, Goulden N, Skelhorn D, Stott J. Effects of an e-health intervention 'iSupport' for reducing distress of dementia carers: protocol for a randomised controlled trial and feasibility study. BMJ Open 2022; 12:e064314. [PMID: 36130751 PMCID: PMC9494593 DOI: 10.1136/bmjopen-2022-064314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION In the UK, National Health Service (NHS) guidelines recommend that informal carers of people living with dementia should be offered training to help them develop care skills and manage their own physical and mental health. The WHO recommends access to affordable, proven, well-designed, online technologies for education, skills training and support for dementia carers. In response to these recommendations, this multisite randomised controlled trial (RCT) is the first study in the UK to evaluate the clinical and cost-effectiveness of an online support programme developed by the WHO called 'iSupport for dementia carers'. METHODS AND ANALYSIS 350 informal carers (age 18+ years) living in Britain who self-identify as experiencing stress and depression will be recruited. They will be randomised to receive 'iSupport', or standardised information about caring for someone with dementia (control-comparison). Data will be collected via videoconferencing (eg, Zoom) or telephone interview at baseline, 3 months and 6 months. Intention-to-treat analysis will ascertain effectiveness in the primary outcomes (distress and depression) and combined cost, and quality-adjusted life-year data will be used to assess cost-effectiveness compared with usual care from a public sector and wider societal perspective. A mixed-methods process evaluation with a subgroup of carers in the intervention (~N=50) will explore the barriers and facilitators to implementing 'iSupport'. A non-randomised feasibility study will adapt 'iSupport' for young carers (n=38 participants, age 11-17 years). ETHICS AND DISSEMINATION The research plan was scrutinised by National Institute for Health Research reviewers ahead of funding being awarded. Ethical approval was granted by Bangor University's School of Health and Medical Sciences Academic Ethics Committee, reference number 2021-16915. Dissemination plans include delivering events for stakeholders, social media, a project website, developing policy briefings, presenting at conferences and producing articles for open access publications. TRIAL REGISTRATION NUMBER ISRCTN17420703.
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Affiliation(s)
- Gill Windle
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Greg Flynn
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Zoe Hoare
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | | | - Kieren Egan
- Department of Computer and Information Science, University of Strathclyde, Glasgow, UK
| | | | - Carys Jones
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Aimee Spector
- Department of Clinical, Educational and Health Psychology, University College London (UCL), London, UK
| | - Katherine Algar-Skaife
- Department of Neuro-medicine and Movement Science (INB), Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Gwenllian Hughes
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Paul Brocklehurst
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Nia Goulden
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Debbie Skelhorn
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Joshua Stott
- Department of Clinical, Educational and Health Psychology, University College London (UCL), London, UK
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Brijnath B, Baruah U, Antoniades J, Varghese M, Cooper C, Dow B, Kent M, Loganathan S. Using digital media to improve dementia care in India: A pilot randomised control trial (Preprint). JMIR Res Protoc 2022; 11:e38456. [PMID: 35653168 PMCID: PMC9204579 DOI: 10.2196/38456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/01/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Objective Methods Results Conclusions Trial Registration International Registered Report Identifier (IRRID)
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Affiliation(s)
| | - Upasana Baruah
- Institute of Human Behaviour & Allied Sciences, Delhi, India
| | | | - Mathew Varghese
- National Institute of Mental Health and Neuro Sciences, Bengaluru, India
| | | | - Briony Dow
- National Ageing Research Institute, Parkville, Australia
| | | | - Santosh Loganathan
- National Institute of Mental Health and Neuro Sciences, Bengaluru, India
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Teles S, Ferreira A, Paúl C. Feasibility of an online training and support program for dementia carers: results from a mixed-methods pilot randomized controlled trial. BMC Geriatr 2022; 22:173. [PMID: 35232389 DOI: 10.1186/s12877-022-02831-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 02/02/2022] [Indexed: 12/25/2022] Open
Abstract
Background iSupport is an online program developed by the World Health Organization to provide education, skills training, and social support to informal carers of persons with dementia. This pilot study examines the feasibility of the protocol for a main effectiveness trial of iSupport-Portugal and explores how the intervention and control arms compare over time on well-being outcomes. Methods A mixed-methods experimental parallel between-group design with two arms is followed. Participants were recruited nationwide, by referral or advertising, through the National Alzheimer’s Association. Inclusion criteria are being Portuguese adults, providing e-consent, providing unpaid care to someone with dementia for at least 6 months, experiencing relevant scores on burden (≥ 21 on ZBI) or depression or anxiety (≥ 8 on HADS), and using webpages autonomously. Participants were consecutively randomized to receive iSupport-Portugal or an education-only e-book and were not blinded to group assignment. Data were collected online with self-administered instruments, at baseline, 3 and 6 months after. Outcomes comprise caregiver burden, depression, anxiety, QoL, positive aspects of caregiving, and self-efficacy. Generalized estimating equations were used to estimate group, time, and group-by-time effects. Intervention engagement data were extracted from iSupport’s platform. Semi-structured interviews were conducted. Results Forty-two participants were allocated to the intervention (N = 21) and control (N = 21) arms. Participation (78.1%) and retention rates (73.8%) were fair. More carers in the control arm completed the study (N = 20, 95.2%) than in the intervention arm (N = 11; 52.4%) (χ2 = 9.98, p = .002). Non-completers were younger, spent less time caring, and scored higher on anxiety. Among carers in the intervention arm, the average attendance rate was of 53.7%. At post-test 38.9% of participants still used iSupport; the remainder participants interrupted use within 2 weeks (Mdn). For per-protocol analyses, significant group-by-time interaction effects favouring the intervention were found for anxiety (Wald χ2 = 6.17, p = .046) and for environmental QoL (Wald χ2 = 7.06, p = .029). Those effects were not observed in intention-to-treat analyses adjusted for age. Interviewees from the intervention arm (N = 12) reported positive results of iSupport on knowledge and on experiencing positive feelings. No adverse effects were reported. Conclusions This study provides information for a forthcoming full-scale effectiveness trial, as on the acceptability and potential results of iSupport-Portugal. iSupport is suggested as a relevant resource for Portuguese carers. Trial registration ClinicalTrials.gov, NCT04104568. 26/09/2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-02831-z.
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Baruah U, Loganathan S, Shivakumar P, Pot AM, Mehta KM, Gallagher-Thompson D, Dua T, Varghese M. Adaptation of an online training and support program for caregivers of people with dementia to Indian cultural setting. Asian J Psychiatr 2021; 59:102624. [PMID: 33770675 DOI: 10.1016/j.ajp.2021.102624] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 02/10/2021] [Accepted: 02/22/2021] [Indexed: 12/13/2022]
Abstract
Support for caregivers of people with dementia has been identified as an action area in the Global Action Plan on the Public Health Response to Dementia 2017-2025 by the World Health Organization (WHO). As a step towards that, WHO developed iSupport - an online program to provide support and training for caregivers of people with dementia. To address the need of caregivers in India, the iSupport program was adapted to the Indian cultural setting. The process of adaptation consisted of four phases: (a) information gathering (review of literature and focus group discussions), (b) preliminary adaptation design (modifications using an adaptation guide), (c) preliminary adaptation tests (face-to-face interviews and online test run), and (d) adaptation refinement (final modifications to the intervention and study process). The initial adaptation was carried out by effecting changes in words, names, resources, caregiving scenarios and audio files to make the English version of iSupport suitable to the Indian cultural context. The results of the qualitative adaptation tests provided additional recommendations like changing the links to India specific websites, revising the eligibility criterion for caregiving duration, re-wording of e-mail texts, inclusion of a time estimate required to complete the assessments and decreasing the numbers of screens that the caregivers had to navigate in the program, which were incorporated in the final phase. Preliminary data showed that the caregivers who participated in the adaptation process found the changes acceptable. Translation of iSupport to different Indian languages could be undertaken after initial effectiveness of the program is established.
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Affiliation(s)
- Upasana Baruah
- Geriatric Clinic and Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Santosh Loganathan
- Geriatric Clinic and Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Prafulla Shivakumar
- Geriatric Clinic and Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Anne Margriet Pot
- Department of Mental Health and Substance Use, World Health Organization (WHO), Geneva, Switzerland
| | - Kala M Mehta
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Dolores Gallagher-Thompson
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States; Betty Irene Moore School of Nursing, University of California, Davis, CA, United States
| | - Tarun Dua
- Department of Mental Health and Substance Use, World Health Organization (WHO), Geneva, Switzerland
| | - Mathew Varghese
- Geriatric Clinic and Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
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Baruah U, Varghese M, Loganathan S, Mehta KM, Gallagher-Thompson D, Zandi D, Dua T, Pot AM. Feasibility and preliminary effectiveness of an online training and support program for caregivers of people with dementia in India: a randomized controlled trial. Int J Geriatr Psychiatry 2021; 36:606-617. [PMID: 33491811 DOI: 10.1002/gps.5502] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/22/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Internet-based interventions involving elements of cognitive behavior therapy, psychoeducation, relaxation and skills training for caregivers of people with dementia have been found to be promising in Western countries. Given these outcomes, the adapted version of a multi-component online caregiver skills training and support program of the World Health Organization, called iSupport, was tested for feasibility and preliminary effectiveness in India. METHODS One hundred fifty-one caregivers of family members with a diagnosis of Alzheimer's disease or dementia were randomized to either the intervention arm (iSupport; n = 74) or to the control group (an education-only e-book program; n = 77). Participants were assessed using self-rated measures of depression and perceived burden, which were the primary outcome measures, at baseline and 3-month follow-up. Person-centered attitude, self-efficacy, mastery and self-rated health were also assessed. RESULTS Fifty-five caregivers (29 in the iSupport group and 26 in the control condition) completed the study. The recruitment and retention rate of the study were 44.67% and 36.42% respectively. No significant differences were found between the two groups at 3-month follow-up on the primary outcomes. Among the secondary outcomes, significant improvement was only seen in caregivers' person-centered attitude towards persons with dementia in the iSupport group (t = 2.228; p < 0.05). CONCLUSIONS Despite efforts to recruit and retain participants to the online program, this study had a low recruitment and retention rate, which require closer attention and indicates a need for further adaptations of the Indian version of the iSupport program to improve its acceptability and accessibility. The lessons learned from this study will guide the further development of caregiver training and support interventions in India. The trial was registered with the Clinical Trials Registry-India (Trial Registration No. CTRI/2017/02/007876).
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Affiliation(s)
- Upasana Baruah
- Department of Psychiatry, Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Mathew Varghese
- Department of Psychiatry, Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Santosh Loganathan
- Department of Psychiatry, Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Kala M Mehta
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Dolores Gallagher-Thompson
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA.,Betty Irene Moore School of Nursing, University of California, Davis, California, USA
| | - Diana Zandi
- Department of Integrated Health Services, World Health Organization (WHO), Geneva, Switzerland
| | - Tarun Dua
- Department of Mental Health and Substance Use, World Health Organization (WHO), Geneva, Switzerland
| | - Anne Margriet Pot
- Department of Mental Health and Substance Use, World Health Organization (WHO), Geneva, Switzerland
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González-Fraile E, Ballesteros J, Rueda JR, Santos-Zorrozúa B, Solà I, McCleery J. Remotely delivered information, training and support for informal caregivers of people with dementia. Cochrane Database Syst Rev 2021; 1:CD006440. [PMID: 33417236 PMCID: PMC8094510 DOI: 10.1002/14651858.cd006440.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Many people with dementia are cared for at home by unpaid informal caregivers, usually family members. Caregivers may experience a range of physical, emotional, financial and social harms, which are often described collectively as caregiver burden. The degree of burden experienced is associated with characteristics of the caregiver, such as gender, and characteristics of the person with dementia, such as dementia stage, and the presence of behavioural problems or neuropsychiatric disturbances. It is a strong predictor of admission to residential care for people with dementia. Psychoeducational interventions might prevent or reduce caregiver burden. Overall, they are intended to improve caregivers' knowledge about the disease and its care; to increase caregivers' sense of competence and their ability to cope with difficult situations; to relieve feelings of isolation and allow caregivers to attend to their own emotional and physical needs. These interventions are heterogeneous, varying in their theoretical framework, components, and delivery formats. Interventions that are delivered remotely, using printed materials, telephone or video technologies, may be particularly suitable for caregivers who have difficulty accessing face-to-face services because of their own health problems, poor access to transport, or absence of substitute care. During the COVID-19 pandemic, containment measures in many countries required people to be isolated in their homes, including people with dementia and their family carers. In such circumstances, there is no alternative to remote delivery of interventions. OBJECTIVES To assess the efficacy and acceptability of remotely delivered interventions aiming to reduce burden and improve mood and quality of life of informal caregivers of people with dementia. SEARCH METHODS We searched the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE, Embase and four other databases, as well as two international trials registries, on 10 April 2020. We also examined the bibliographies of relevant review papers and published trials. SELECTION CRITERIA We included only randomised controlled trials that assessed the remote delivery of structured interventions for informal caregivers who were providing care for people with dementia living at home. Caregivers had to be unpaid adults (relatives or members of the person's community). The interventions could be delivered using printed materials, the telephone, the Internet or a mixture of these, but could not involve any face-to-face contact with professionals. We categorised intervention components as information, training or support. Information interventions included two key elements: (i) they provided standardised information, and (ii) the caregiver played a passive role. Support interventions promoted interaction with other people (professionals or peers). Training interventions trained caregivers in practical skills to manage care. We excluded interventions that were primarily individual psychotherapy. Our primary outcomes were caregiver burden, mood, health-related quality of life and dropout for any reason. Secondary outcomes were caregiver knowledge and skills, use of health and social care resources, admission of the person with dementia to institutional care, and quality of life of the person with dementia. DATA COLLECTION AND ANALYSIS Study selection, data extraction and assessment of the risk of bias in included studies were done independently by two review authors. We used the Template for Intervention Description and Replication (TIDieR) to describe the interventions. We conducted meta-analyses using a random-effects model to derive estimates of effect size. We used GRADE methods to describe our degree of certainty about effect estimates. MAIN RESULTS We included 26 studies in this review (2367 participants). We compared (1) interventions involving training, support or both, with or without information (experimental interventions) with usual treatment, waiting list or attention control (12 studies, 944 participants); and (2) the same experimental interventions with provision of information alone (14 studies, 1423 participants). We downgraded evidence for study limitations and, for some outcomes, for inconsistency between studies. There was a frequent risk of bias from self-rating of subjective outcomes by participants who were not blind to the intervention. Randomisation methods were not always well-reported and there was potential for attrition bias in some studies. Therefore, all evidence was of moderate or low certainty. In the comparison of experimental interventions with usual treatment, waiting list or attention control, we found that the experimental interventions probably have little or no effect on caregiver burden (nine studies, 597 participants; standardised mean difference (SMD) -0.06, 95% confidence interval (CI) -0.35 to 0.23); depressive symptoms (eight studies, 638 participants; SMD -0.05, 95% CI -0.22 to 0.12); or health-related quality of life (two studies, 311 participants; SMD 0.10, 95% CI -0.13 to 0.32). The experimental interventions probably result in little or no difference in dropout for any reason (eight studies, 661 participants; risk ratio (RR) 1.15, 95% CI 0.87 to 1.53). In the comparison of experimental interventions with a control condition of information alone, we found that experimental interventions may result in a slight reduction in caregiver burden (nine studies, 650 participants; SMD -0.24, 95% CI -0.51 to 0.04); probably result in a slight improvement in depressive symptoms (11 studies, 1100 participants; SMD -0.25, 95% CI -0.43 to -0.06); may result in little or no difference in caregiver health-related quality of life (two studies, 257 participants; SMD -0.03, 95% CI -0.28 to 0.21); and probably result in an increase in dropouts for any reason (12 studies, 1266 participants; RR 1.51, 95% CI 1.04 to 2.20). AUTHORS' CONCLUSIONS Remotely delivered interventions including support, training or both, with or without information, may slightly reduce caregiver burden and improve caregiver depressive symptoms when compared with provision of information alone, but not when compared with usual treatment, waiting list or attention control. They seem to make little or no difference to health-related quality of life. Caregivers receiving training or support were more likely than those receiving information alone to drop out of the studies, which might limit applicability. The efficacy of these interventions may depend on the nature and availability of usual services in the study settings.
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Affiliation(s)
| | - Javier Ballesteros
- Department of Neuroscience, University of the Basque Country, CIBER Salud Mental (CIBERSAM), Leioa, Spain
| | - José-Ramón Rueda
- Department of Preventive Medicine and Public Health, University of the Basque Country, Leioa, Spain
| | - Borja Santos-Zorrozúa
- Scientific coordination Unit, Biocruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Ivan Solà
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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Sivakumar PT, Mukku SSR, Kar N, Manjunatha N, Phutane VH, Sinha P, Kumar CN, Math SB. Geriatric Telepsychiatry: Promoting Access to Geriatric Mental Health Care Beyond the Physical Barriers. Indian J Psychol Med 2020; 42:41S-46S. [PMID: 33354062 PMCID: PMC7736734 DOI: 10.1177/0253717620958380] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Psychiatric illnesses are an important contributor of morbidity and mortality in older adults. There is increase in older adults with psychiatric disorders paralleling their growth in absolute numbers. This leads to challenges in mental health care and service delivery. Several barriers that exists in our community hinder older adults from receiving mental health care. Additionally, lack of adequate human resources in geriatric mental health care compounds the problem. Telemedicine, though not new in other fields of medicine, is relatively new in the practice of psychiatry in India. This is probably due to lack of clear guidelines and regulations regarding the same in India. There is a recent increase in teleconsultations in India similar to other developed countries due to ongoing COVID-19 pandemic. The recent telepsychiatry operational guidelines have made telepsychiatry a legitimate and official practice in India. Challenges specific to older adults in the form of low digital literacy, sensory issues, and cognitive impairment can be overcome by adopting telepsychiatry services in coming years. Concerns related to security and safety of telepsychiatry require further evaluation.
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Affiliation(s)
- Palanimuthu Thangaraju Sivakumar
- Dept. of Psychiatry, Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Shiva Shanker Reddy Mukku
- Dept. of Psychiatry, Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Nilamadhab Kar
- Black Country Healthcare NHS Foundation Trust, Wolverhampton, England, United Kingdom
| | | | - Vivek Haridas Phutane
- Goulburn Valley Area Mental Health Services (GVAMHS), Goulburn Valley Health, Shepparton and Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Preeti Sinha
- Dept. of Psychiatry, Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | | | - Suresh Bada Math
- Tele Medicine Centre, Dept. of Psychiatry, NIMHANS, Bengaluru, India
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Han J, Guo G, Hong L. Impact of professionally facilitated peer support for family carers of people with dementia in a WeChat virtual community. J Telemed Telecare 2020; 28:68-76. [PMID: 32192386 DOI: 10.1177/1357633x20910830] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Dementia is an important issue affecting families and society. Family carers face challenges accessing support due to homebound duties of caring for people with dementia. Internet-based support provides feasible and accessible opportunities. METHODS A single-group repeated-measures study was conducted with carers who provide primary care or regularly participate in care for relatives with dementia in a WeChat virtual community. Interventions included three to six months of peer and professional support, included peer emotional support, lectures and consultation, technique support and articles. Self-administered online questionnaires were used pre and post intervention to collect carers' feedback on activities, indicators of depression, helplessness, perceived stress, carer burden, distress caused by responsive behaviours and self-efficacy. RESULTS A total of 159 carers participated. Of these, 136 (85.5%) were active members according to the amount of information shared in community. A total of 92.4% of carers thought the help and support from the community were important or very important. There were statistically significant differences after intervention for depression (p < 0.05), perceived stress (p < 0.05), helplessness (p < 0.001), self-efficacy total score (p < 0.05) and two domains of gathering information and obtaining support (p < 0.05). There was no statistically significant decrease after intervention for distress caused by responsive behaviours and carer burden (p>0.05). DISCUSSION Professional facilitated peer support based on WeChat virtual community is feasible and acceptable for family carers of people with dementia. It can reduce carers' perceived pressure, helplessness and depression, and improve self-efficacy compared to pre participation.
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Affiliation(s)
- Jing Han
- Peking University School of Nursing, PR China.,Nursing Department of Medicine College, Shihezi University, PR China
| | - Guifang Guo
- Peking University School of Nursing, PR China
| | - Li Hong
- Lezhi College, Lovepama Technology Co Ltd, PR China
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Teles S, Ferreira A, Seeher K, Fréel S, Paúl C. Online training and support program (iSupport) for informal dementia caregivers: protocol for an intervention study in Portugal. BMC Geriatr 2020; 20:10. [PMID: 31914936 PMCID: PMC6950829 DOI: 10.1186/s12877-019-1364-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/22/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Informal caregivers (IC) of people with dementia (PwD) are at greater risk of developing physical and mental health problems when compared to the general population and to IC of people with other chronic diseases. Internet-based interventions have been explored for their potential to minimize the negative effects of caring, accounting for their ubiquitous nature, convenient delivery, potential scalability and presumed (cost) effectiveness. iSupport is a self-help online program developed by the World Health Organization (WHO) to provide education, skills training and support to IC of PwD. This paper describes the design of an intervention study aimed at determining the effectiveness of a Portuguese culturally adapted version of iSupport on mental health and other well-being outcomes. METHODS The study follows an experimental parallel between-group design with two arms: access to the five modules and twenty-three lessons of "iSupport" for three months (intervention group); or access to an education-only e-book (comparison group). One hundred and eighty four participants will be recruited by referral from national associations. Inclusion criteria are: being 18 years or older and provide e-consent; being a self-reported non-paid caregiver for at least six months; of a person with a formal diagnosis of dementia; being skilled to use internet; and experience a clinically relevant level of burden (≥ 21 on Zarit Burden Interview) or depression or anxiety symptoms (≥ 8 on Hospital Anxiety and Depression Scale). Data is collected online, resorting to self-administered instruments, at baseline, 3 and 6 months after baseline. The primary outcome is caregiver burden, measured by the Zarit Burden Interview. Symptoms of depression and anxiety, quality of life, positive aspects of caregiving and general self-efficacy are secondary study outcomes. The data analysis will follow an Intention-to-treat (ITT) protocol. DISCUSSION This protocol is an important resource for the many organizations in several countries aiming to replicate iSupport. Findings from this intervention study will offer evidence to bolster an informed decision making on scaling up iSupport as a new intervention program with minimal costs aimed at minimizing the psychological distress of IC of PwD in Portugal and elsewhere. TRIAL REGISTRATION ClinicalTrials.gov, NCT04104568. Registered 26 September 2019.
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Affiliation(s)
- Soraia Teles
- Department of Behavioral Sciences, Institute of Biomedical Sciences Abel Salazar, University of Porto (ICBAS-UP), Rua de Jorge Viterbo Ferreira, 228, 4050-313, Porto, Portugal. .,Center for Health Technology and Services Research (CINTESIS), Rua Dr. Plácido da Costa, 4200-450, Porto, Portugal. .,Faculty of Medicine, University of Porto (FMUP), Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Ana Ferreira
- Center for Health Technology and Services Research (CINTESIS), Rua Dr. Plácido da Costa, 4200-450, Porto, Portugal.,Faculty of Medicine, University of Porto (FMUP), Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Katrin Seeher
- Department of Mental Health and Substance Use (MSD), World Health Organization, Avenue Appia 20, 1202, Geneva, Switzerland
| | - Stéfanie Fréel
- Department of Mental Health and Substance Use (MSD), World Health Organization, Avenue Appia 20, 1202, Geneva, Switzerland
| | - Constança Paúl
- Department of Behavioral Sciences, Institute of Biomedical Sciences Abel Salazar, University of Porto (ICBAS-UP), Rua de Jorge Viterbo Ferreira, 228, 4050-313, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Rua Dr. Plácido da Costa, 4200-450, Porto, Portugal
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Hinton L, Tran D, Nguyen TN, Ho J, Gitlin L. Interventions to support family caregivers of people living with dementia in high, middle and low-income countries in Asia: a scoping review. BMJ Glob Health 2019; 4:e001830. [PMID: 31798992 PMCID: PMC6861057 DOI: 10.1136/bmjgh-2019-001830] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/25/2019] [Accepted: 09/28/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Despite increasing numbers of persons living with Alzheimer's disease and Alzheimer's-related dementias (AD/ADRD) in Asia, particularly in low-income countries (LIC) and middle-income countries (MIC), surprisingly little is known about the current state of the evidence for family caregiver interventions. The objectives of this scoping review were to: (1) describe the evidence for efficacy of family dementia-caregiver psychosocial interventions in Asian countries, (2) compare evidence across LIC, MIC, and high-income countries (HIC), and (3) characterise cultural adaptions to interventions developed outside Asia. METHODS The inclusion criteria included: (1) conducted in Asia (2) included an intervention delivered to a family caregiver of a person living with AD/ADRD, (3) reported quantitative outcomes for the family caregiver and (4) published in a peer-reviewed journal with full text available in English. RESULTS Thirty intervention trials were identified meeting inclusion criteria and all reported statistically significant (p<0.05) improvement in one or more caregiver outcomes. Interventions usually included multiple components. The most frequently reported outcomes (ie, by ≥20% of studies) were caregiver depression, burden, quality of life and self-efficacy. Overall, 26 (87%) of the studies were conducted in HIC in Asia, primarily in Hong Kong SAR-China and Taiwan, and only 4 (13%) in LIC and MIC in Asia. Seven studies (23%) used interventions developed in USA and several described cultural adaptations. CONCLUSION This scoping review found substantial evidence, particularly from high-income Asian countries, that a wide range of interventions improve AD/ADRD family caregiver outcomes. However, critical knowledge gaps exist, particularly for LIC and MIC in Asia, where the number of persons with dementia is numerically largest and projected to increase dramatically in coming decades. The field could also benefit from more detailed descriptions of the process and types of cultural adaptations to interventions.
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Affiliation(s)
- Ladson Hinton
- Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California, USA
| | - Duyen Tran
- University of California Davis, Davis, California, USA
| | | | - Janis Ho
- Touro University California, Vallejo, California, USA
| | - Laura Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania, USA
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Pinto-Bruno ÁC, Pot AM, Kleiboer A, Droes RM, van Straten A. An Online Minimally Guided Intervention to Support Family and Other Unpaid Carers of People With Dementia: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e14106. [PMID: 31603433 PMCID: PMC6819009 DOI: 10.2196/14106] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 07/26/2019] [Accepted: 07/28/2019] [Indexed: 01/29/2023] Open
Abstract
Background About three-quarters of people with dementia live in their own homes, with help from family members and/or other unpaid carers, such as friends or neighbors. Often, unpaid carers themselves experience negative consequences, such as stress, burden, and symptoms of depression or anxiety. Research has shown that these consequences can be alleviated by psychosocial and psychological interventions. Moreover, there are indications that those interventions can be effective when offered online. Objective This paper describes the protocol of a randomized controlled trial (RCT) that will take place in the Netherlands to evaluate the effectiveness of iSupport, a minimally guided, internet-based intervention to improve carers’ mental health and coping resources. Methods A superiority two-arm RCT comparing the effects of the online support program with a waiting list control condition will be carried out in the Netherlands. The iSupport intervention was developed by the World Health Organization and is based on cognitive behavioral therapy principles. It has five main themes divided into 23 lessons. Carers can pick and choose which lessons they want to complete. We aim to recruit 200 unpaid carers. The experimental group (n=100) will be provided with access to the intervention for 3 months following randomization; those in the waiting list control group (n=100) will be granted access to the intervention after 3 months. Assessments will be conducted at baseline (T0), 3 months after baseline (post intervention, T1), and 6 months after baseline (follow-up, T2). The primary outcome is perceived stress, measured by the Perceived Stress Scale. Secondary outcomes are symptoms of depression and anxiety, caregiver burden, sense of competence, self-efficacy, mastery, and carers’ attitudes toward dementia and their person-centered approach (ie, to what extent carers tailor the provided care to the interest, needs, and history of the person with dementia). Results Recruitment for the trial started in January 2019. As of July 2019, we have enrolled 120 participants.
Data collection is expected to be completed by March 2020. Once all the data have been collected, we will conduct the data analyses between April and May 2020. We aim to publish our results in a manuscript by June 2020. Conclusions Online interventions have shown promising results in improving the mental health of carers of people with dementia. Additionally, online interventions may overcome accessibility barriers. If successful, this intervention will have important potential for implementation as a public health intervention, since costs and support by trained staff are minimal. Trial Registration Netherlands Trial Register (NTL) NL6417; https://www.trialregister.nl/trial/6417 International Registered Report Identifier (IRRID) DERR1-10.2196/14106
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Affiliation(s)
- Ángel C Pinto-Bruno
- Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Anne Margriet Pot
- Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,School of Psychology, University of Queensland, Brisbane, Australia.,Optentia Research Focus Area, North-West University, Vanderbijlpark, Gauteng, South Africa
| | - Annet Kleiboer
- Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rose-Marie Droes
- Department of Psychiatry, Amsterdam University Medical Centers (at VUmc), Amsterdam Public Health Institute, Amsterdam, Netherlands
| | - Annemieke van Straten
- Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Pot AM, Gallagher‐Thompson D, Xiao LD, Willemse BM, Rosier I, Mehta KM, Zandi D, Dua T. iSupport: a WHO global online intervention for informal caregivers of people with dementia. World Psychiatry 2019; 18:365-366. [PMID: 31496096 PMCID: PMC6732694 DOI: 10.1002/wps.20684] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | | | - Lily D. Xiao
- School of Nursing and Health Sciences, Faculty of Medicine, Nursing and Health Sciences, Flinders UniversityAdelaideAustralia
| | | | - Iris Rosier
- Netherlands Institute on Mental Health and AddictionUtrechtThe Netherlands
| | - Kala M. Mehta
- Department of Psychiatry and Behavioral Sciences, Stanford University School of MedicineStanfordCAUSA
| | | | - Tarun Dua
- World Health OrganizationGenevaSwitzerland
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