Caring for the caregiver: Why policy must shift from addressing needs to enabling caregivers to flourish.

Policies supporting caregivers ("caregiver policies") are limited in the extent to which they meet the needs of those who care for others. Where policies do exist, they focus on relieving the burdens associated with caring or the needs of the person they care for, rather than consider the holistic needs of the caregiver that would enable them to flourish. We argue that the established approach to caregiver policies reflects a policy failure, requiring a reassessment of current practice related to caregiver support. Often, caregiver policies target the care recipient rather than the caregiver's needs. Through a consultative exercise, we identified five areas of need that existing caregiver policies touch upon. Yet current approaches remain piecemeal and inadequate in a global context. Caregiver policies should not just relieve burden to the extent that caregivers can continue in the role, but they should support caregivers to flourish, and future work may benefit from drawing on related frameworks from positive psychology, such as the PERMA™ model; this is important for both policymakers and researchers.

Effectiveness of a Cluster Randomized Controlled Trial Involving Community-Based Intervention for Older Adults With Type 2 Diabetes Mellitus in Singapore.

PURPOSE: The purpose of the study was to investigate the effectiveness of a community-based intervention on improving knowledge about diabetes, self-care behaviors, and glycemic control among older adults with type 2 diabetes mellitus (T2DM) in Singapore, a country in Asia with a high prevalence of diabetes. METHODS: A 3-arm cluster randomized controlled trial involving community-dwelling older adults ages 55 to 99 with T2DM was conducted. Intervention group 1 and 2 participants received a 12-session intervention program designed to teach knowledge and practical skills in diabetes self-care with psychological techniques for behavioral change like problem solving, goal setting, and motivational interviewing. In addition, intervention group 2 participants received a glucometer and a supply of accessories each. The control group received routine care from their health care providers. RESULTS: Compared to the control group, intervention group 2 reported an increase in medication adherence and self-monitoring of blood glucose (SMBG) at 3-month follow-up and increased knowledge about diabetes and self-care behavior in general diet control at 6-month follow-up. CONCLUSIONS: The community-based intervention should be extended to more older adults with T2DM in the community. Glucometers and accessories could be provided at subsidized rates or be made free contingent on older adults' income status to overcome the barrier of performing SMBG.

Exploring the Perspective of Diabetes, Diabetes Self-Management, and Quality of Life Among Older Adults With Type 2 Diabetes: A Qualitative Study Before and During the COVID-19 Pandemic.

PURPOSE: The purpose of the study was to explore the perspective and impact of diabetes, diabetes self-management, and quality of life (QoL) among older adults with Type 2 diabetes (T2DM) before and during the COVID-19 pandemic to better inform T2DM self-management interventions. METHODS: A qualitative descriptive approach with focus group discussions (n = 5 sessions with 5-6 older adults per session) and in-depth interviews (n = 15) was conducted with community-dwelling older adults with T2DM. RESULTS: Five themes emerged. The definition of diabetes carries negative connotations, QoL is defined in terms of biopsychosocial health, diabetes self-management refers to the ability to adhere to medical advice and lifestyle changes, the QoL of older adults is differentially affected by COVID-19 measures, and important aspects of diabetes self-management activities are impacted by COVID-19 measures. CONCLUSIONS: Understanding older adults' perspectives on diabetes, diabetes self-management, and QoL provided insights into the facilitators and barriers to diabetes self-management practices before and during the COVID-19 pandemic. Findings inform the need for greater bottom-up initiatives and the need for a multipronged approach that considers the intra- and interpersonal and current policy factors to encourage diabetes self-management behaviors, especially during the COVID-19 era.

Sociodemographic characteristics associated with self-care and quality of life among community-dwelling older adults with type 2 diabetes.

AIMS: To assess how well community-dwelling older adults in Singapore were coping with their diabetes, and the sociodemographic characteristics that were associated with their level of coping. METHODS: This was a cross-sectional study involving 257 older adults. Multiple regression was used to assess the associations between various sociodemographic characteristics and coping measures of present quality of life and level of self-care. RESULTS: Older adults mainly sought care in the primary care setting. They were not coping well given their mean scores for diabetes-dependent quality of life and the self-care index were -3.57 and 3.55 respectively. Compared to those with post-secondary education, individuals who had no formal (adjusted B -0.92, p 0.003), primary level (adjusted B -0.76, p < 0.001) and secondary level (adjusted B -0.50, p < 0.02) education reported lower present quality of life. Those with prior lowest skill level occupations were less likely to consume a healthy diet per week than those with prior highest skill level occupations (adjusted B -1.48, p 0.004). CONCLUSIONS: There should be provision of diabetes self-care interventions targeting older adults in Singapore especially for those with lower education and work skill levels. As the first line of contacts, primary care providers should advocate for diabetes self-care and develop community-based interventions for these priority groups.

Promoting BioPsychoSocial health of older adults using a Community for Successful Ageing program (ComSA) in Singapore: A mixed-methods evaluation.

BioPsychoSocial health promotion is increasingly emphasized for Successful Ageing. Few programs are known to target BioPsychoSocial health of older adults and their community. The Community for Successful Ageing: Community Development program (ComSA CD) was developed in Singapore for this purpose. This study assessed program effects on BioPsychoSocial health and civic engagement behaviours of participants. ComSA CD offered self-care healthy lifestyle education (Bio-physical), guided autobiography (Psychological) and a civic engagement component which galvanized participants to solve community issues (Social). Recruitment occurred through self-care or guided autobiography; following which participants were funnelled into the civic engagement component. A mixed-methods quasi-experimental evaluation was conducted, using a pre-post one-year survey (N=232) with those exposed and unexposed (rejected) to ComSA CD. Using a generalized linear model, associations between post one-year BioPsychoSocial outcomes and exposure group were quantified using percentage change, adjusting for baseline outcome and group differences. Concurrently, program effects were explored through six focus groups with program implementers and participants using thematic analysis. The program had multiple positive effects. Participants recruited via self-care also taking part in civic engagement reported 31% higher frequency of self-care (95% CI=21% to 68%) post one-year compared to unexposed participants. Qualitative findings illustrated how the civic engagement component stimulated agency of participants to push for neighborhood changes and civic engagement initiatives. The quantitative survey highlighted that this effect was strongest among those funnelled from guided-autobiography (92% higher frequency of civic engagement at post one-year than unexposed; 95%CI=41% to 178%) compared to those funnelled from self-care (53% higher than unexposed, 95%CI=17% to 114%). It was found qualitatively that guided-autobiography enabled more meaningful bonding and communication than the self-care component, explaining quantitative effects on social support only present among guided autobiography participants (36% higher than unexposed; 95%CI=11% to 68%). Findings highlighted the importance of improving group dynamics for collective action.

Exploring the implementation of the Community for Successful Ageing (ComSA)program in Singapore: lessons learnt on program delivery for improving BioPsychoSocial health.

BACKGROUND: The Community for Successful Ageing (ComSA) program has implemented overlapping BioPsychoSocial (BPS) components as part of a Community Development (CD) grassroots and volunteer-led initiative. Implementation of such multi-component programming is influenced by known program characteristics including novelty, complexity and observability as well as related organizational factors. As such, we explored ComSA CD's implementation from the organizational perspective, seeking to inform program improvements. METHODS: We conducted four focus groups with program staff, partners and trainers (total N = 21 participants). Findings were analysed using an interpretative approach and synthesized into a line of argument informing lessons learnt. RESULTS: An implementation framework was identified. It is guided by considering the influence of known program characteristics across major themes, representing three core implementation stages. These and supporting sub-themes are elaborated in turn: 1) Creating commitment toward the program was challenged by novelty and at times a lack of shared understanding of ComSA CD, particularly relating to the S component. Overall, cohesion within organizational contexts and having a strong rapport with the community (ability to engage) were needed to persuade volunteers and participants to commit to the program. 2) Coordination and resource allocation were influenced by the complexity of interconnecting BPS components - requiring aligning communication between partners and adapting the BPS sequence, given the separated management structure of program trainers. Efficiency of resource utilization was constrained by the ability to pool and match resources given the limited manpower and community partners who worked-in-silo due to a KPI-centric culture. 3) Collaborative program monitoring and appraisal increased observability of the program's benefits, but depended on partners' prior commitment. Despite appreciating its holistic BPS programming, dropout rate was used as a way to gauge program success, which has limited interpretability. Occasional uncertainty about the program value contributed to concerns about duplicating existing ageing programs, particularly those related to the B component. CONCLUSION: Lessons learnt for improving BPS programming include (1) eliciting better participants' buy-in and shared program vision, (2) increasing adaptability of BPS sequence and building a culture of shared values for working together (3) and developing comprehensive monitoring systems for program appraisal.

Theory and Design of the Community for successful ageing (ComSA) program in Singapore: connecting BioPsychoSocial health and quality of life experiences of older adults.

BACKGROUND: Despite the emphasis on holistic health promotion in community programs for older people, few studies explicitly consider how BioPsychoSocial (BPS) health elements are interconnected and function to improve Quality of Life (QoL). The Community for Successful Ageing (ComSA) program in Singapore focuses on Community Development (CD) initiatives for older people, accounting for BPS theory in its design and content. Biological (B) health is conceived as physiological and cognitive functioning and related biological self-care; Psychological (P) health as feelings of life satisfaction, and Social health (S) as perceived social support and civic engagement. Furthermore, three overlapping sub-constructs are theorized to connect these elements. Namely Bio-Psychological (BP) health in terms of self-perceptions of ageing; the Psycho-Social (PS) aspects of interpersonal communication; and the Socio-Communal (SC) health in terms of civic engagement. BPS health is conceived as distinct from QoL, defined as composed of control, autonomy, self-realisation and pleasure (measured by CASP-19) of the older person. We examined 1) interconnections of BPS constructs and related sub-constructs and 2) their associations with QoL to inform a practical, applied program theory. METHODS: A baseline survey (n = 321) of program participants (Mean = 70 years, SD = 8.73). All continuous variables were binarized as 'high' if the scores were above the median. Multivariate logistic regression was used to assess 1) the adjusted effect of each BPS construct on CASP-19, and 2) the odds of scoring high on one BPS construct with the odds of scoring high on a related sub-construct (e.g. B and BP health). RESULTS: The strongest relationship with QoL was markedly with BP self-perceptions of ageing (OR = 4.07, 95%CI = 2.21-7.49), followed by P life satisfaction (OR = 3.66, 95%CI = 2.04-6.57), PS interpersonal communication (OR = 2.42, 95%CI = 1.23-4.77), SC civic engagement (OR = 1.94, 95%CI = 1.05-3.57), and S social support (OR = 1.89, 95%CI = 1.06-3.38). Core B, P and S health were closely associated with their sub-constructs. CONCLUSION: ComSA CD is tightly coupled to its proposed program theory. It offers classes to improve B self-care and BP self-perceptions of ageing, group-based guided autobiography to improve P life-satisfaction and PS interpersonal communication, and community initiatives that encourage seniors to solve community issues. This holistic approach is likely to enhance ageing experiences and QoL.

Explaining the continuum of social participation among older adults in Singapore: from 'closed doors' to active ageing in multi-ethnic community settings.

OBJECTIVES: This study aims to identify and explain the continuum in which older people in Singapore participate in community and social life, highlighting the influence of culture and policy context on social participation. METHODS: Using an ethnographic approach in a neighbourhood (n=109), we conducted focus groups with older adults of different ethnicities, exploring experiences of social participation. Next, participants took 50 photographs relating to 'lives of elders', showcasing the socio-ecological context that influenced social participation. Lastly, go-along interviews were conducted in various precincts with community leaders. RESULTS: A continuum of social participation emerged among older adults, ranging from (1) marginalization and exclusion, to (2) 'comfort-zoning' alone (3) seeking consistent social interactions, (4) expansion of social network, and (5) giving back to society. Seeking consistent social interactions was shaped by a preference for cultural grouping and ethnic values, but also a desire for emotional safety. Attitudes about expanding one's social network depended on the psychosocial adjustment of the older person to the prospect of gossip and 'trouble' of managing social relations. Despite the societal desirability of an active ageing lifestyle, cultural scripts emphasizing family meant older adults organized participation in social and community life, around family responsibilities. Institutionalizing family reliance in Singapore's welfare approach penalized lower-income older adults with little family support from accessing subsidies, and left some living on the margins. DISCUSSION: To promote inclusiveness, ageing programs should address preferences for social participation, overcoming barriers at the individual, ethnic culture and policy level.

Self-Care for Older People (SCOPE): a cluster randomized controlled trial of self-care training and health outcomes in low-income elderly in Singapore.

UNLABELLED: Population aging is associated with a higher prevalence of chronic health conditions. Previous studies have shown that older persons, specifically those with chronic conditions, often lack sufficient knowledge about their condition and thus frequently have poor self-care skills. Efforts to increase general health screenings and improve access to chronic condition management resources are hampered by a lack of disease and health awareness. Self-Care for Older People (SCOPE) study, a cluster randomized controlled trial in Singapore, was designed to evaluate the impact of a self-care program for chronic disease awareness and management of specific health measures and quality of life of older people over eighteen months. SCOPE provided self-care education targeted at older people with low income and low education in order to improve health-related knowledge. A total of 378 low-income older people with no or minimal disability, defined as having difficulty in one or more activities of daily living (ADL), were recruited from senior activity centers. The measurements taken included self-reported health conditions, health and disease knowledge questions, and biomarkers (HbA1c, blood pressure, peak expiratory flow, lipid panel, albumin, and creatinine). SCOPE was also designed to provide information for policy makers on chronic disease burden and healthcare facility utilization among community-dwelling older adults. TRIAL REGISTRATION NUMBER: NCT01672177.