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.

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.

Older Korean Americans' Perceived Burdensomeness to Their Healthcare Partners: An Egocentric Network Assessment.

Objectives: The objective is to examine how older Korean Americans' perceived burdensomeness to their healthcare partners is associated with the characteristics of older adult participants (egos) and their healthcare partners (alters). Methods:Surveys of 2150 participants in the Study of Older Korean Americans provided ego data. Participants were also asked to list up to three individuals whom they usually asked for help on health-related matters or healthcare use, which generated 3402 alters. Multilevel modeling was conducted to examine the role of the characteristics of egos and alters, as well as their cross-level interactions. Results: Perceived burdensomeness was negatively associated with English-speaking ability and residence in a low Korean density area. Perceived burden was also lowered when emotional support was received from the alters, and this pattern was pronounced among those with multi-comorbidity. Discussion: By identifying older immigrants prone to the sense of burdensomeness, the study suggests strategies to promote their health and healthcare use.

Relationship of social isolation with mental distress among older Korean Americans: The moderating role of social cohesion.

Social isolation has been associated with poor mental health outcomes, particularly for older immigrants who do not have a protective social environment. The purpose of this study was to investigate the relationship of social isolation (living alone, marginal family ties and marginal friend ties) with mental distress and to examine the moderating role of social cohesion (family cohesion and community cohesion). We hypothesised that social isolation and social cohesion would be directly associated with mental distress and that social cohesion would buffer the influence of social isolation on mental distress. Data were drawn from the Study of Older Korean Americans (SOKA), which included 2150 older Korean Americans aged 60 or over in multiple areas, collected during 2017-2018. A series of hierarchical regression models of mental distress examined the direct and interactive role of social isolation and social cohesion. Approximately one-third of the sample lived alone, 20% had marginal family ties and 27% had marginal friend ties. All three indicators of social isolation had a significant direct effect on mental health; however, living alone lost its statistical significance with the inclusion of social cohesion variables. Both indicators of family and community cohesion were significantly associated with lower levels of mental distress. In addition, family cohesion buffered the negative effects of marginal ties to family and friends on mental distress. The significant role of a positive social environment must be considered when addressing the needs of older immigrants who are socially isolated.

Performance of an Abbreviated Lubben Social Network Scale (LSNS-6) in Three Ethnic Groups of Older Asian Americans.

BACKGROUND AND OBJECTIVES: The present study examined the measurement quality and performance of an abbreviated Lubben Social Network Scale (LSNS-6) in three ethnic groups (Chinese, Koreans, and Vietnamese) of older Asian Americans, addressing both within- and cross-group validations. RESEARCH DESIGN AND METHODS: We selected 605 participants aged 50 or older (242 Chinese, 150 Koreans, and 213 Vietnamese) from the 2015 Asian American Quality of Life survey, conducted with self-identified Asian Americans aged 18 or above living in central Texas. We analyzed LSNS-6 data on measurement qualities (internal consistency and corrected item-total correlation), dimensionality (exploratory and confirmatory factor analyses), and correlations with other indicators. RESULTS: LSNS-6 showed very good internal consistency in each ethnic group, and the two-factor structure of family and friends were invariant across the groups. The items on friends demonstrated greater homogeneity than those on family and emerged as a first factor. Both subscale and total scores of LSNS-6 were associated in expected directions with the social and health indicators considered. DISCUSSION AND IMPLICATIONS: The findings confirm the measurement qualities of LSNS-6 within each group and provide support for measurement invariance across the groups. While the observed difference in family and friend networks warrants further investigation, LSNS-6 serves as a viable option for the assessment of social networks. When using LSNS-6 with older Asian Americans, it is highly recommended to use the family/friend subscales in consideration of cultural and immigration contexts.

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.

Health risks posed by social and linguistic isolation in older Korean Americans.

OBJECTIVES: Inspired by the notion of double jeopardy positing the dual disadvantage in the coexistence of different sources of vulnerability, the present study examined health risks posed by social and linguistic isolation in older Korean Americans. DESIGN: A cross-sectional study, using a four-cell classification to compare isolation types (no isolation, social isolation only, linguistic isolation only, and dual isolation) and to examine their impacts on physical (self-rated health), mental (mental distress), and cognitive (cognitive performance) health. SETTING AND PARTICIPANTS: Data are from the Study of Older Korean Americans survey of Korean immigrants aged 60 or older (n = 2032), conducted in five states in the United States (California, New York, Texas, Hawaii, and Florida). MEASUREMENT: Social isolation was indexed by the Lubben Social Network Scale-6; linguistic isolation, by a question on English-speaking ability. Physical, mental, and cognitive health were indicated by a single-item self-rating of health, the Kessler Psychological Distress Scale 6, and the Mini-Mental State Examination, respectively. RESULTS: The dual-isolation group exhibited notable sociodemographic and health disadvantages. The odds of having fair/poor health, mental distress, and cognitive impairment were 2.21-3.17 times higher in the dual-isolation group than in the no-isolation group. CONCLUSION: Our findings confirm that both social relationships and language proficiency are key elements for older immigrants' social connectedness and integration, the deprivation of which puts them at heightened risk in multiple dimensions of health.

Self-rated Physical, Mental, Oral, and Cognitive Health in Older Korean Immigrants: The Role of Health Indicators and Sociocultural Factors.

Guided by the models of health assessment and social determinants of health, we examined predictors of self-rated physical, mental, oral, and cognitive health of older Korean immigrants. Data came from the Study of Older Korean Americans (SOKA; N = 2,061, Mean age = 73.2). Multivariate regression models of self-ratings of health were tested with health indicators (both domain-specific and other health indicators including chronic disease, functional disability, mental distress, problems with teeth or gums, and cognitive function) and sociocultural factors (acculturation, social network, and ethnic community social cohesion). For self-rated physical, mental, and oral health, indicators specific to the targeted domain played a primary role, with those of other health domains playing a secondary role. Acculturation and social network were significant predictors of all four measures. Findings highlight the importance of holistic health assessment that considers a wide range of health domains as well as sociocultural contexts.

The Role of Social Networks on Depressive Symptoms: A Comparison of Older Koreans in Three Geographic Areas.

The purpose of this study was to examine the correlates of depressive symptoms among older Korean adults in three geographic locations with varying densities of the Korean population: mainland Korea (mostly Koreans), New York metropolitan area (high Korean density), and west central Florida (low Korean density). The study focused on the role of family and friend networks. Data were drawn from three sources: (1) a multistage national sample of Koreans in South Korea (n = 403); (2) a survey conducted in the western/central Florida area that used a variety of culturally sensitive sampling strategies (n = 672); and (3) a survey in the New York metropolitan area (n = 420) that replicated the Florida study. For those living in Korea, living alone and lower perceived financial status were independently associated with higher levels of depressive symptoms. For the New York and Florida samples, fair or poor self-rating of health, lower levels of acculturation, and weaker ties with family were related to higher levels of depressive symptoms. Similar to the older Korean sample, lower perceived financial status was linked with greater depressive symptoms in the New York sample. The overall results suggest that it is important to consider the interplay of the social network, personal, and cultural resources when working with older adults in diverse contexts. Intervention efforts should address mental health issues tailored to cultural and social settings.

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.

Profiles of Social Engagement and Their Association With Loneliness and Self-Rated Health Among Older Korean Immigrants.

The purposes of this study were to (1) develop a typology of social engagement in older Korean immigrants in the United States and (2) compare the groups in the typology regarding their level of loneliness and self-rated health. Data were drawn from the Study of Older Korean Americans covering the five geographic locations (N = 2,149). Using eight criterion variables concerning the type and frequency of activities, latent profile analysis identified a six-group model as the most optimal with the following groups: diverse, active, moderately social, structured, sedentary, and restricted. When the restricted group was used as the reference, the groups that were more socially engaged were found to have lower levels of loneliness. Additionally, being a member of the active or moderately social group was associated with more favorable self-ratings of health. These findings hold implications for understanding the variability of social engagement and how it relates to health and well-being.

Determinants of Self-rated Cognitive Health among Older Korean Americans.

BACKGROUND AND OBJECTIVES: In response to the dearth of information on cognitive health in older ethnic minorities, in the present study, we examined factors associated with self-rated cognitive health (SRCH) in older Korean Americans. Drawing from the World Health Organization's framework of social determinants of health, we examined how a broad spectrum of factors might influence the way in which older Korean Americans perceive and evaluate their own cognitive health. RESEARCH DESIGN AND METHODS: Using data from the Study of Older Korean Americans (SOKA; N = 2,061, mean age = 73.2), a series of hierarchical linear regression models of SRCH was tested with sequential entry of predictors: (1) Mini-Mental State Examination (MMSE) score of cognitive status, (2) demographic variables, (3) physical and mental health status, (4) health behaviors, and (5) socio-cultural and community factors. RESULTS: In addition to cognitive screening outcomes, each set of variables made a significant contribution to the predictive model of SRCH. Positive ratings of cognitive health were observed among older individuals with greater education, good physical and mental health, involvement in regular exercise, and socio-cultural resources (social networks, acculturation, and family solidarity). DISCUSSION AND IMPLICATIONS: The SRCH of older adults goes beyond cognitive screening outcomes, suggesting a need to incorporate the various sources of social determinants when seeking to promote the cognitive health of older populations.

Healthcare Navigation Self-Sufficiency in Older Korean Immigrants.

Using data from surveys with Korean Americans aged 60 years or above (n = 2,150), the level of healthcare navigation self-sufficiency was assessed, and its related factors were explored. The overall status of self-sufficiency was low; for example, over half of the sample needed assistance with reading and filling out medical documents, and nearly half needed someone to interpret during medical visits. Diminished self-sufficiency in healthcare navigation was associated with disadvantaged social status (e.g., advanced age, female gender, and low education), early stages of immigration (short length of stay in the U.S. and low English proficiency), and lack of personal health resources (e.g., poor health condition and lack of health insurance). The findings shed light on older immigrants' challenges in the use of health services in a broad sense and help identify areas of patient burden and avenues for interventions.

Factors associated with dental service use of older Korean Americans.

OBJECTIVES: Based on Andersen's healthcare utilization model, the present study examined factors associated with dental service use in older Korean Americans. Focus was on predisposing characteristics (age, gender, marital status, education and region), oral health needs (problems with teeth or gums and self-rated oral health) and enabling factors (dental health insurance, length of stay in the United States, acculturation and family network). METHODS: Using data from surveys with Korean Americans aged 60 or older (N = 2128), a Poisson regression model examined predictors of dental visit in the past 12 months. FINDINGS: More than 21% of the sample reported having a problem with teeth or gums, and over half rated their oral health as either fair or poor. Approximately 71% lacked dental health insurance. The number of dental visits in the past 12 months averaged 1.40 (SD = 1.74), with about 38% having no dental visits at all. Multivariate analyses showed that higher levels of education, the presence of a problem with teeth or gums, dental health insurance coverage, longer length of stay in the United States, and larger family networks were associated with 1.01-1.35 times higher number of dental visits. CONCLUSION: The findings not only confirmed the critical role of dental health insurance as a service enabler but also highlighted the importance of considering older ethnic immigrants' oral health and dental care from the perspectives of culture and family.

Loneliness as a mediator in the relationship between social engagement and depressive symptoms: Age differences among community-dwelling Korean adults.

The purpose of this study was to examine whether loneliness mediates the relationship between social engagement and depressive symptoms and to determine how age moderates the mediation effect. Data for this study came from the survey with community-dwelling adults aged 18 and older in South Korea, from March to April 2017. The total of 1,017 respondents were drawn from three age groups (18-44, 45-64, or 65 and older). The mediating effect of loneliness was tested between each of three social engagement-related variables (family network, friend network, and perceived community support) and depressive symptoms. The results showed age differences in mediation: the effect was most pronounced in the relationship of family network with loneliness for the older group, whereas the size of friend network significantly predicted loneliness for younger adults. Both younger and older groups felt less lonely when they had a higher level of perceived community support; the middle age group remained uninfluenced by the mediation effects. Our findings confirm that loneliness is one of the mechanisms by which social engagement exerts its effect on depressive symptoms. As the Korean society embraces its growing proportions of older adults, the results of the study provide implications for adaptive strategies for changing social engagement need and mental health associated with ageing.

Mental Health Service Use and Perceived Unmet Needs for Mental Health Care in Asian Americans.

Using data from the Asian American Quality of Life (AAQoL, n = 2609) survey, logistic regression models of mental health service use and perceived unmet needs were estimated with background variables, ethnicity, and mental health status. More than 44% of the participants were categorized as having mental distress (Kessler 6 [K6] ≥ 6) and 6.1% as having serious mental illness (SMI, K6 ≥ 13). About 23% had used services (mental health specialist, general doctor, and/or religious leader) for their emotional concerns during the past year, and about 7% reported that there was a time that they needed mental health care but could not get it. In the multivariate analyses, the presence of mental distress and SMI increased the odds of using any service and having perceived unmet needs. Those who had used services exhibited higher odds of reporting unmet needs, calling concerns about the quality of services and user satisfaction.

Source of Health Information and Unmet Healthcare Needs in Asian Americans.

BACKGROUND: Responding to the disparities in accessing and obtaining health information and healthcare among immigrant populations, the present study focused on Asian Americans. Using a sample that reflects Asian Americans' cultural and linguistic diversities, the goal was to explore the typologies of health information source and their predictability to unmet healthcare needs (i.e., the experience of not being able to get needed medical care). METHODS: Data were drawn from the 2015 Asian American Quality of Life Survey (N = 2,592), conducted using culturally and linguistically sensitive approaches. Latent class analysis on nine sources of health information across interpersonal networks (family members, close friends, acquaintances, and health professionals) and Internet-based communication technologies (mobile apps, email listservs, social networking sites, online communities, and health websites) identified six classes: 'resource-heavy,' 'human-oriented,' 'expertise-focused,' 'family-dominant,' 'resource-scarce,' and 'health professional-dominant.' RESULTS: Compared to the resource-heavy group, the odds of having an unmet healthcare need were 2.94 times greater in the family-dominant group and 4.13 times greater in the resource-scarce group. DISCUSSION: Findings provide implications for interventions with respect to subgroups to be prioritized and areas to be targeted in efforts to promote access and acquisition of health information and health services in Asian Americans.

The risk typology of healthcare access and its association with unmet healthcare needs in Asian Americans.

Using data from the 2015 Asian American Quality of Life Survey (N = 2,609), latent profile analysis was conducted on general (health insurance, usual place for care and income) and immigrant-specific (nativity, length of stay in the U.S., English proficiency and acculturation) risk factors of healthcare access. Latent profile analysis identified a three-cluster model (low-risk, moderate-risk and high-risk groups). Compared with the low-risk group, the odds of having an unmet healthcare need was 1.52 times greater in the moderate-risk group and 2.24 times greater in the high-risk group. Challenging the myth of model minority, the present sample of Asian Americans demonstrates its vulnerability in access to healthcare. Findings also show the heterogeneity in healthcare access risk profiles.

Oral Health and Dental Care in Older Asian Americans in Central Texas.

OBJECTIVES: To examine factors associated with dental health insurance, self-rated oral health, and use of preventive dental care services in older Asian Americans. DESIGN: Cross-sectional survey. SETTING: The Asian American Quality of Life Survey was conducted with 2,614 Asian Americans living in central Texas using questionnaires available in English and six Asian languages. PARTICIPANTS: Asian American Quality of Life Survey participants aged 60 and older (N = 533; mean age = 69.4 ± 6.9). MEASUREMENTS: Participants were asked whether they had insurance that covered the cost of any dental visit, how they would rate their overall oral health status, and whether they had visited a dental clinic for a routine examination in the past 12 months. Information was also collected on sociodemographic and immigration-related variables. RESULTS: More than 61% of the sample had no dental health insurance, 45% reported that their oral health was fair or poor, and 44% had not used preventive dental care services. A series of logistic regression analyses identified factors posing a significant risk to oral health and dental care. For example, those with limited English proficiency were 3.5 times as likely to lack dental health insurance and 3.2 times as likely to rate their oral health as fair or poor. The odds of not using preventive dental care services were 6.4 times as great in those without dental health insurance. CONCLUSION: The overall findings call attention to efforts to promote oral health and dental care in older Asian Americans.

The Knowing-Doing Gap in Advance Directives in Asian Americans: The Role of Education and Acculturation.

OBJECTIVES: The purposes of the present study were (1) to explore the completion rate of advance directives (ADs) in a sample of Asian Americans and (2) to examine the direct and moderating effects of knowledge of AD, education, and acculturation in predicting AD completion. Education and acculturation were conceptualized as moderators in the link between knowledge and completion of ADs. METHODS: Using data from 2609 participants in the 2015 Asian American Quality of Life survey (aged 18-98), logistic regression analyses on AD completion were conducted, testing both direct and moderating effects. RESULTS: The overall AD completion rate in sample was about 12%. The AD knowledge and acculturation independently predicted AD completion. No direct effect of education was found; however, it interacted with AD knowledge. The AD knowledge was more likely to be translated into completion in the group with higher education. CONCLUSIONS: The AD completion rate observed in the present sample of Asian Americans was much lower than that of the US general population (26%-36%). The interactive role of education helps to explain the gap between AD knowledge and completion and suggests intervention strategies.