Briony Dow

Objectives: This paper reports the health economic component of the broader Promoting Independence Through Quality Dementia Care at Home (PITCH). The broader PITCH trial primarily evaluated the effect of dementia training on home care workers' competence in providing dementia care; this analysis evaluated intervention costs and selected secondary client and caregiver outcomes. Methods: The PITCH intervention was tested via a multi‐site national pragmatic stepped‐wedge cluster randomised clinical trial, conducted across three Australian states. A micro‐costing approach was used to estimate intervention and resource use costs. Secondary outcomes for clients and caregivers, including quality of life (QoL), caregiver burden and dyadic interaction, were assessed. Means (SDs) described costs and outcomes, with linear and multilevel mixed‐effects regression used to estimate crude and adjusted mean differences, respectively. Results: There were no significant improvements in most client and caregiver health, QoL, caregiver burden or dyadic interaction outcomes during the intervention phase, with decreases in proxy‐reported Dementia QoL Utility (DEMQOL‐U) and client self‐reported visual analogue scale (EQ VAS). Improvements in caregiver burden and dyadic interaction were observed but were not statistically significant. Total costs increased from AU$68,925 in the control to AU$133,660 in the intervention phase, with an adjusted mean difference of AU$67,146 (95% CI: AU$16,957 to AU$117,334). Conclusions: This health economic analysis should be interpreted separately from and alongside, the main PITCH trial findings on the primary outcome of home care workers' competence. Within this secondary analysis, PITCH was associated with higher total costs during the intervention phase and no clear evidence of improvement in the selected secondary client and caregiver outcomes.

Background: People who care for a family member with dementia alongside paid work often experience role conflict. This study explores whether work-care role conflict (WCRC) modifies the effectiveness of Draw Care, an online and culturally adapted carer support intervention. Methods: Secondary exploratory analysis of a single-blind, parallel-group trial (August 2023-November 2024) that compared Draw Care against waitlist control in adult carers from diverse linguistic backgrounds. To formally test whether WCRC moderated the effect of the Draw Care intervention, we ran a full-sample linear mixed model that included a 3-way interaction between time-point, treatment group, and an indicator of WCRC. Work-care role conflict was operationalized as self-report of missed work or reduced productivity due to competing care and employment demands. Outcomes included carer burden, mood, quality of life, and productivity/activity impairment at 6 and 12 weeks. Results: Forty-two of 93 carers reported WCRC. Reductions in caregiver burden due to treatment at 6 weeks (−10.00; 95% CI, −19.70 to −0.31, p = .043) and 12 weeks (−9.56; 95% CI, −18.83 to −0.29, p = .043) were significantly larger in participants with WCRC than without. This moderating effect of WCRC was driven by a robust, absolute reduction in caregiver burden in intervention group participants with WCRC over the initial 6 weeks (−7.19, 95% CI, −12.72 to −1.67, p = .011), with much of this improvement preserved at 12 weeks (−6.85, 95% CI, −12.17 to −1.53, p = .012). Conclusions: WCRC appears to modify the effectiveness of Draw Care, suggesting that the intervention may be particularly helpful for carers navigating role conflict. Clinical Trial Registration Number: ACTRN12622000382774 and ACTRN12622000358741

Background: Technology can deliver culturally and linguistically appropriate resources to support ethnically diverse family carers (hereafter referred to as carers) of people living with dementia. However, carers’ involvement in research on the development and evaluation of such digital health interventions is limited. Objective: This study aims to user-test the co-designed Draw-Care multilingual, web-based dementia resource with and for carers. Methods: We evaluated the web-based resource through observation sessions to collect carer feedback, using a mixed methods approach. This comprised the online, validated eHealth Literacy Scale and survey questions assessing the perceived usefulness and importance of the internet for health-related decision-making and access to health resources. In addition, “think-aloud” website navigation sessions were conducted, and Hotjar analytics were used to capture participants’ behavior on the website. Quantitative and analytics data were analyzed descriptively, and qualitative data were analyzed using instant data analysis, followed by thematic analysis. Results: Between March and April 2023, a total of 30 carers participated in the user-testing sessions (women, n=20, 67%; mean age 61, SD 13.5 years). The mean eHealth Literacy Scale score was 30 (SD 6.1). Overall, 18 (60%) participants perceived the internet as useful, and laptops and tablets were the most commonly used devices for accessing resources, each used by 9 (30%) participants. Vietnamese (n=5, 17%), Mandarin (n=5, 17%), and English (n=5, 17%) were the top 3 languages the resource was accessed in. A total of 28 (93%) participants could navigate and log in to the website with little to no support. Qualitative results showed that overall, the Draw-Care web-based resource was acceptable, culturally responsive, engaging, and usable. However, navigation was more complicated for those using smaller screens (eg, smartphones and tablets). There were linguistic discrepancies arising from translation issues in Vietnamese and Mandarin, and 14 (46%) participants found it difficult to identify and use the chatbot (ie, virtual helper interface). Issues identified with the prototype Draw-Care website and the proposed improvements included eliminating the virtual helper, simplifying the rating scale from a 5-point smiling emoticon scale to a 3-star rating scale, improving the visibility of the feedback button, and ensuring translation accuracy. Conclusions: To our knowledge, this is the first study to evaluate a bespoke multilingual website delivering a novel, co-designed, and culturally adapted digital intervention in 10 languages for ethnically diverse family carers of people living with dementia. Findings from this user-testing study undertaken with carers uncovered usability issues requiring remediation and emphasized the importance of inclusive, accessible, culturally sensitive, engaging, and beneficial content and design. Key revisions were implemented before the randomized controlled trial commenced. International Registered Report Identifier (IRRID): RR2-10.1177/20552076231205733

Background: The World Health Organisation’s (WHO) iSupport Lite program contains six short practical public health support messages for carers of people with dementia to reduce stress and improve their mental health. We culturally adapted WHO’s iSupport Lite into a digital intervention—‘Draw-Care’—comprising six animated films and tipsheets hosted on a website and available in 10 languages. Aim: To assess the effectiveness of ‘Draw-Care’ on multilingual family carers’ burden, mood and quality of life. Methods: A single-blind, parallel-group randomised clinical trial conducted with multilingual adult carers with internet access. The trial was community-based, conducted online, between 1 August 2023 and 8 November 2024, with follow-up at 6- and 12-weeks. The target was 194 participants (156 needed with 25% attrition). The primary outcome was reduction in carer burden, as measured by the Zarit Burden Interview (ZBI). Secondary outcomes were improvement in carer mood and quality of life, as measured by the Centre for Epidemiological Studies Depression (CES-D), the World Health Organisation Quality of Life Scale (WHOQOL-Bref), Care-related Quality of Life instrument (CarerQoL-7D), and productivity and activity impairment as measured by the Work Productivity and Activity Impairment Questionnaire as adapted for caregiving (WPAI:CG). Findings: One hundred sixteen participants consented and 93 (46 waitlist control, 47 intervention) were included in the analyses. Participants mean age was 54.80 (SD 13.33), 72 (77.4%) were women, and 29 (31.5%), 27 (29.4%) and 22 (23.9%) were from European, Vietnamese and Chinese backgrounds, respectively. No statistically significant differences were observed between the intervention and control groups on the ZBI, CES-D, WHOQOL-Bref and WPAI:CG. Null effects for some outcomes may be due to ceiling effects or insufficient power. A statistically significantly higher mean CarerQoL-VAS score was found for the intervention group (mean difference = 0.75, 95% CL: 0.25 to 1.24, P = .003) over 6- and 12-weeks, compared to the control. Interpretation: ‘Draw-Care’ showed no significant effect on carers’ burden and mood but did show significant improvements in some carers’ quality of life measures.

This study examined the impact of befriending on depression, anxiety, perceived social support and loneliness in older people living in residential aged care homes. A pragmatic randomized controlled trial compared depressive symptoms (Geriatric Depression Scale-15), anxiety symptoms (Geriatric Anxiety Inventory), loneliness (UCLA loneliness scale), and perceived social support (Lubben Social Network Scale) measured at baseline, 8 weeks and 16 weeks post baseline for people randomized to receive either befriending or usual care. Trial registration ANZCTR N12619000676112. Among N = 345 participants, a significant reduction in depressive symptoms for people receiving befriending compared to the control group: 0.76 points lower on GDS at 8 weeks and 0.95 lower at 16 weeks (Cohen's d = -0.458). Loneliness (UCLA) was 2.39 units lower than the control group at 8 weeks and 2.71 units lower at 16 weeks (Cohen's d -0.481). There was no significant difference for anxiety symptoms or perceived social support. Befriending led to a small improvement in depressive symptoms and loneliness in older people living in residential aged care. The improvement in depressive symptoms and loneliness indicates that befriending may be a useful supplement to psychological services for those living in residential aged care.

BACKGROUND Technology can deliver culturally and linguistically appropriate resources to support ethnically diverse family carers (hereafter referred to as carers) of people living with dementia. However, carers’ involvement in research on the development and evaluation of such digital health interventions is limited. OBJECTIVE This study aims to user-test the co-designed Draw-Care multilingual, web-based dementia resource with and for carers. METHODS We evaluated the web-based resource through observation sessions to collect carer feedback, using a mixed methods approach. This comprised the online, validated eHealth Literacy Scale and survey questions assessing the perceived usefulness and importance of the internet for health-related decision-making and access to health resources. In addition, “think-aloud” website navigation sessions were conducted, and Hotjar analytics were used to capture participants’ behavior on the website. Quantitative and analytics data were analyzed descriptively, and qualitative data were analyzed using instant data analysis, followed by thematic analysis. RESULTS Between March and April 2023, a total of 30 carers participated in the user-testing sessions (women, n=20, 67%; mean age 61, SD 13.5 years). The mean eHealth Literacy Scale score was 30 (SD 6.1). Overall, 18 (60%) participants perceived the internet as useful, and laptops and tablets were the most commonly used devices for accessing resources, each used by 9 (30%) participants. Vietnamese (n=5, 17%), Mandarin (n=5, 17%), and English (n=5, 17%) were the top 3 languages the resource was accessed in. A total of 28 (93%) participants could navigate and log in to the website with little to no support. Qualitative results showed that overall, the Draw-Care web-based resource was acceptable, culturally responsive, engaging, and usable. However, navigation was more complicated for those using smaller screens (eg, smartphones and tablets). There were linguistic discrepancies arising from translation issues in Vietnamese and Mandarin, and 14 (46%) participants found it difficult to identify and use the chatbot (ie, virtual helper interface). Issues identified with the prototype Draw-Care website and the proposed improvements included eliminating the virtual helper, simplifying the rating scale from a 5-point smiling emoticon scale to a 3-star rating scale, improving the visibility of the feedback button, and ensuring translation accuracy. CONCLUSIONS To our knowledge, this is the first study to evaluate a bespoke multilingual website delivering a novel, co-designed, and culturally adapted digital intervention in 10 languages for ethnically diverse family carers of people living with dementia. Findings from this user-testing study undertaken with carers uncovered usability issues requiring remediation and emphasized the importance of inclusive, accessible, culturally sensitive, engaging, and beneficial content and design. Key revisions were implemented before the randomized controlled trial commenced. INTERNATIONAL REGISTERED REPORT RR2-10.1177/20552076231205733

Background and Objectives: The global need for older persons’ care, driven by demographic shifts such as an aging population and increased life expectancy, is outpacing the available care workforce. Nursing home operators face complex workforce challenges, including high turnover and low retention, particularly among personal care workers (PCWs). The objective of this review was to understand the factors influencing PCWs’ intention to leave. Research Design and Methods: Following Whittemore and Knafl’s methodology and adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, an integrative review of peer-reviewed literature published between 1997 and 2024 was undertaken. A comprehensive search was conducted across several databases, including Business Source Complete, CINAHL Complete, Medline Complete, APA PsycINFO, and EMBASE. All studies underwent independent screening and quality assessment using the Mixed-Methods Appraisal Tool. Results: Included were 21 articles reporting 20 studies using quantitative (n = 17), qualitative (n = 3), and mixed methods (n = 1), which identified various factors influencing PCWs’ intention to leave. These factors were categorized as individual, job and organizational, and socio-political-environmental. Demographic characteristics, employee satisfaction, health, career development, workplace conditions, leadership, empowerment, resident connections, and societal perceptions influenced personal care workers’ intentions to leave. Discussion and Implications: The findings of this review reveal opportunities for nursing home operators and policy-makers to implement strategies to mitigate the high rates of turnover through PCW role and organizational reforms. Further, the findings underscore the need for qualitative research exploring the perceptions and experiences shaping the employment intentions of current and former PCWs.

Background and objectives There is interest in routinely measuring quality of life (QoL) in aged care homes, evidenced by the Australian Government’s implementation of QoL as a mandatory quality indicator. This study explores views of aged care staff, residents, and family members on the benefits, challenges, and feasibility of implementing routine QoL measures. Methods Qualitative data were gathered to explore staff, resident, and family perspectives on QoL measurement in aged care homes, including purpose, benefits, implementation, and best practice. Two staff workshops were conducted at different aged care homes, and semi-structured interviews were held with 29 proxies (9 family members and 20 staff) and 24 residents. Workshops and interviews were transcribed verbatim, and thematically analysed via a qualitative interpretive approach using NVivo software. Results Analysis yielded four key themes: (1) benefits of routine QoL measurement; (2) challenges in implementation; (3) best practice for collecting surveys; (4) validity concerns. Identified benefits included potentially improved care, monitoring service performance, and informing family members. Staff participants recommended integrating measures into existing care planning and having oversight from a registered nurse. Participants identified potential implementation challenges, including administrative burden, time and resourcing constraints, conflicts of interest, and resistance from staff, providers, and residents. Conclusions This study identifies potential benefits to implementing routine QoL measurement in residential aged care homes. To maximise these benefits, it is important to consider how measurement can be integrated in ways that contribute to existing care planning and practices.

Background and Objectives: Screening for elder abuse can improve detection, but many health providers lack the necessary skills and confidence. To address this, training for health providers on elder abuse screening was codesigned as part of a trial aimed at improving elder abuse detection and response. Research Design and Methods: Between March and April 2023, 7 health providers and 10 older people and family carers participated in 2 national Australian online codesign workshops. Using the World Café method, discussions focused on what knowledge and skills health providers needed for screening; clinical and social issues affecting screening and referral; and support older people needed throughout the process. Data were thematically analyzed. Results: Participants said health providers should take a trauma-informed, person-centered approach to screening, and explain the limits of confidentiality to older people. Clinical, social, and systemic issues such as dementia, ethnic diversity, and housing availability complicated screening and referrals. To facilitate disclosure, participants said health providers needed to reflect on whether they held ageist views. There were differing opinions on the length of the training and whether all health providers or only social workers should screen for abuse. Discussion and Implications: Participants’ feedback on trauma-informed care, consent, and cognitive impairment concorded with evidence on best practice responses to elder abuse and were integrated into the training. Given operational constraints in health services, feedback from health providers about the training length and the inclusion of all health providers in screening were prioritized. The training is being evaluated in a national trial.