Examining cultural adaptations of the savvy caregiver program for Korean American caregivers using the framework for reporting adaptations and modifications-enhanced (FRAME).

BACKGROUND: The Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) is a tool that systematically guides decision-making and reporting of adaptations made to evidence-based interventions. Using FRAME, we documented the process and outcomes of adapting the Savvy Caregiver Program (SCP) for Korean American dementia caregivers. METHODS: Sequential adaptation was initiated with linguistic attunement, followed by pilot implementation and full adaptation. Our data-driven adaptation with multiple data sources and a feedback loop among multiple stakeholders yielded a total of 32 modifications, and each was coded according to the eight domains of FRAME: (1) what was modified, (2) who participated in recommending and deciding the modification to be made, (3) when the modification occurred, (4) whether the modification was planned, (5) whether the modification was fidelity-consistent, (6) whether the modification was temporary, (7) at what level of delivery, the modification was made, and (8) why the modification was made. RESULTS: The areas of adaptation were evenly distributed across context (37.5%), content (31.2%), and training (31.2%). The primary reasons for modification were for engagement (62.5%), followed by fit with recipients (43.8%) and outcome improvement (31.1%). About 66% of the modifications were applied to the entire target group, and all modifications were fidelity-consistent. CONCLUSIONS: The FRAME categorization provided a detailed understanding of the process and nature of adapting the SCP and served as a foundation for further implementation and scale-up. FRAME not only serves as a guide for adapting evidence-based interventions but also promotes their replicability and scalability.

Risk Factors for Elder Mistreatment Among Older Korean Americans.

Using data from a sample of older Korean Americans (n = 2,150), we examined the prevalence and associated factors of physical, emotional, and financial mistreatment. Given the importance of contextual factors, we examined the effect of immigration-related (years in the U.S. and acculturation) and interpersonal/community-related (family solidarity, social network, and ethnic community social cohesion) factors in addition to sociodemographic and health-related characteristics. The rate of experiencing physical, emotional, and financial mistreatment during the past year was 3%, 37.9%, and 16.1%, respectively. Younger age and lower family solidarity were common risk factors for emotional and financial mistreatment. The experience of emotional mistreatment was also more likely among females and those with higher level of acculturation, smaller social networks, and lower ethnic community social cohesion. Chronic disease was an additional risk factor for financial mistreatment. The findings suggest targeted prevention and intervention strategies for elder mistreatment.

Intervention to promote preventive dental care for older Korean-American Medi-Cal enrollees in Los Angeles.

BACKGROUND: In California, preventive dental care is covered by Medi-Cal (California's Medicaid program). However, many beneficiaries do not use their dental benefits. Given that a lack of knowledge about oral health and insurance coverage contributes to this underutilization, promoting the use of dental benefits among eligible individuals via an educational program is imperative. Responding to the particular needs of older immigrants with limited English proficiency, we developed a digital oral health intervention for older Korean-American Medi-Cal enrollees in Los Angeles. This educational intervention is designed to be delivered via computers and the Internet. It consists of a 15-min self-running PowerPoint presentation narrated in Korean with links to additional information on the Internet. The slides contain information about the basic etiology of oral diseases, oral hygiene, common myths about oral health and dental care, Medi-Cal coverage of preventive dental care, and how to find a dental clinic. METHODS: We pilot tested the intervention with 12 participants to examine its feasibility and acceptability. We also obtained participants' qualitative feedback about the intervention. RESULTS: A post-intervention quantitative assessment yielded high participant satisfaction and improved oral health and dental care knowledge. Participant responses to the intervention yielded four themes: (1) content and structure, (2) linguistic and cultural aspects, (3) delivery mode, and (4) additional concerns and suggestions. CONCLUSIONS: Our findings confirm the intervention's feasibility and acceptability and suggest further refinement.

Dementia Caregiving Experiences Among Korean Americans: Qualitative Inquiry Using the Stress Process Perspective.

Dementia caregiving involves a challenging and complex process, especially for immigrant families. Using a qualitative method, this study provides an in-depth exploration of caregiving experiences among Korean American caregivers of people living with dementia. Based on various sampling strategies, 16 Korean American caregivers of family members/relatives with dementia were recruited in the greater Los Angeles area. Guided by the stress process model and the constant comparative method, themes and subthemes were derived and categorized into four domains: (1) background/context; (2) perception/appraisal; (3) resources/coping, and (4) caregiver burden/reward. Findings suggest that intervention efforts should focus on educating and training dementia caregivers.

Mental Health Impact of Bullying by Ethnic Peers in Senior Housing: A Study with Older Korean American Residents in the Greater Los Angeles Area.

Using data from Korean-American residents (N = 343) in subsidized senior housing in the Los Angeles area, we examined the effect of peer bullying on mental health. About 18% of the sample had been a target of bullying, and over 31% had witnessed someone being bullied. Being a target of bullying was a significant predictor for both depressive symptoms and anxiety, whereas witnessing other residents being bullied was a significant predictor for anxiety only. Findings shed light on the adverse mental health impacts of peer bullying among ethnic minority older residents in senior housing.

The Role of Social Isolation on Mediating Depression and Anxiety among Primary Family Caregivers of Older Adults: A Two-Wave Mediation Analysis.

BACKGROUND: Primary family caregivers of older people with chronic care conditions are highly vulnerable to social isolation and psychological strains such as depression and anxiety due to their demanding responsibilities. This study examines how social isolation mediates the relationship between caregiving stress and mental health symptoms of primary family caregivers. METHODS: The analytic sample included 881 primary caregivers of older adults from the 2015 and 2017 National Study of Caregiving (NSOC). Social isolation was measured using a composite structure that includes objective social disconnectedness and subjective loneliness. Two-wave mediation models were estimated to examine longitudinally if social isolation mediated the relationship between caregiving stress (subjective & objective stress) and mental health symptoms (depression & anxiety) of primary caregivers. RESULTS: The study findings indicate that both subjective (ß = 0.32, p < 0.001) and objective stress (ß = 0.21, p = 0.003) have direct effects on depression among primary caregivers. Social isolation was found to only mediate the relationship between objective stress and depression (ß = 0.18, p < 0.001). In contrast, no significant direct and indirect pathway was found in the anxiety model. CONCLUSIONS: The study demonstrates the internal mechanism where objective strains of caregiving make family caregivers socially isolated, which in turn leads to increased symptoms of depression. Future interventions and practices aimed at improving the psychological well-being of family caregivers should prioritize strategies aimed at increasing social engagement, particularly for those with heavy caregiver burdens.

Perceived racial discrimination and mental distress in older Korean Americans: the moderating role of ethnic resources.

OBJECTIVES: To examine associations among perceived racial discrimination, ethnic resources, and mental distress in older Korean Americans. Ethnic resources included ethnic identity (how closely individuals identify themselves with other members of the same ethnic background) and sense of community (individuals' feelings of belonging to their ethnic group). We examined the direct effect of perceived racial discrimination and these ethnic resources, as well as their interactions, hypothesizing that mental distress associated with perceived racial discrimination would be reduced by ethnic resources. DESIGN: Using survey data from the Study of Older Korean Americans (N = 2,150), linear regression models of mental distress were examined for direct and interactive roles of perceived racial discrimination and ethnic resources. RESULTS: Mental distress was directly associated with perceived racial discrimination (B = 1.90, SE = .20, p < .001), ethnic identity (B = -.41, SE = .13, p < .01), and sense of community (B = -.45, SE = .12, p < .001). Perceived racial discrimination interacted significantly with sense of community (B = -1.86, SE = .28, p < .001). Subgroup analyses suggested that in the context of experiencing racial discrimination, a high sense of community can serve as a buffer against mental distress. CONCLUSIONS: Ethnic resources are a benefit in coping with experiences of discrimination. The moderating role of sense of community suggests the value of fostering social capital in ethnic communities to protect and promote older immigrants' mental health.

Factors Associated With Dietary Risks in Older Korean Americans.

Given the importance of healthy eating in the later years of life, the present study examined factors associated with dietary risks in older Korean Americans. We hypothesized that dietary risks would be associated with sociodemographic disadvantages, adverse health conditions, and limited sociocultural resources. Dietary risks were assessed with a scale covering five behavioral and situational risk factors (eating alone, skipping meals, functional challenges, oral health problems, and financial difficulties). Analyses of the data from the Study of Older Korean Americans (N = 2,150) showed that the sample on average had 1.13 risks (SD = 1.31), eating alone having the highest frequency (35.6%). Supporting the hypothesis, higher levels of dietary risks were found in individuals with sociodemographic disadvantages, poorer physical and mental health status, smaller social networks, and lower acculturation. Findings suggest concerted efforts to promote dietary behaviors and call attention to older immigrants who are socially and culturally isolated.

Changes in Depressive Symptoms of Korean American Dementia Caregivers After Attending the Savvy Caregiver Program: Preliminary Findings with a Pilot Sample.

OBJECTIVES: Language accommodation is indispensable in making evidence-based interventions available and accessible to ethnic minorities with limited English proficiency. As part of the larger effort to culturally adapt the Savvy Caregiver Program for Korean American dementia caregivers, we first conducted linguistic adaptation, and the present study reports the preliminary findings on participants' changes in depressive Symptoms. METHODS: The linguistically adapted program was delivered to two small groups of Korean American dementia caregivers (total n = 13) by two Savvy-certified Korean-speaking trainers. Participants' depressive symptoms were assessed at three time points (pre-intervention, immediate post-intervention, and 6-month follow-up). RESULTS: Following the intervention, participants exhibited lowered depressive symptoms (t = 8.64, p < .001, Cohen's d = .89). This benefit was sustained at 6-month follow-up. CONCLUSIONS: Findings suggest that the therapeutic benefit of the Savvy Caregiver Program could potentially be shared with linguistic minorities when delivered in their native language. CLINICAL IMPLICATIONS: Although limited in its scope and nature, the pilot study with linguistic adaptation sheds light on efforts to close the gap in the evidence-based intervention delivery.

Safety Concerns for Persons with Dementia in Senior Housing: A Qualitative Study with Korean American Caregivers in Los Angeles.

Subsidized senior housing helps many socioeconomically disadvantaged older adults pursue independent living and aging in place. However, cognitive impairment or dementia poses a critical challenge to many residents' ability to live independently and safely. Focusing on Korean American dementia caregivers, a group known to be vulnerable to caregiving burden but understudied, we explored the safety of persons with dementia in senior housing from the perspectives of caregivers. Qualitative data from nine caregivers whose care recipients were current or former residents of subsidized senior housing in Los Angeles were analyzed by the constant comparative method. Major concerns emerged were: (1) fire risks, (2) wandering, (3) physical injury (e.g., self-harm, falls), and (4) potential neglect. Caregivers also mentioned errors in the self-administration of medications, potential financial exploitation, and interpersonal conflicts. These concerns provide implications for services and programs for the safety of persons with dementia who live in senior housing.

Racial/Ethnic Differences in Correspondence Between Subjective Cognitive Ratings and Cognitive Impairment.

OBJECTIVES: Responding to racial/ethnic disparities in dementia diagnosis and care, we examined the role of race/ethnicity in the correspondence between subjective and objective ratings of cognitive impairment. Our examination focused on the two types of discordance: (1) positive ratings in the presence of cognitive impairment and (2) negative ratings in the absence of cognitive impairment. DESIGN AND PARTICIPANTS: A cross-sectional assessment was conducted using the data from the Harmonized Cognitive Assessment Protocol project, a sub-study of the Health and Retirement Study. Our analytic sample included 3,096 participants: 2,257 non-Hispanic Whites, 498 Blacks, and 341 Hispanics. MEASUREMENTS: Discordant groups were identified based on self-ratings of cognition (positive versus negative) and the Langa-Weir classification of cognitive impairment (normal versus impaired). RESULTS: Blacks and Hispanics were more prone to falsely positive perceptions of their cognitive function in the presence of cognitive impairment than non-Hispanic Whites. On the other hand, non-Hispanic Whites were more likely to manifest negative ratings even in the absence of cognitive impairment. CONCLUSION: Our findings demonstrate the critical role of race/ethnicity in determining discordance between subjective and objective measures of cognition and highlight the importance of a tailored effort to promote dementia diagnosis and care.

Cultural adaptation of the savvy caregiver program for Korean Americans with limited English proficiency: a feasibility and acceptability study.

BACKGROUND: Limited English proficiency (LEP) of dementia caregivers poses a critical barrier to these caregivers' access to evidence-based interventions. In an effort to make such interventions available and accessible to dementia caregivers with LEP, in the present study we use Barrera and colleagues' (2011) three-step model of cultural adaptation: (1) information gathering, (2) preliminary adaptation, and (3) full adaptation. Selecting Korean Americans as a target group and the Savvy Caregiver Program (SCP) as a target intervention, we demonstrate the sequential process of cultural adaption and report the outcomes on feasibility and acceptability. METHODS: Preliminary adaptation with linguistic attunement was conducted by translating the SCP manual into Korean and certifying two lay individuals who were bilingual in English and Korean as Savvy trainers. The 6-week online SCP program was delivered by the two trainers in Korean with six to seven caregiver participants per trainer (N = 13). Feasibility and acceptability of the SCP for both caregiver participants and trainers were assessed using mixed methods, and their data then informed full adaptation. RESULTS: Findings not only showed the initial efficacy of the linguistically attuned SCP but also suggested areas for further modification. Data-driven assessment yielded a list of recommended changes for full adaptation, which was reviewed by the SCP developer to ensure fidelity and by community and research partners to confirm contextual and cultural relevance. CONCLUSIONS: The adopted changes are broadly summarized as representing logistical, technical, and cultural issues. Given our refined set of educational materials and implementation guidelines, we discuss future directions for research and development.

Social isolation in Asian Americans: risks associated with socio-demographic, health, and immigration factors.

OBJECTIVES: The present study examined the factors associated with social isolation in Asian Americans. Three types of social isolation (social isolation from family, social isolation from friends, and overall social isolation), identified by the Lubben Social Network Scale-6, were examined with a sample of Asian Americans representing diverse ethnic groups (Chinese, Asian Indian, Korean, Vietnamese, Filipino, and other Asians) and a broad age range (18-98). DESIGN: Using data from the 2015 Asian American Quality of Life Survey (N = 2609), logistic regression models examined how each type of social isolation was predicted by sociodemographic (age, gender, ethnic origin, marital status, education, and perceived financial status), health-related (chronic medical conditions and self-rated health), and immigration-related (proportion of life in the United States and English proficiency) variables. RESULTS: The percentage of the sample that fell into the category of social isolation from family, social isolation from friends, and overall isolation ranged from 18.2% to 19.3%. At 36% in the friend category and 33% in the overall category, the Vietnamese sample showed a heightened risk of social isolation. Regression analyses indicated that, for both family and friend categories, individuals who were in the middle-aged group (40-59 years old) and who had limited English proficiency demonstrated higher odds of being isolated. Reflecting relational differences in family and friend networks, the risk associated with unmarried status was specific to social isolation from family, whereas having unmet financial needs was only associated with social isolation from friends. CONCLUSIONS: The study findings expand our understanding of the multiple domains of social isolation in an understudied population and emphasize the importance of developing prevention and intervention programs to foster social connectedness among Asian Americans. Our findings on risk factors and ethnic variations help identify the groups to be prioritized in intervention efforts and suggest ways to approach them.

Racial and ethnic differences in cognitive health appraisals: a comparison of non-Hispanic White, non-Hispanic Black, and Hispanic older adults.

OBJECTIVES: To investigate the relationship between cognitive performance and cognitive health appraisals across non-Hispanic White, non-Hispanic Black, and Hispanic older adults in the United States and to explore within-group variations by examining interactions between cognitive performance and background and health variables. METHOD: The sample (N = 3,099) included 2,260 non-Hispanic White, 498 non-Hispanic Black, and 341 Hispanic adults aged 65 or older, from the 2016-2017 Harmonized Cognitive Assessment Protocol. Regression models of cognitive health appraisals, indicated by self-rated cognitive health, were examined in the entire sample and in racial and ethnic subgroups to test direct and interactive effects of cognitive performance, indicated by the Mini-Mental State Examination (MMSE). RESULTS: The regression model for the entire sample showed direct effects of cognitive performance and race/ethnicity on cognitive health appraisals, as well as a significant interaction between cognitive performance and being non-Hispanic Black. Cognitive performance and cognitive health appraisals were positively associated in non-Hispanic Whites but not significantly associated in non-Hispanic Blacks. Our subsequent analysis within each racial/ethnic group showed that the effect of cognitive performance in non-Hispanic Blacks and Hispanics became either reversed or nonsignificant when background and health variables were considered. Modification by age or chronic medical conditions in each racial and ethnic group was also observed. CONCLUSION: Overall, these findings suggest that perceptions and appraisals of cognitive health vary by race and ethnicity and hold implications for how these differences should be considered in research and practice with diverse groups of older adults.

Chronic Conditions and Psychological Distress in Older Asian Americans: The Mediating Role of Subjective Health Perception.

Given the importance of understanding the connection between physical and mental health in old age, the study examined the mediating role of subjective health perception in the relationship between chronic conditions and psychological distress among older Asian Americans. Using data from 533 Asian Americans aged 60 and over in the 2016 Asian American Quality of Life Study, the direct and indirect effect models were tested with multivariate linear regressions and the PROCESS macro. Results show that chronic conditions pose significant risks to psychological distress and that subjective health perception mediates their association. The observed role of subjective health perception as an intervening step between physical and mental health offers implications for gerontological social work research and practice by highlighting the importance of positive self-appraisals for the health and well-being in later years of life.

Cognitive health risks posed by social isolation and loneliness in older Korean Americans.

BACKGROUND: This study examines associations among social isolation, loneliness, and cognitive health risks in older Korean Americans, focusing on the mediating role of loneliness in the relationship between social isolation and objective and subjective measures of cognitive impairment. METHODS: Data are from 2061 participants in the Study of Older Korean Americans, a multi-state survey of Korean immigrants age 60 and older (Mage = 73.2, SD = 7.93). Social isolation was indexed with the Lubben Social Network Scale- 6; loneliness, with the short-form UCLA Loneliness Scale. Objective and subjective measures of cognitive impairment included the Mini-Mental State Examination and a single-item self-rating of cognitive health. RESULTS: In the logistic regression model for objective cognitive impairment, social isolation was significantly associated, but loneliness was not. In the model for subjective cognitive impairment, both social isolation and loneliness were significant factors. However, the effect of social isolation became non-significant when loneliness was considered, suggesting a potential mediating role of loneliness. The subsequent mediation analysis confirmed that the indirect effect of social isolation on subjective cognitive impairment through loneliness was significant (B = .20, SE = .03, 95% CI = .12, .28). CONCLUSION: Our analyses provide evidence for the proposed mediating effect of loneliness in the relationship between social isolation and subjective cognitive impairment. Intervention efforts should focus on reducing feelings of loneliness experienced by older immigrants, possibly by engaging them in socially meaningful and cognitively stimulating activities.

Preference for patient-provider ethnic concordance in Asian Americans.

Objectives: The present study examined factors associated with the preference for patient-provider ethnic concordance in Asian Americans.Design: With data drawn from the 2015 Asian American Quality of Life Survey (N = 2535), a logistic regression model of the preference for patient-provider ethnic concordance was tested with demographic (age, gender, ethnicity, marital status, education), health and access (chronic medical conditions, self-rated health, health insurance coverage), immigration-related (place of birth, length of stay in the US, English proficiency, acculturation), and adverse experience (perceived discrimination, communication problems in healthcare settings) variables.Results: Over half (52.4%) of those in the sample preferred to be treated by a healthcare provider from their own ethnic background. In a multivariate model, the odds for preferring ethnic concordance were 1.52-1.64 times higher among individuals in earlier stages of immigration, language acquisition, and acculturation. Individuals who had experienced communication problems in healthcare settings presented 3.74 times higher odds for preferring ethnic concordance than did counterparts without such experience.Conclusions: The results emphasized the value of paying attention to patient-provider concordance when treating Asian Americans either relatively new to the country or who have had previous problems communicating with health professionals. The findings also provide implications for improving workforce diversity in healthcare delivery and medical education.

The moderating role of social factors in the relationship between an incident of fall and depressive symptoms: a study with a national sample of older adults in South Korea.

OBJECTIVES: The purpose of the study was to examine the effect of an incident of fall on depressive symptoms and the moderating role of social factors (marital status, living arrangement, family network, and friend network) in older adults in South Korea. We hypothesized that the adverse mental health effect of a fall would be pronounced among those who lack social resources (e.g., no spouse, living alone, and social disconnectedness). METHOD: Using the 2017 National Survey of Older Koreans, data were drawn from 8,522 survey participants (aged 65 or older). Multivariate linear regression models of depressive symptoms were examined with an array of predictors: (1) demographic and health variables, (2) social factors, (3) an incident of fall, and (4) interactions between falls and social factors. RESULTS: More than 15% of the sample had at least one fall in the past 12 months. Higher levels of depressive symptoms were associated with an incident of fall, not married and living alone, and lack of family and friend networks. Not married and living alone and family network significantly moderated the relationship between falls and depressive symptoms. The adverse mental health effect of a fall was more pronounced among those who were not married and living alone and who reported not having any close family members than their counterparts. CONCLUSION: The findings highlight the critical role of family and social resources in protecting older Koreans from the negative mental health consequences of a fall. Findings also provide implications for developing fall prevention and management programs, suggesting prioritizing older adults with limited social resources.

Older Korean Americans' concern about Alzheimer's disease: the role of immigration-related factors and objective and subjective cognitive status.

Objectives: The present study examined the associations between immigration-related factors and objective and subjective cognitive status with older Korean Americans' concern about developing Alzheimer's Disease (AD). It was hypothesized that (1) AD concern would be associated with immigration-related factors and (2) self-rated cognitive status would mediate the relationship between cognitive performance (Mini Mental State Examination (MMSE) scores) and concern about AD.Method: Using data from the Study of Older Korean Americans (n = 2061, mean age = 73.2; 66.8% female), the direct and indirect effect models were tested.Results: Korean American immigrants with a higher level of acculturation had better cognitive performance, more positive self-ratings of cognitive status, and a lower level of concern about AD. Both poor cognitive performance and negative self-ratings of cognitive status were associated with increased concern about AD. Supporting the mediation hypothesis, the indirect effect of cognitive performance on AD concern through self-rated cognitive status was significant (bias corrected 95% confidence interval for the indirect effect = -.012, -.003).Conclusion: The mediation model not only helps us better understand the psychological mechanisms that underlie the link between cognitive status and AD concern but also highlights the potential importance of subjective perceptions about cognitive status as an avenue for interventions.

The role of self-rated mental health in seeking professional mental health services among older Korean immigrants.

OBJECTIVES: The gap between mental health needs and service use in racial/ethnic minorities continues to be a major public health concern. Focusing on older Korean immigrants, the present study examined linkages among mental distress, self-rated mental health (SRMH), and the use of professional mental health services. We hypothesized that SRMH would play a mediating role in the relationship between mental distress and the use of professional mental health services. METHOD: Using data from the Study of Older Korean Americans (SOKA; N = 2,150, Mean age = 73.4), the direct and indirect effect models were tested. RESULTS: Nearly 30% of the sample fell within the category of experiencing mental distress, but only a small proportion (5.7%) had used professional mental health services. Supporting our hypothesis, the pathway from mental distress to the use of professional mental health services was influenced by an individual's subjective perception of mental health status: the indirect effect of mental distress on service use through SRMH (.04 [.01]) was significant (bias-corrected 95% confidence interval for the indirect effect = .02, .06). CONCLUSION: The findings of this study not only contribute to our understanding of help-seeking processes in a group at high mental health risk but also suggest avenues to promote their use of mental health services.